Citation Nr: 21015891 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 19-04 453 DATE: March 18, 2021 ORDER An initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to March 8, 2018, is denied. An initial rating in excess of 70 percent for PTSD since March 8, 2018, is denied. An initial rating in excess of 10 percent for bilateral hearing loss from September 1, 2015, to November 15, 2015, is denied. An initial rating in excess of 30 percent for bilateral hearing loss from November 16, 2015, to February 28, 2018, is denied. An initial rating in excess of 40 percent for bilateral hearing loss since March 1, 2018, is denied. New and material evidence having been received, the application to reopen the claim for diabetes mellitus (DM) is granted. New and material evidence having been received, the application to reopen the claim for right upper extremity (RUE) peripheral neuropathy (PN) is granted. New and material evidence having been received, the application to reopen the claim for left upper extremity (LLE) PN is granted. New and material evidence having been received, the application to reopen the claim for right lower extremity (RLE) PN is granted. New and material evidence having been received, the application to reopen the claim for left lower extremity (LLE) PN is granted. New and material evidence having been received, the application to reopen the claim for a cardiovascular (CV) disorder manifested by irregular heartbeat is denied. New and material evidence having been received, the application to reopen the claim for loss of use of creative organ is denied. New and material evidence having been received, the application to reopen the claim for hypertension is granted. New and material evidence having been received, the application to reopen the claim for a vision disorder of the right eye is granted. Service connection for hypertension is denied. Service connection for a vision disorder of the right eye is denied. Service connection for a disorder manifested by blood clots is denied. Service connection for residuals of a stroke is denied. REMANDED Entitlement to service connection for DM. Entitlement to service connection for PN of the RUE. Entitlement to service connection for PN of the LUE. Entitlement to service connection for PN of the RLE. Entitlement to service connection for PN of the LLE. FINDINGS OF FACT 1. The Veteran had active service from November 1965 to December 1968. 2. Prior to March 8, 2018, PTSD was productive of moderate symptoms causing occasional decrease in work efficiency, including excessive worry, restlessness, feelings of depression and worthlessness, irritability, sleep disturbance, difficulty relaxing, daily irritability/hatefulness, sleep disturbance, and muscle tension causing headaches. 3. Since March 8, 2018, PTSD has been manifested by anxiety and excessive worry, racing thoughts, irritability, mild memory loss, panic attacks weekly or less often, pessimistic mood, and variable affect. 4. From September 1, 2015, to November 15, 2015, hearing acuity was no worse than Level IV in each ear; from November 16, 2018 to February 28, 2018, hearing acuity was no worse than Level III in the right ear and Level V in the left ear; since March 1, 2018, hearing acuity has been no worse than Level VII in each ear. 5. An unappealed April 2014 rating decision denied applications to reopen claims for service connection for DM and bilateral upper and lower PN, as well as original claims for service connection for hypertension, a vision disorder of the right eye, irregular heartbeat, and loss of use of creative organ. 6. The evidence submitted since the April 2014 decision offered details of the Veteran’s claimed service in the Republic of Vietnam and reflected diagnoses and treatment for DM, PN, hypertension, and right eye disorders; but not treatment or diagnosis for irregular heartbeat or loss of use of creative organ, erectile dysfunction and did not provide evidence of in-service incurrence or a nexus to service or service-connected disabilities for these disorders. 7. Hypertension was not shown in service, was not shown to a compensable degree within one year of service, and symptoms were not continuous since service; hypertension is not causally or etiologically related to service. 8. A right eye disorder was not shown during service; a current right eye disorder, diagnosed as dry eye, cataract (post-extraction), and posterior capsular opacification is not causally or etiologically related to service or to service-connected disability. 9. A disorder manifested by blood clots was not shown during service; a current disorder manifested by blood clots, diagnosed as peripheral vascular disease (PVD), hypercoagulable state, and deep vein thrombosis (DVT), is not causally or etiologically related to service. 10. Stroke or brain thrombosis was not shown in service; brain thrombosis was not shown to a compensable degree within one year of service and symptoms were not continuous since service; residuals of a stroke or brain thrombosis is not causally or etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for initial rating in excess of 30 percent for PTSD prior to March 8, 2018, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2020). 2. The criteria for an initial rating in excess of 70 percent for PTSD, since March 8, 2018, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2020). 