Citation Nr: 21028199 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-63 156 DATE: May 10, 2021 ORDER Entitlement to service connection for high blood pressure is dismissed. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. Entitlement to an initial rating in excess of 10 percent for right ankle degenerative joint disease (right ankle condition) is denied. Entitlement to an initial compensable rating for right ankle neurolemma, status-post excision biopsy (neurolemma), is denied. REMANDED In addition, the following issues are remanded to the agency of original jurisdiction (AOJ) for further action: Entitlement to service connection for testicle pain (also claimed as testicular injury; Entitlement to service connection for aching groin; Entitlement to service connection for enlarged prostate; Entitlement to service connection for erectile dysfunction; Entitlement to service connection for right ear hearing loss; Entitlement to an initial compensable rating for hearing loss of the left ear; and Entitlement to a total disability rating based on individual unemployability (TDIU). FINDINGS OF FACT 1. At the Veteran's hearing in January 2020, prior to the promulgation of a decision in the appeal, the Veteran asserted that a withdrawal of the claim for service connection for high blood pressure was requested. 2. The probative evidence of record demonstrates that the Veteran's PTSD is etiologically related to service. 3. The probative evidence of record does not establish that during the period on appeal, the Veteran's right ankle manifested in marked limitation in his range of motion. 4. The probative evidence of record demonstrates that the Veteran's neurolemma of the right ankle does not manifest in individual symptomology sufficient to warrant a separate compensable rating. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim for service connection for high blood pressure have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for entitlement to an initial rating in excess of 10 percent for a right ankle condition are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 4. The criteria for an initial noncompensable rating for a neurolemma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.124a, Diagnostic Code 8799-8725. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Marines from March 1983 to March 1987. The Veteran's claims on appeal arrive at the Board of Veterans Appeals (Board) from four different rating decisions and appeal streams. The February 2013 rating granted service connection for the right ankle disabilities and the Veteran appealed the initial ratings. The October 2012 rating decision denied claims of service connection for enlarged prostate, erectile dysfunction, testicular pain, groin pain, hearing loss, and hypertension. The Veteran timely appealed these denials. The May 2014 rating decision denied service connection for a psychiatric disability. the Veteran also timely appealed this denial. The June 2018 rating decision denied TDIU, and the Veteran timely appealed. The Veteran appeared and testified at a hearing before the undersigned Veteran's Law Judge (VLJ) in January 2020. A transcript of the hearing is associated with the record. At that time, the undersigned took account of all outstanding hearing requests that were pending. Thus, there are no outstanding hearing requests. At the hearing, the representative stated that the Veteran's ankle scar was on appeal. However, the claim was not appealed to the Board and the Board will not address it. The Veteran submitted a notice of disagreement on it, and a statement of the case was issued. However, the Veteran's November 2017 VA Form 9, substantive appeal, specifically limited the issues to those listed above. After the hearing, the Veteran submitted a private medical opinion. As the evidence relates to a grant of benefits herein, there is no prejudice to the Veteran for the Board to consider the evidence in the first instance. Withdrawn Claim 1. Entitlement to service connection for high blood pressure is dismissed The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the Veteran, through his authorized representative, stated at the hearing that he wished to withdraw the issue of service connection for high blood pressure. An oral withdrawal of an appeal, such as one made at a hearing, must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); see Acree v. O'Rourke, 891 F.3d 1009, 1014 (Fed. Cir. 2018) (the Board must address all three prongs of the DeLisio standard when it applies). The Board has considered the oral withdrawal and finds that it meets the standard: although the Veteran did not state himself that he was withdrawing the claim, his attorney representative was present at the hearing when the undersigned asked if the claim was being withdrawn and the Veteran did not object to the withdrawal. As the Veteran is represented, the Board infers that the withdrawal was done with the full understanding of the consequences of such action on the part of the Veteran. