Citation Nr: 21025953 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-29 198 DATE: April 29, 2021 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for diverticulitis is denied. Entitlement to service connection for a psychiatric disability is denied. Entitlement to a rating higher than 0 percent for left ear hearing loss is denied. REMANDED Entitlement to service connection for a left heel injury is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for heart disease is remanded. Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran’s symptoms are attributable to a known clinical diagnosis of GERD, which was not incurred in service and is not due to or the result of service. 2. The preponderance of the evidence shows that the Veteran’s symptoms are attributable to a known diagnosis of diverticulitis, which was not incurred in service and is not due to or the result of service. 3. The preponderance of the evidence is against finding that any psychiatric disability is etiologically related to a disease, injury, or event in service. 4. The Veteran has, at worst, Level II hearing loss in the left ear, and the hearing loss in the right ear is not service-connected. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for gastroesophageal reflux disease (GERD) have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317. 2. The criteria for entitlement to service connection for diverticulitis have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317. 3. The criteria for entitlement to service connection for a psychiatric disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. Throughout the period of appeal, the criteria for a rating higher than 0 percent for left ear hearing loss have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1984 to February 1995 with subsequent service in the Army Reserve. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in August 2015 by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Muskogee, Oklahoma. This case was previously remanded for further development. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the AOJ, the Board finds that there has been substantial compliance with the prior remand directives concerning the claims for service connection for GERD, service connection for diverticulitis, service connection for a psychiatric disability, and entitlement to a higher rating for left ear hearing loss. Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection In general, service connection may be established for disability or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303 (d). To establish a service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability may be service-connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or that was chronic as defined by regulation with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303 (a),(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for gastroesophageal reflux disease (GERD) A service examination report from October 1991 found that the Veteran had a normal genitourinary system. A January 1995 service separation physical found that the Veteran had a normal genitourinary system. On a Report of Medical History completed in January 1995, the Veteran indicated that he did not experience frequent indigestion, stomach, or intestinal trouble. A March 1997 Reserves examination report found that the Veteran had a normal genitourinary system. On a Report of Medical History completed in March 1997, the Veteran indicated that he did not experience frequent indigestion, stomach, or intestinal trouble. In January 2001, the Veteran underwent an esophagogastroduodenoscopy. The diagnosis was GERD. At a June 2019 Board hearing, the Veteran stated that he began experiencing GERD symptoms in the mid to late 1980s. He stated that he had a colonoscopy, and the examiner brought up GERD. A September 2019 letter from J.W.E., M.D., states that the Veteran started having epigastric discomfort, heartburn, and severe acid reflux while he was on active duty. It was noted that an EGD taken in 2001 found peptic esophagitis, and since that time, the Veteran was started on a proton pump inhibitor. Dr. E. opined that it was more likely than not that the Veteran’s GERD was service-connected because of the occurrence of symptoms while the Veteran was on active duty. The examiner explained that an abnormal lower esophageal sphincter pressure and increased reflux during transient lower esophageal sphincter relaxations was the key factor in which abnormal amounts of gastric acid entered the esophagus and caused mucosal damage. On VA examination in November 2020, the Veteran reported that his symptoms of reflux, stomach pain, and regurgitation started in the service. He controlled the symptoms with medication. The examiner diagnosed GERD. The examiner opined that the Veteran’s GERD was less likely than not incurred in or caused by service. The examiner noted that the service medical records did not show any complaints or conditions related to the abdomen or viscera. The examiner further noted that the GERD did not start until many years after service. The examiner explained that GERD has multiple risk factors including obesity, diet, and smoking. The examiner noted that the Veteran had a history of smoking which spanned over 30 years, and obesity was noted in the medical record. The Board has considered whether service connection for GERD could be warranted as a result of exposure to environmental hazards while on active duty in the Persian Gulf. Service connection may be established for certain disabilities under 38 C.F.R. § 3.317. Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a), (b). Pursuant to 38 U.S.C. § 1117, the definition of qualifying chronic disability includes: (a) undiagnosed illness, (b) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, and (c) a diagnosed illness that the Secretary of VA determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2). Objective indications of a qualifying chronic disability include both signs, in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or a chronic multisymptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 U.S.C. § 1117(g). However, based on a careful review of the evidence of record, including the Veteran’s post-service medical records, the Board finds that the Veteran’s current symptoms are attributable to a known clinical diagnosis of GERD. Therefore, service connection for GERD cannot be established due an undiagnosed illness due to service in the Persian Gulf as the claimed disability is medically diagnosed. 