3. The criteria for an initial rating in excess of 10 percent for bilateral hearing loss from September 1, 2015, to November 15, 2015, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.85, 4.87, DC 6100 (2020). 4. The criteria for a rating in excess of 30 percent for bilateral hearing loss from November 16, 2015, to February 28, 2018, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.85, 4.87, DC 6100 (2020). 5. The criteria for a rating in excess of 40 percent for bilateral hearing loss since March 1, 2018, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.85, 4.87, DC 6100 (2020). 6. The April 2014 RO rating decision, which denied reopening of the claims for service connection for DM, bilateral upper and lower PN, a CV disorder manifested by irregular heartbeat, loss of use of creative organ, hypertension, and a vision disorder of the right eye, is final. 38 U.S.C. § 7105 (2012). 7. The evidence received since the April 2014 rating decision is new and material; the claim for DM is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 8. The evidence received since the April 2014 rating decision is new and material; the claim for PN of the RUE is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 9. The evidence received since the April 2014 rating decision is new and material; the claim for PN of the LUE is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 10. The evidence received since the April 2014 rating decision is new and material; the claim for PN of the RLE is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 11. The evidence received since the April 2014 rating decision is new and material; the claim for PN of the LLE is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 12. The evidence received since the April 2014 rating decision is not new and material; the claim for a CV disorder manifested by irregular heartbeat is not reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 13. The evidence received since the April 2014 rating decision is not new and material; the claim for loss of use of creative organ is not reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 14. The evidence received since the April 2014 rating decision is new and material; the claim for hypertension is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 15. The evidence received since the April 2014 rating decision is new and material; the claim for vision disorder of the right eye is reopened. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2020). 16. Hypertension was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.309 (2020). 17. A vision disorder of the right eye was not incurred in service and is not caused or aggravated by service-connected disability. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2020). 18. A disorder manifested by blood clots was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2020). 19. Stroke was not incurred in service, brain thrombosis is not presumed to have been incurred in service, and stroke was not cause or aggravated by service-connected disability. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The matters come to the Board on appeal of multiple rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). One December 2015 rating decision effected the Board’s February 2015 grant of service connection for an acquired psychiatric disorder, characterizing the disability as “acquired psychiatric disorder to include anxiety disorder and depressive disorder.” A second December 2015 rating decision denied reopening the claims for service connection for left ear hearing loss, irregular heartbeat, hypertension, DM, PN of the bilateral upper and lower extremities, loss of use of creative organ, a vision disorder of the right eye, a disorder manifested by blood clots, and stroke. With regard to the claims for service connection for a disorder manifested by blood clots and for stroke, within a year of the April 2014 rating decision, additional medical evidence showing contemporaneous treatment for a coagulation disorder, as well as treatment for recurrent blood clots in 1993 was received. This evidence was both new and material as it was not of record at the time of the April 2014 decision and it also goes to the element of in-service incurrence by providing evidence of onset and decades earlier treatment for a clotting disorder. Consequently, the April 2014 rating decision was not final as to the issues of entitlement to service connection for a disorder manifested by blood clots and for stroke, and the original claims for service connection adjudicated in that decision are on appeal. See 38 C.F.R. § 3.156(b); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011); Jennings v. Mansfield, 509 F.3d 1362 (2007) (a claim becomes final and subject to a motion to reopen only after the period for appeal has run, and any interim submissions before finality must be considered by the VA as part of the original claim). The Veteran also appealed an August 2017 rating decision which denied an increased rating for right ear hearing loss. Notably, an increased rating for right ear hearing loss was previously denied in the second December 2015 rating decision, but he did not appeal that issue when filing his February 2016 notice of disagreement (NOD) with the December 2015 rating decisions. Nevertheless, a December 2018 decision granted