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal of this issue, and it is dismissed. Service Connection 2. Entitlement to service connection for PTSD The Veteran contends that he has a diagnosis of PTSD that is etiologically related to military service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In addition to the direct method of service connection, there are specific additional criteria to establish service connection for PTSD: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). While the stressor must be corroborated under certain circumstances, if the criteria in 38 C.F.R. § 3.304 (f)(3) are met, corroboration is not required: 1) the claimed stressor is related to fear of hostile military or terrorist activity; 2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; 3) the Veteran's symptoms are related to the claimed stressor; 4) a VA (or VA-contracted) psychiatrist/psychologist confirms the stressor is adequate to support a PTSD diagnosis (see Nat'l Org. of Veterans' Advocates v. Sec'y of Veterans Affairs, 669 F.3d 1340 (Fed. Cir. 2012)); and 5) there is no clear and convincing evidence to the contrary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The AOJ denied the Veteran's claim because he did not have a diagnosis of PTSD that was based on a corroborated stressor, as required in order to grant benefits. Turning first to the diagnosis of PTSD, the Veteran submitted a private opinion from J. A., M.A., a licensed mental health professional. After reviewing the Veteran's file and interviewing the Veteran, J.A. diagnosed the Veteran with PTSD, "second to stressors in the military." See Third Party Correspondence, received February 27, 2017. The Board gives the opinion great probative weight because it is based on a review of the file, an interview with the Veteran, and the clinician has the expertise to make such a determination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, it is supported by the September 2018 VA examination and February 2020 private opinion that diagnose "other specified trauma and stressor related disorder" which the February 2020 opinion describes as a "subthreshold of PTSD." Therefore, the Board finds that the first element of service connection, a diagnosis of PTSD, is met. Shedden, supra. Turning next to whether a stressor is corroborated, the Veteran claims two stressors: one involved a deployment to Beirut wherein he was in a hostile environment soon after the Beirut bombing; and the second involved the physical altercation and possible slaying of an individual in Israel. See document labeled VA examination, received February 14, 2020. As to the first, the record contains the command history for the USS Nassau, the naval ship on which the Veteran was stationed. See Third Party Correspondence, received March 20, 2019. In this history, it corroborates that the Veteran's command was sent to Beirut. Other statements of record detail the Veteran's experiences there, which comport with a hostile situation. Therefore, the second element of service connection, an in-service event/stressor, has been met. The Board will not address the second incident as it involves international relations. Turning to the third element, the February 2017 and February 2020 private opinions find that it is at least as likely as not the Veteran's PTSD is related to his stressor. Thus, the third element is met. While the Board finds that the stressor is confirmed, the Board also finds that if it wasn't, the opinions of record substantiate that the criteria in 38 C.F.R. § 3.304 (f)(3) are met and corroboration would not be required. Therefore, the Board finds that the criteria for service connection for the Veteran's PTSD are met. Thus, the claim is granted. Absent a relative balance of the evidence for and against the claim, the evidence is not in equipoise and the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating The Veteran contends that his right ankle and neurolemma conditions warrant higher initial ratings. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). Here, the Board finds that the ratings have been consistent through the period at issue. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 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 limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In addition to the general criteria for increased ratings claims, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Further, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Right ankle The Veteran's right ankle disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Ratings under this code are available at 10 percent for moderate limited motion and 20 percent for marked limited motion. The terms "moderate" and "marked" are not defined under VA regulations as in effect at the time of this claim. Those terms also do not appear to have a generally accepted medical definition. 