38 C.F.R. § 3.317. The Board has also considered whether service connection for GERD could be warranted on a direct basis. The Board has carefully considered the September 2019 opinion offered by Dr. E. However, while Dr. E. based the positive opinion on the presence of symptoms while the Veteran was on active duty, Dr. E. did not cite to any specific documentation in service of the claimed symptoms. Similarly, Dr. E. did not acknowledge that the Veteran indicated on Reports of Medical History dated in January 1995 and March 1997 that he did not experience frequent indigestion, stomach, or intestinal trouble. Therefore, the September 2019 letter from Dr. E. does not contain adequate reasoning necessary to support a grant of service connection, and it is outweighed by the other evidence of record. The only other evidence which provides any connection between the Veteran’s GERD and service comes from the Veteran himself. It is to be noted that the Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran’s lay statements. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the specific issue in this case, whether GERD was caused by active service, or is otherwise related to service, those issues fall outside the realm of common knowledge of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide such opinions. The Board finds the November 2020 VA examiner’s opinion to be more probative than the lay statements of record and more persuasive than the private opinion. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The opinion of the November 2020 VA examiner is highly probative because it is supported by detailed rationale and provided by a trained medical professional. The VA examiner specifically identified and discussed the Veteran’s contentions and theory concerning GERD. Significantly, the November 2020 VA examiner discussed risk factors for GERD and provided an alternative etiology for the Veteran’s GERD. Accordingly, the November 2020 VA opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Accordingly, after a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The preponderance of the evidence is against a finding of a causal connection between the Veteran’s service and GERD or that GERD was present during service. The Board is appreciative of the Veteran’s faithful and honorable service to our country. However, because the preponderance of the evidence is against the claim, the claim must be denied. As the preponderance of the evidence is against the claim of entitlement to service connection for GERD, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for diverticulitis A service examination report from October 1991 found that the Veteran had a normal genitourinary system, anus, rectum, abdomen, and viscera. The Veteran’s January 1995 service separation physical found that he had a normal genitourinary system, anus, rectum, abdomen, and viscera. On a Report of Medical History completed in January 1995, the Veteran indicated that he did not experience frequent indigestion, stomach, rectal disease, or intestinal trouble. A March 1997 Reserves examination report found that the Veteran had a normal genitourinary system, abdomen, and viscera. On a Report of Medical History completed in March 1997, the Veteran indicated that he did not experience frequent indigestion, stomach, rectal disease, or intestinal trouble. During an esophagogastroduodenoscopy performed in January 2001, the treatment provider observed multiple diverticula throughout the sigmoid colon. The diagnosis was diverticulitis. In June 2013, the Veteran underwent a sigmoid resection. At a June 2019 Board hearing, the Veteran stated that he began experiencing intestinal-type symptoms around mid-1991. He described the symptoms as something residing in the abdomen with a knife trying to get out. He saw a gastrointestinal specialist in the early 2000s. He underwent surgery in 2013. A September 2019 letter from J.W.E., M.D., states that the Veteran started having left lower quadrant pain, fever, chills, and diarrhea while he was serving in Desert Storm. It was noted that the Veteran had symptomatic treatment but was not diagnosed with diverticulitis. A colonoscopy taken in January 2001 showed resolving diverticulitis. Since that time, the Veteran experienced two to four acute diverticulitis infections per year. The examiner opined that the Veteran’s diverticulitis was service-connected because of the symptoms that occurred while the Veteran was serving in Desert Storm. The examiner noted that diverticula usually develop in naturally weak places, and the colon gives way under pressure. The infection and inflammation of the diverticula caused diverticulitis. On VA examination in November 2020, the Veteran reported that he started experiencing sharp pains in the lower left abdomen in 1994. He was admitted to the hospital in 2012 and was placed on antibiotics. He had a sigmoid resection which resulted in a perforation to the small bowel. The Veteran underwent an ileostomy that was later reversed. The examiner diagnosed diverticulitis. The examiner opined that the Veteran’s diverticulitis was less likely than not incurred in or caused by service. The examiner noted that the service medical records did not show any complaints or conditions related to the abdomen or viscera. The examiner further noted that the diverticulitis did not start until many years after service. The examiner explained that diverticulitis has multiple risk factors including obesity, diet, and smoking. The examiner noted that the Veteran had a history of smoking which spanned over 30 years, and obesity was noted in the medical record. The Board has considered whether service connection for diverticulitis could be warranted as a result of exposure to environmental hazards while on active duty in the Persian Gulf. However, based on a careful review of the evidence of record, including the Veteran’s post-service medical records, the Board finds that the Veteran’s current symptoms are attributable to a known clinical diagnosis of diverticulitis. Therefore, service connection for diverticulitis cannot be established due an undiagnosed illness due to service in the Persian Gulf as the claimed disability is medically diagnosed. 