service connection for left ear hearing loss, effective September 1, 2015. This action fully satisfied the appeal of that issue. The hearing loss disability was then recharacterized as bilateral hearing loss; thus, the period on appeal for the rating assigned to the Veteran’s hearing loss extends to the claim filed in September 2015. Service connection for an acquired psychiatric disorder, to include anxiety disorder and depressive disorder, was granted in a February 2015 Board decision. This grant was put into effect by the Agency of Original Jurisdiction (AOJ) in a December 2015 rating decision. A January 2019 Board decision then granted service connection for PTSD. This grant was put into effect by the AOJ in a February 2019 rating decision which recharacterized the service-connected acquired psychiatric disorder as PTSD, as reflected in the issues above. There was no change in the rating assigned. The Veteran has set forth arguments regarding the effective date assigned for the acquired psychiatric disorder, but whether the argument is for an earlier effective date for service connection or for a given rating is unclear. Moreover, the effective date for any aspect of the acquired psychiatric disorder benefits granted was not properly appealed. The February 2016 NOD did not indicate that the Veteran was contesting an effective date, and entitlement to an earlier effective date of any kind was not addressed in the December 2018 statement of the case. Therefore, the Board does not have jurisdiction over the issue of entitlement to an earlier effective date for either the grant of service connection or the ratings assigned for the acquired psychiatric disorder. Finally, a claim of entitlement to a total disability rating due to individual unemployability (TDIU) was raised by the Veteran in 2006, and the claim was denied in a February 2007 rating decision; however, he has not presented argument in favor of a TDIU in connection with the increased rating claims for PTSD and bilateral hearing loss, and the evidence does not otherwise suggest that he is not employable due solely to his service-connected disabilities. Therefore, the claim of entitlement to a TDIU has not been raised in connection with this appeal and is not within the Board’s jurisdiction. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Ratings 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. 38 U.S.C. § 1155; 38 C.F.R. Part 4. PTSD All psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under the General Rating Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, and mild memory loss (i.e. forgetting names, directions, or recent events). A 50 percent rating is warranted under the General Rating Formula for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks occurring more than once a week, difficulty in understanding complex commands, impairment of short-term memory (i.e. retention of only highly learned material or forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted under the General Rating Formula for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as an unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and an inability to establish and maintain effective relationships. A 100 percent rating is warranted under the General Rating Formula for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including the ability to maintain minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that a veteran experiences symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Prior to March 8, 2018. Turning to the evidence, in an October 2010 VA examination, the Veteran described having a great relationship with his wife and both sons, being inseparable from his brother, and taking care of his father who lived nearby. He indicated that he socialized frequently with friends, and spent time with others, dining out and visiting family. He also reported working at his church. He stated that he worried about 75 to 80 percent of the day and felt depressed at times and was compelled to check his finances every day. The Veteran described sleep impairment in the form of initial and middle insomnia. He reported hallucinations, which the examiner stated sounded hypnagogic in nature. The examiner observed that the Veteran exhibited hand-wringing and was tense. The examiner also noted that the Veteran was neatly groomed and clean and that his speech was unremarkable. Short- and long-term memory were normal. There were no deficits of judgment or insight. The examiner noted obsessive-compulsive traits with moderate symptoms of anxiety disorder. In December 2010, the Veteran underwent a private psychological evaluation. He reported that his wife was “very good to [him].” He denied interpersonal problems when working and having left a job due to emotional or behavioral problems. He endorsed flat-line emotions, depersonalization, and dissociative episodes in which he “loses time.” In addition, he described sleep problems, concentration and focus difficulties, and hypervigilance. The examiner noted that the Veteran was somewhat vague, with poor comprehension and frequent misunderstandings. The Veteran’s attention span was short and psychomotor agitation increased. Speech patterns were coherent. The ability to abstract was moderately impaired, but the ability to calculate was within normal limits. Affect was generally normal, but