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 terminology such as "moderate" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. During the pendency of this appeal, however, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020), effective from February 7, 2021. Diagnostic Code 5271 was affected by this change and the terms marked and moderate were given range of motion limitations. Marked means less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Moderate means less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. Alternative and additional Diagnostic Codes for the ankle are available under 38 C.F.R. § 4.71a, as follows: Under Diagnostic Code 5270, ankylosis of the ankle in plantar flexion less than 30 degrees is rated at 20 percent; ankylosis in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 and 10 degrees is rated at 30 percent; and ankylosis in plantar flexion at more than 40 degrees, in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion, or eversion deformity is rated at 40 percent. Under Diagnostic Code 5272, ankylosis of the subastragalar or tarsal joint is rated at 10 percent for ankylosis in good weight-bearing position and at 20 percent for ankylosis in poor weight-bearing position. Under Diagnostic Code 5273, malunion of the os calcis or astragalus is rated at 10 percent for moderate deformity and 20 percent for marked deformity. Under Diagnostic Code 5274, astragalectomy is rated at 20 percent. Evidence The Board finds the most probative evidence of record to be the VA examinations of record. The examiners have the medical expertise to assess objective limitations from the Veteran's service-connected disability. Further, the Board finds that the concurrent medical records to not contain any range of motion measurements or reports of flare-ups or functional loss. Thus, the Board gives the VA examinations great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's lay statements are consistent with the findings of the VA examinations. The Veteran's first VA examination was in November 2012. The Veteran reported intermittent pain in his right foot with activities, that the pain was alleviated by rest and medication, and he considered the pain a flare-up. Upon range of motion testing, the range of motion of the Veteran's ankle was within normal limits, without evidence of painful motion. The examination was entirely within normal limits except that pain was noted on movement and upon palpation. The Veteran had bilateral arthritis of the ankles. The Veteran's second VA examination was in February 2017. The Veteran reported he could not run or climb ladders. He did not report flare-ups. Upon range of motion testing, his dorsiflexion was limited to 10 degrees and plantar flexion was limited to 40 degrees. The Veteran had pain with weightbearing. The remainder of the examination was within normal limits. The Veteran testified that his right ankle feels unstable and he has the sensation of numbness and sometimes falls because of it. He also testified that while he has radiculopathy of the bilateral lower extremities, his right leg is worse and he often falls to the right. However, the Veteran did not report these symptoms to the examiners and there is no treatment specifically for the ankle for instability and falls. Analysis The Board finds that the Veteran's right ankle disability, which has been manifested by painful motion and flare ups, does not more nearly approximate the rating criteria for the maximum limitation of motion rating of 20 percent, corresponding to marked limitation of motion under Diagnostic Code 5271. The Board notes that normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Further, the regulatory changes provide measurements for the required range of motion lost for a marked limitation of motion: less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion. At most, the range of motion of the Veteran's right ankle has manifested in dorsiflexion at 0-10 degrees and plantar flexion at 0-40 degrees, with pain during both motions, and pain on weight bearing Notwithstanding the above, the Board has also considered other potentially applicable Diagnostic Codes that may provide a basis for higher evaluations for the right ankle. The range of motion findings exhibited by the Veteran are inconsistent with a finding of ankylosis, or "immobility and consolidation." Accordingly, the Board finds that the provisions of Diagnostic Code 5270 pertaining to ankylosis are not for application. Since ankylosis has not been shown, the provisions of Diagnostic 5272, which govern ankylosis of the subastragalar or tarsal joint, are likewise not applicable to the current claim. Additionally, with regard to Diagnostic Code 5273, malunion of the os calcis or astragalus has not been demonstrated. Regarding Diagnostic Code 5274, the medical evidence is without complaints of or treatment for an astragalectomy of the ankle, which involves removal of the ankle bone. As such, a rating under this provision is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5274. Furthermore, there is no evidence of record indicating that the Veteran has neurological manifestations related to his ankle disability. While the Veteran testified to ankle instability, the remainder of the record does not indicate instability. As such, the Board declines to find additional functional loss due to instability. Additionally, there is no other potentially applicable Diagnostic Code that would provide a basis for a higher evaluation of the Veteran's right ankle disability. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The examiner's considered the Veteran's complaints and the evidence does not show that even during flare-ups, the Veteran's range of motion or symptomology would approximate a greater degree of range of motion lost. While the Veteran reported pain and some functional loss, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Despite the Veteran's contention of a greater degree of limitation on his ankle condition, the disability rating assigned herein indicates a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for his right ankle condition. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Neurolemma The Veteran's neurolemma disability has been rated as noncompensable under Diagnostic Code 8799-8725: neuralgia of the posterior tibial nerve. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition. For the following reasons, the Board finds that Diagnostic Code 8725 is the most appropriate diagnostic code under which to rate the Veteran's disability, and there is no other diagnostic code that would be appropriate in the evaluation of his neurolemma disability or result in a separate or higher rating. Under Diagnostic Code 8725, complete paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; and impaired plantar flexion warrants a 30 percent rating. A 20 percent rating is warranted for severe incomplete paralysis. A 10 percent rating is warranted for both moderate and mild ratings. In every instance where the schedule does not provide a noncompensable (zero) percent evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Thus, the AOJ assigned an initial noncompensable rating because mild incomplete paralysis was not shown. Evidence The Board finds the most probative evidence of record to be the VA examinations of record. The examiners have the medical expertise to assess objective limitations from the Veteran's service-connected disability. Further, the Board finds that while the concurrent medical records contain reports of pain, they do not address the differentiation of symptoms which is critical to the determination of the propriety of a separate compensable rating. Thus, the Board gives the VA examinations great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's lay statements are consistent with the findings of the VA examinations. The Veteran has had three examinations which address the symptoms of his neurolemma, but none of the examinations were solely dedicated to the neurolemma. Rather, the Board must deduce the Veteran's symptoms by contrasting them with the other examinations of record to determine what the symptoms of the neurolemma are alone. The first was in November 2012, an examination for the Veteran's right ankle and neurolemma. The Veteran reported that he had a neurolemma removed in January 2007, with some relief after the procedure. He had intermittent pain at the right foot with activities, which the Veteran described as a flare-up. While many of the findings related to the Veteran's right ankle are described above, pertinent to the Veteran's neurolemma, the Veteran had tenderness and pain upon movement and palpation. These symptoms are accounted for in the right ankle rating above. The second examination was in February 2017, which addressed radiculopathy of the bilateral lower extremities and the neurolemma. (The claim for radiculopathy is not on appeal). Other than an abnormal gait, which the examiner found to be related to the Veteran's "right ankle condition," no specific neurological deficiencies were related to the Veteran's neurolemma. The examiner also found that the tibial nerve (the Diagnostic Code under which the neurolemma is rated), did not manifest in any paralysis. The Veteran also had an ankle examination in February 2017, but the Veteran's symptomology is similar to the November 2012 examination. The Veteran had another examination in April 2018 that addressed his radiculopathy conditions. This time, the abnormal gait was related to the Veteran's radiculopathy conditions. The tibial nerve again did not manifest in any paralysis. The Board has considered the Veteran's treatment records. The Veteran generally reported pain and neurological conditions related to his right ankle, but these were not separated out from other complaints related to his service-connected right ankle and/or separate radiculopathy conditions. The earliest record the Board can locate addressing neurological symptoms of the Veteran's neurolemma condition comes in October 2013 wherein the Veteran reported "post-operative numbness and burning." However, the Veteran was service-connected for radiculopathy of the bilateral lower extremities at that time and the symptomology was considered in that rating. Analysis In consideration of the above, the finds that an initial compensable rating for the Veteran's neurolemma condition has not been met. To warrant a higher rating, the condition would have to manifest in some mild degree of incomplete paralysis of the following symptoms: paralysis of the muscles of sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; and plantar flexion is impaired. At most, the Board finds that the Veteran has flare-ups of pain at the right foot with activities. However, as described in the right ankle section above, this painful movement was considered in the assignment of the rating for that disability. Further, while the Veteran reported some neurological manifestations and/or instability, this is not supported as separate symptomology apart from his other service-connected conditions. Importantly, pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. Here, the probative evidence of record does not indicate any independent symptomology related to the Veteran's neurolemma. Therefore, to assign a compensable rating for the neurolemma disability would violate the rule against pyramiding. Despite the Veteran's contention of a greater degree of limitation from his neurolemma condition, the probative evidence of record does not indicate the Veteran's symptoms warrant a separate, compensable rating. The critical question in this case is whether the problems he has cited meet a higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a compensable rating for his neurolemma condition. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 5. Entitlement to service connection for testicle pain (also claimed as testicular injury is remanded. 6. Entitlement to service connection for aching groin is remanded. 7. Entitlement to service connection for enlarged prostate is remanded. 8. Entitlement to service connection for erectile dysfunction is remanded. The Veteran contends that he has lower abdomen issues that are etiologically related to service. While the Veteran has various complaints related to these issues in his VA medical records, the Board finds the only comprehensive diagnosis for complaints related to the location of these pains to be ilioinguinal nerve neuritis. The Veteran, through his own lay statements and "buddy letters", has contended that he developed pain in service, which has continued to the present. The pain is located at his lower abdomen, groin, and upper thigh. The Veteran testified that he believes the pain is related to heavy work he did during service. Alternatively, he contends it is related to contaminated drinking water on the USS Nassau, contaminated water at Camp LeJeune, or secondary to his service-connected back disability. See VA 21-4138 Statement in Support of Claim, received November 13, 2012; Third Party Correspondence, received December 12, 2013; and four letters marked Buddy/Lay Statement, received January 9, 2017. A VA examination is necessary prior to final adjudication of a claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifested during an applicable presumption period for which the veteran qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence of record for VA to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Board finds the criteria are met. As such, the Board finds that a remand for an examination and opinion is warranted in this case. 9. Entitlement to service connection for right ear hearing loss is remanded. 10. Entitlement to an initial compensable rating for hearing loss of the left ear is remanded. The Veteran was last afforded a VA audiological examination in February 2017. However, during the January 2020 Board hearing the Veteran testified that his hearing loss has increased in severity since the June 2018 VA examination, which indicates a worsening of the disability. The Veteran is not service-connected for hearing loss of the right ear because his hearing loss does not meet VA's definition of a disability. Further, the Veteran's left ear is rated as noncompensable. Thus, the claims must be remanded, and the Veteran should be afforded a new VA examination to determine the current severity of his service-connected bilateral hearing loss. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). 11. Entitlement to a TDIU is remanded. Because a decision on the remanded issues of service connection and initial ratings could significantly impact a decision on the issue entitlement to a TDIU, the issues are inextricably intertwined. Thus, a remand of the claim for a TDIU is required. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records from April 2019 to the present. 2. Thereafter, schedule the Veteran with a clinician of appropriate knowledge and training to address the diagnosis, nature, and etiology of the Veteran's claimed disorders related to his groin. The clinician should answer the following questions: (a) What, if any, diagnoses related to the Veteran's groin has the Veteran had during the pendency of the proceeding (since October 2011), to include ilioinguinal nerve neuritis, testicle pain, aching groin, enlarged prostate, and/or erectile dysfunction? (b) Are any of the diagnoses at least as likely as not related to service, to include the following asserted in-service events: heavy work he did during service and/or related to contaminated drinking water on the USS Nassau? (c) Are any of the diagnoses caused or aggravated by the Veteran's service-connected lumbar spine degenerative joint disease and intervertebral disc syndrome. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. (d) Are any of the diagnoses at least at likely as not related to contaminants in the water during service at Camp Lejeune? The examiner is advised that a negative opinion cannot be based solely on the fact that the disabilities are not on the list of diseases that are presumptively associated with exposure to contaminants in the water supply at Camp Lejeune. (e) If any one of the diagnoses are found to be at least as likely as not related to service (by any of the above listed means), is it at least as likely as not that the other diagnoses are related to the now service-connected condition? (example: erectile dysfunction is caused/aggravated by ilioinguinal nerve neuritis)? 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 4. Thereafter, readjudicate the Veteran's claims, to include the inextricably intertwined claim of entitlement to a TDIU. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. M. Hitchcock 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.