38 C.F.R. § 3.317. The Board has also considered whether service connection for diverticulitis could be warranted on a direct basis. The Board has carefully considered the September 2019 opinion offered by Dr. E. However, while Dr. E. based the positive opinion on the presence of symptoms while the Veteran was on active duty, Dr. E. did not cite to any specific documentation of the claimed symptoms in service. Similarly, Dr. E. did not acknowledge that the Veteran indicated on Reports of Medical History dated in January 1995 and March 1997 that he did not experience frequent indigestion, stomach, or intestinal trouble. Therefore, the September 2019 letter from Dr. E. does not contain the reasoning necessary to support a grant of service connection, and it is outweighed by the other evidence of record. The only other evidence which provides any connection between the Veteran’s diverticulitis and service comes from the Veteran himself. It is to be noted that the Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran’s lay statements. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the specific issue in this case, whether diverticulitis was caused by active service, or is otherwise related to service, those issues fall outside the realm of common knowledge of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide such opinions. The Board finds the November 2020 VA examiner’s opinion to be more probative than the lay statements of record and more persuasive that the private opinion. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The opinion of the November 2020 VA examiner is highly probative because it is supported by detailed rationale and provided by a trained medical professional. The VA examiner specifically identified and discussed the Veteran’s contentions and theory concerning diverticulitis. The November 2020 VA examiner discussed risk factors for diverticulitis and provided an alternative etiology for the Veteran’s diverticulitis. Accordingly, the November 2020 VA opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Accordingly, after a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The preponderance of the evidence is against a finding of a causal connection between the Veteran’s service and diverticulitis or that diverticulitis was present during service. As the preponderance of the evidence is against the claim of entitlement to service connection for diverticulitis, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a psychiatric disability A service examination report from October 1991 found that the Veteran was psychiatrically normal. The Veteran’s January 1995 service separation physical found that he was psychiatrically normal. On a Report of Medical History completed in January 1995, the Veteran indicated that he experienced depression or excessive worry. The Veteran wrote that he was going through extensive personal troubles and was depressed and worried. On VA examination in May 2014, the examiner stated that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD. The examiner diagnosed adjustment disorder with depressed mood. The examiner stated that since the Veteran’s multiple colon surgeries in 2013, the Veteran had problems with depressed mood, reduced interest in activities, and lowered energy. The examiner opined that it was at least as likely as not that the Veteran’s adjustment disorder was cause by or a result of surgeries and physical health. Following careful review of the evidence of record, the Board finds the preponderance of the evidence is against the claim for service connection for a psychiatric disability. The only evidence which provides any connection between the Veteran’s psychiatric disability and service comes from the Veteran himself. It is to be noted that the Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran’s lay statements. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the specific issue in this case, whether a psychiatric disability was caused by active service, or is related to a non-service-connected cause, those issues fall outside the realm of common knowledge of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide such opinions, and no competent nexus opinions are of record. The Board finds the May 2014 VA examiner’s opinion to be more probative than the lay statements of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The opinion of the May 2014 VA examiner is highly probative because it is supported by detailed rationale and provided by a trained medical professional. The May 2020 VA examiner attributed the Veteran’s psychiatric disorder to a nonservice-connected cause, multiple colon surgeries. Accordingly, the May 2020 VA opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Accordingly, after a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The preponderance of the evidence is against a finding of a causal connection between the Veteran’s service and a psychiatric disability. While the Veteran complained of depression and worry at separation from service based on experiencing personal problems, he was found to be psychiatrically normal at separation from service. As the preponderance of the evidence is against the claim of entitlement to service connection for a psychiatric disability, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 4. Entitlement to a rating higher than 0 percent for left ear hearing loss Ratings of hearing loss range from 0 to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability for hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. In such cases, the Roman numeral value is determined using both Table VI and VIA and whichever table results in a higher Roman numeral value is used to calculate a rating using Table VII. 38 C.F.R. § 4.86. On VA examination in December 2014, pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG LEFT 15 20 25 80 35 The speech recognition score using the Maryland CNC test was 100 percent for the left ear. The Veteran reported that he had trouble understanding speech when there was competing noise if he did not see the speaker’s face or if the speaker was at a distance. On VA examination in November 2020, pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG LEFT 35 35 55 80 51 The speech recognition score using the Maryland CNC test was 84 percent for the left ear. The Veteran reported that he had trouble hearing conversations with background noise. As a preliminary matter, the Board observes that the pure tone thresholds recorded on the audiological examinations does not show an exceptional hearing impairment as defined by regulation, as the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is not 55 decibels or more, and the pure tone threshold is not 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. Thus, Table VIa is not for application. 