he reported that his mood was not happy and that his days would start good and then decline to “dread.” The examiner found the Veteran’s judgment to be fair and insight to be poor, but noted that he was oriented to person, place, and time. Memory was broadly intact, but the Veteran had difficulty remembering names and addresses. The examiner diagnosed PTSD, anxiety disorder, depressive disorder, and cognitive disorder rule-out vascular dementia and suggested that some of the Veteran’s deficits of comprehension may have been due to the Veteran’s stroke in 1998. In a January 2011 VA examination, the Veteran continued to report being close with his wife and sons. He reported working on a show car and being active in a car club and in the Masonic Lodge. He described worrying and feeling tense and restless all the time, as well as feelings of hopelessness and worthlessness and irritability. He reported sleep disturbance due to feeling restless and up and down all night. The examiner found the Veteran to be clean and neatly groomed with unremarkable speech and psychomotor activity, and appropriate affect. The Veteran’s mood was good, and he was oriented to person, place, and time. The examiner documented no deficits of judgment or insight. Recent, remote, and immediate memory were normal. No panic attacks, obsessive or ritualistic behavior, homicidal or suicidal thoughts, hallucinations, or delusions were noted. The examiner indicated that the Veteran’s overall functional impairment was moderate, with symptoms causing an occasional decrease in work efficiency. A review of VA treatment notes reflects that the Veteran is seen on a regular basis for medication management. The mental health symptoms reported during these visits do not reflect a disability more severe than documented at the VA examinations. Based on the above, a rating in excess of 30 percent is not warranted for the period prior to March 8, 2018. Initially, the December 2010 private psychological evaluation suggested that some of the Veteran’s cognitive deficits were due to vascular dementia rather than his service-connected acquired psychiatric disorder. Nevertheless, the extent to which this disorder may impact the severity of the acquired psychiatric disorder symptoms is not ascertainable. Accordingly, the Board associates all symptoms with the Veteran’s service-connected PTSD. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Thus, the medical evidence reflects that the Veteran’s psychiatric disorder was productive of moderate symptoms causing occasional decrease in work efficiency, including excessive worry, restlessness, feelings of depression and worthlessness, irritability, sleep disturbance, difficulty relaxing, and muscle tension causing headaches. He had good family relationships, socialized with friends and engaged in multiple social activities, and engaged in appropriate self-care and personal hygiene. He did not endorse panic attacks to any extent and denied suicidal and homicidal ideation and symptoms of psychosis. While the December 2010 private evaluation noted some impairment of memory, judgment, and insight, these deficits were not found at neither the October 2010 nor January 2011 VA examinations. Therefore, considering the frequency and duration of these symptoms, the Board finds that his overall impairment does not more closely approximate a rating in excess of 30 percent for his PTSD for this period. Since March 8, 2018. At the March 2018 VA examination, the Veteran continued to described good relationships with his family but indicated that he rarely socialized and had stopped attending church and club meetings. He indicated that he had increased irritability and was nervous of no reason. He described excessive worry, anxiety, and racing thoughts. The examiner documented anxiety, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation or mood, and difficulty in establishing and maintaining work and social relationships. Speech was unremarkable, and the Veteran was oriented and cooperative. Mood was pessimistic, and his affect was variable. VA treatment notes continued to show the Veteran is seen on a regular basis for medication management. However, the mental health symptoms reported in such treatment notes did not reflect more severe manifestations of PTSD than documented at the VA examination. For this period, the medical evidence overall demonstrates occupational and social impairment with deficiencies in most areas throughout the appeal period, but not total occupational and social impairment. The evidence shows that the Veteran’s psychiatric disorder is manifested by anxiety and excessive worry, racing thoughts, irritability, mild memory loss, panic attacks weekly or less often, pessimistic mood, and variable affect. In addition, while he continued to have good relationships with his family, he had ceased engaging in church, clubs, and other organizations and rarely socialized. Such symptomatology does not more closely approximate a rating in excess of 70 percent rating. However, the overall disability picture does not rise to the severity of a 100 percent rating. For example, at no point did the evidence support a finding of persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives, own occupation or own name, or impairment of judgment or insight; nor was evidence of a similar type and degree of such