38 C.F.R. § 4.86. Consequently, the Board will evaluate the Veteran’s hearing using Table VI. Applying the method for evaluating hearing loss to the results of the Veteran’s December 2014 audiological evaluation reveals Level I hearing in the left ear, based on application of the reported findings to Table VI. The nonservice-connected right ear is assigned Level I for rating purposes. 38 C.F.R. §§3.383, 4.85(f). Application of these findings to Table VII results in a 0 percent rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. Applying the method for evaluating hearing loss to the results of the Veteran’s November 2020 audiological evaluation reveals Level II hearing in the left ear, based on application of the reported findings to Table VI. The nonservice-connected right ear is assigned Level I for rating purposes. 38 C.F.R. §§ 3.383, 4.85(f). Application of these findings to Table VII results in a 0 percent rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, in this case, a lay opinion falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To the extent that the Veteran contends that his hearing loss is more severe than currently rated, while he is competent to report symptoms such as difficulty understanding speech, he is not competent to report that his hearing acuity is of sufficient severity to warrant a certain percentage rating because such an opinion requires medical expertise and training in evaluating hearing impairment, which he does not possess, and the use of audiometric equipment. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Based upon the results from the VA examinations, the Board finds that the criteria for a compensable disability rating for left ear hearing loss have not been met. 38 C.F.R. §§ 4.85, 4.86. The Board finds that the preponderance of the evidence is against the claim for increase and the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a left heel injury is remanded. 2. Entitlement to service connection for hypertension is remanded. 3. Entitlement to service connection for heart disease is remanded. 4. Entitlement to service connection for sleep apnea is remanded. In March 2020, the Board remanded the issues of entitlement to service connection for left heel, hypertension, heart disease, and sleep apnea disabilities to provide the Veteran with VA examinations to determine the nature of the claimed disabilities and their relationship, if any, to active service. The requested examinations were performed in November 2020. The examiner diagnosed bilateral plantar fasciitis, hypertension, coronary heart disease, atherosclerosis, and obstructive sleep apnea. The examiner opined that the disabilities were less likely than not incurred in or caused by service, essentially because there were no records which showed a left heel disability, hypertension, heart disease, or sleep apnea. The Board finds that the November 2020 VA examiner’s opinions are incomplete since the examiner relied on the absence of evidence in the service medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, further VA examination is required. When VA provides an examination, even if not required to do so, an adequate one must be provided. Barr v. Nicholson, 21 Vet. App. 303, (2007). The matters are REMANDED for the following action: 1. Obtain all VA treatment records not already associated with the claims file. All attempts to locate records must be documented in the claims file. 2. Schedule the Veteran for a VA examination to determine the etiology of claimed residuals of a left heel injury. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any residuals of a left heel injury had their onset in or are otherwise related to service. The examiner is requested to consider the Veteran’s report that he injured the left heel while on active duty. The examiner is further requested to consider the service medical record from April 1987 which indicates that the Veteran hit the heel of the right foot on concrete that morning and the Veteran’s indication on a January 1995 Report of Medical History completed at the conclusion of a period of active duty that he had foot trouble. The examiner is further requested to discuss the September 2019 letter from Dr. E. in which Dr. E. attributed the Veteran’s heel pain to bilateral calcaneal spurs. If it is determined that there is another more likely etiology for the Veteran’s left heel pain, that should be stated. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. The examiner must consider the Veteran’s statements and all lay statements regarding onset in service and statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). 3. Schedule the Veteran for a VA examination to determine the etiology of hypertension and heart disease. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any hypertension and heart disease had their onset in or are otherwise related to service, or whether any hypertension or heart disease manifested within one year following separation from service. If it is determined that there is another more likely etiology for hypertension and heart disease, that should be stated. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. The examiner must consider the Veteran’s statements and all lay statements regarding onset in service and statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). 4. Schedule the Veteran for a VA examination to determine the etiology of sleep apnea. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that sleep apnea had its onset in or is otherwise related to service. If it is determined that there is another more likely etiology for sleep apnea, that should be stated. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. The examiner must consider the Veteran’s statements and all lay statements regarding onset in service and statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, 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.