symptoms found. Rather, the Veteran consistently appeared appropriately groomed and capable of maintaining effective relationships with his wife and children. Thus, his acquired psychiatric disorder symptoms had not rendered him totally impaired. The Board has also considered the Veteran’s lay statements that his disability is worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s PTSD has been provided by the medical personnel who have 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 other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and the appeals are denied. Bilateral Hearing Loss Ratings for hearing loss disability are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level, in decibels (dB) as measured by pure tone audiometric tests in frequencies 1000, 2000, 3000, and 4000 Hertz (Hz). 38 C.F.R. § 4.85, DC 6100. An examination for hearing impairment for VA purposes must include a controlled speech discrimination test (Maryland CNC). To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Exceptional patterns of hearing impairment allow for assignment of the Roman numeral designation using Table VI or an alternate table, Table VIA, whichever is more beneficial to the Veteran. 38 C.F.R. § 4.86. This applies to two patterns. In both patterns each ear will be evaluated separately. The first pattern is where the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 dB or more. 38C.F.R. § 4.86(a). The second pattern is where the pure tone threshold is 30 decibels or less at 1000 Hz and 70 dB or more at 2000 Hz. If the second pattern exists, the Roman numeral will be elevated to the next higher numeral. Turning to the medical evidence, a March 2014 VA examination found the following testing results: HERTZ 1000 2000 3000 4000 RIGHT 25 70 75 65 LEFT 20 65 75 75 The average pure tone threshold was 59 in the right ear, and 59 in the left ear. Speech audiometry revealed speech recognition ability of 80 percent in the right ear and 76 percent in the left ear. In a November 2015 VA examination, the pure tone thresholds, in decibels, were reported as follows:   HERTZ 1000 2000 3000 4000 RIGHT 55 85 95 85 LEFT 50 75 90 95 The average pure tone threshold was 80 in the right ear, and 78 in the left ear. Speech audiometry revealed speech recognition ability of 86 percent in the right ear and 76 percent in the left ear. A March 2018 VA examination yielded the following test results: HERTZ 1000 2000 3000 4000 RIGHT 45 75 90 80 LEFT 50 80 75 80 The average pure tone threshold was 72 in the right ear, and 71 in the left ear. Speech audiometry revealed speech recognition ability of 60 percent in the right ear and 64 percent in the left ear. Accordingly, based on the above findings, ratings in excess of those assigned are not warranted. Applying Table VII to the test results in March 2014, the Veteran had Level IV hearing in each ear, which does not warrant a rating in excess of 10 percent rating. In November 2015, the test results revealed Level III hearing in the right ear and Level V hearing in the left ear, which does not warrant a rating in excess of 30 percent. Finally, the March 2018 test results reflected Level VII hearing acuity in each ear, which does not warrant a rating in excess of 40 percent. A review of treatment records shows that the Veteran has been issued hearing aids for his disability; however, treatment notes do not reflect audiological findings more severe than found at any of the VA examinations. Therefore, the evidence does not show that the Veteran’s hearing acuity at any time during the period on appeal has been so impaired as to support ratings in excess of the 10 percent assigned prior to November 16, 2015, the 30 percent assigned from that date through February 28, 2018, and the 70 percent assigned since March 1, 2018. In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In this regard, the examiners specifically noted the Veteran’s complaint that he had difficulty understanding conversational speech, even with the use of hearing aids. Therefore, the Board finds that no prejudice to the Veteran in that the functional effects of his hearing loss disability were adequately addressed by the examiner and are sufficient for the Board to consider whether referral for an extra-schedular rating is warranted under 38 C.F.R. § 3.321(b). Accordingly, the preponderance of the evidence is against ratings in excess of those assigned for bilateral hearing loss. Therefore, the appeals are denied. Applications to Reopen Based on New and Material Evidence Prior unappealed rating decisions may not be reopened absent the submission of new and material evidence warranting revision of the previous decision. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. “New” evidence means evidence “not previously submitted to agency decisionmakers.” “Material” evidence means “evidence that, by itself or when considered with previous evidence of record, related to an unestablished fact necessary to substantiate the claim.” 38 C.F.R. § 3.156(a). In order to be “new and material” evidence, the evidence must not be cumulative or redundant, and “must raise a reasonable possibility of substantiating the claim,” which has been found to be enabling, not preclusive. See Shade v. Shinseki, 24 Vet. App. 110 (2010). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1991). A February 2007 rating decision denied service connection for DM due to lack of evidence of DM in service or evidence of exposure to Agent Orange. Claims for service connection for PN of the right and left upper and lower extremities were denied on the basis that the evidence did not reflect a current diagnosis of these disabilities. In an April 2014 rating decision, these claims were reopened as the evidence showed the requisite diagnoses, but service connection was denied due to a lack of nexus between the current disabilities and service. The April 2014 rating decision also denied the RO denied claims for service connection for irregular heartbeat, hypertension, and a vision disorder of the right eye due to the lack of evidence of the disorders in service and a lack of nexus to service. The Veteran did not appeal the denial, and it became final. Since the April 2014 rating decision, additional VA and private treatment records, and lay statements have been received. Among this evidence are October 2020 statements by the Veteran and arguments by his attorney regarding the Veteran’s purported service in the Republic of Vietnam. While the Veteran’s general contention that he served in Vietnam was of record in April 2014, the additional details provided in October 2020 were not. Therefore, this evidence is new, and as it goes to the missing element of in-service incurrence, the Veteran’s claims of entitlement to service connection for DM, bilateral upper and lower PN are reopened. Pertinent to the hypertension and right eye disorder, the new medical evidence shows continued treatment for hypertension, as examination and treatment for disorders of the right eye well as a diagnosis of hypertensive retinopathy. In addition, a diagnosis of dry eye, posterior capsular opacification, and a history of cataract extraction in the eye in 2018, was noted. As this evidence was not of record at the time of the April 2014 denial and is pertinent to the hypertension and right eye disorders for which service connection may be considered, it is material to the claims. Accordingly, the evidence is sufficient to reopen the claims for service connection for hypertension and a right eye disorder. The application to reopen these claims is granted. Pertinent to the irregular heartbeat and loss of use of creative organ, the additional evidence does not reflect diagnosis or treatment for either disorder and does not otherwise go to an element lacking as of the April 2014 denial, namely in-service incurrence or a nexus to service. The additional evidence is not new and does not raise a reasonable possibility of substantiating the claims. Therefore, the applications to reopen the claims for irregular heartbeat and loss of use of creative organ are denied. 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. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Notwithstanding the foregoing provisions regarding presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Hypertension As noted above, the medical evidence reflects treatment for hypertension. Therefore, the criterion of a current disability is met. As to an in-service incurrence, service treatment records (STRs) are silent for complaint, treatment, or diagnosis related to hypertension. The blood pressure reading taken at the November 1968 separation examination was not considered hypertension for VA purposes. In addition, post-service evidence does not otherwise suggest that hypertension was present in service. Therefore, the medical evidence does not support an in-service incurrence. To the extent that the Veteran asserts a nexus between hypertension and service, the medical evidence does not support the contention as no health care provider has made such a connection. Therefore, the medical evidence weighs against service connection for hypertension on a direct basis. Hypertension is a chronic disease under 38 C.F.R. § 3.309 and presumptive service connection will be considered. However, no chronic disease or injury was shown in service. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the earliest date associated with a hypertension diagnosis was a May 2005 VA treatment note. The Veteran separated from service in December 1968. The medical evidence shows that symptoms of his current hypertension developed at least over 23 years after service. As such, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1968 but again, the earliest date of treatment for hypertension was reported to be about 2005. Moreover, an October 2002 discharge summary after hospitalization for pneumonia did not reflect a diagnosis of hypertension. These records are particularly probative as they were given for the purpose of obtaining treatment, incentivizing accuracy. Thus, the evidence does not support presumptive service connection on a “manifested to a compensable degree within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. Vision Disorder in the Right Eye Initially, VA treatment notes show that the Veteran has a refractive error in the right eye; however, to the extent he is claiming service connection for vision impairment in the right eye due to refractive error, such disorder may not be service-connected. Refractive errors of the eyes are congenital or developmental defects and not disease or injury for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9. Thus, service connection is only warranted in such cases when there is evidence of additional disability due to aggravation during service of the congenital defect by superimposed disease or injury. In other words, absent a superimposed disease or injury, service connection may not be granted for refractive error of the eyes, even if visual acuity decreased in service. Nevertheless, the first element of a current disorder of the right eye is met. VA treatment notes reflect diagnoses of dry eye, posterior capsular opacification, and a history of cataract extraction on the right in 2018. In addition, a diagnosis of hypertensive retinopathy was documented in August 2018, although a subsequent August 2018 treatment note specified ocular hypertension on the left only. However, STRs are negative for any complaint, treatment, or diagnosis of a right eye disorder. Further, neither the post-service medical nor lay evidences supports a finding of in-service incurrence. Therefore, the medical evidence does not support the second element of direct service connection. Moreover, while there is a possible disorder of the right eye related to hypertension, a service connection is not established for hypertension, the criterion of a primary service-connected disability is not met for a claim of secondary service connection. Notably, the medical evidence specifically states that the Veteran does not have diabetic retinopathy to warrant inclusion of the right eye claim in the remand below. Accordingly, the preponderance of the evidence is against the claim of entitlement to service connection for a vision disorder in the right eye. Therefore, the appeal is denied. Blood Clots and Stroke Initially, the medical evidence establishes that the Veteran has a diagnosis of peripheral vascular disease and has been treated long-term with anticoagulants due to a history of recurrent DVT. In addition, he had a stroke in 1998, and the medical evidence suggests he has residual effects of the stroke. Therefore, the first element of service connection – a current diagnosis – is met. However, the second element of service connection – an in-service incurrence – is not met. STRs are silent for complaint, treatment, or diagnosis related to blood clots, DVTs, vascular disease, or stroke. Further, the post-service medical and lay evidence does not establish an in-service incurrence for these disorders. Therefore, the medical evidence does not support the appeals on a direct basis. To the extent that the Veteran asserts a nexus between blood clots and the residuals of his stoke and service, no health care provider has ever established such a relationship. Accordingly, the third element of service connection – a medical nexus – is also not met. Thus, a preponderance of the evidence is against service connection for a disorder manifested by blood clots and stroke on a direct basis. Thus, the claims are denied. Brain thromboses are considered a chronic disease under 38 C.F.R. § 3.309 and presumptive service connection will be considered. However, no chronic disease or injury was shown in service. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the earliest date associated with stroke was 1998. Again, the Veteran separated from service in December 1968. The medical evidence shows that earliest evidence of brain thrombosis was at least over 29 years after discharge. As such, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1968 but the earliest date of treatment for brain thrombosis was reported to be 1998. Moreover, a January 1997 head CT did not find evidence of ischemic disease of the brain. Notably, treatment in 1993 for a hypercoagulable state was related to a splenic infarction without reference to the brain. These records are particularly probative as they were given for the purpose of obtaining treatment, incentivizing accuracy. Thus, the evidence does not support presumptive service connection on a “manifested to a compensable degree within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. The Board has considered the Veteran’s lay statements that his hypertension, right eye disorder, disorders manifested by blood clots, and stroke were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorders due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records and clinical evidence obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeals are denied. Finally, the Veteran 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, 369-370 (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 In an October 2020 statement, the Veteran asserted that he was assigned to a mission transporting members of the 101st Airborne from Fort Campbell to the Republic of Vietnam. While the limited military personnel records in the file do not verify such service, no effort was made by the AOJ to obtain the Veteran’s complete personnel file, which may contain record of such orders, or to otherwise confirm such service. Accordingly, the claims for entitlement to service connection for DM and PN of the bilateral upper and lower extremities are remanded. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s complete personnel (201) file. 2. Undertake necessary development to verify the   Veteran’s reported duty transporting members of the 101st Airborne to the Republic of Vietnam. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. M. Schaefer, 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.