Citation Nr: 21028952 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-36 408 DATE: May 12, 2021 ORDER The claim of entitlement to service connection for a heart disorder is denied. The claim of entitlement to service connection for hypertension is denied. The claim of entitlement to service connection for obstructive sleep apnea is denied. The claim of entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus is denied. The claim of entitlement to an initial disability rating in excess of 40 percent for left lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is denied. The claim of entitlement to an initial disability rating in excess of 40 percent for right lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is denied. The claim of entitlement to an initial disability rating in excess of 20 percent for left lower extremity peripheral neuropathy of the femoral nerve is denied. The claim of entitlement to an initial disability rating in excess of 20 percent for right lower extremity peripheral neuropathy of the femoral nerve is denied. The claim of entitlement to a disability rating in excess of 10 percent for coccygectomy residuals with recurrent pilonidal cyst is denied. The claim of entitlement to a disability rating in excess of 10 percent for a painful scar of the coccyx area is denied. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period beginning on July 9, 2014, is granted, subject to the criteria applicable to the payment of monetary benefits. The claim of entitlement to an effective date prior to July 9, 2014, for the grant of service connection for left ear hearing loss is denied. REMANDED The claim of entitlement to right ear hearing loss is remanded. The claim of entitlement to service connection for bilateral cataracts is remanded. The claim of entitlement to a higher initial disability rating for PTSD, rated as 30 percent prior to October 14, 2013, and 50 percent thereafter, is remanded. The claim of entitlement to an initial compensable rating for left ear hearing loss is remanded. The claim of entitlement to a TDIU prior to July 9, 2014, is remanded. The claim of entitlement to an effective date prior to November 30, 2016, for the grant of service connection for left lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is remanded. The claim of entitlement to an effective date prior to November 30, 2016, for the grant of service connection for right lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is remanded. FINDINGS OF FACT 1. A heart disorder has not been present during the period of the claim. 2. The Veteran's hypertension disorder did not originate in service or within one year thereafter, is not etiologically related to service, and was not caused or aggravated by his service-connected diabetes mellitus. 3. The Veteran's sleep apnea did not originate in service, is not etiologically related to service, and was not caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). 4. Throughout the period on appeal, the Veteran's type II diabetes mellitus required insulin and a restricted diet, but not regulation of his activities. 5. Throughout the period on appeal, the Veteran had no more than moderately severe incomplete paralysis of the left sciatic nerve. 6. Throughout the period on appeal, the Veteran had no more than moderately severe incomplete paralysis of the right sciatic nerve. 7. Throughout the period on appeal, the Veteran had no more than moderate incomplete paralysis of the left femoral nerve. 8. Throughout the period on appeal, the Veteran had no more than moderate incomplete paralysis of the right femoral nerve. 9. Throughout the period on appeal, the Veteran's coccygectomy residuals with post-operative recurrent pilonidal cyst has been manifested by painful residuals. 10. The Veteran's coccyx area scar is approximately 7 centimeters long by 3 centimeters wide and painful; it is not unstable and it is not associated with underlying soft tissue damage with an area greater than 39 square centimeters. 11. Resolving all reasonable doubt in the Veteran's favor, the evidence of record demonstrates that his service-connected disabilities rendered him unable to obtain or maintain a substantially gainful occupation beginning on July 9, 2014. 12. The claim of entitlement to service connection for left ear hearing loss was not received prior to July 9, 2014. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for establishing entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for establishing entitlement to service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for a disability rating in excess of 20 percent for type II diabetes mellitus have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.119, Diagnostic Code 7913. 5. The criteria for a disability rating in excess of 40 percent for left peripheral neuropathy of the sciatic and common peroneal nerves have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Codes 8520 and 8521. 6. The criteria for a disability rating in excess of 40 percent for right peripheral neuropathy of the sciatic and common peroneal nerves have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Codes 8520 and 8521. 7. The criteria for a disability rating in excess of 20 percent for left peripheral neuropathy of the femoral have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Code 8526. 8. The criteria for a disability rating in excess of 20 percent for right peripheral neuropathy of the femoral have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Code 8526. 9. The criteria for a disability rating in excess of 10 percent for coccygectomy residuals with post-operative recurrent pilonidal cyst have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.71a, Diagnostic Code 5298. 10. The criteria for an initial disability rating in excess of 10 percent for painful coccyx area scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. 11. The criteria for establishing entitlement to TDIU benefits have been met for the period beginning on July 9, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 12. The criteria for entitlement to an effective date prior to July 9, 2014, for the grant of service connection for left ear hearing loss, have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service in the United States Navy from August 1968 to August 1972. In June 2018, the Board remanded this matter for additional development. While the case was in remand status, in a May 2020 rating decision, the AOJ granted a separate rating for bilateral lower extremity peripheral neuropathy of the femoral nerve as secondary to his diabetes mellitus. A 20 percent rating was assigned for each lower extremity, effective March 6, 2020. When a veteran seeks an increased rating, it is generally presumed that the maximum benefit allowed is sought, and a claim remains in controversy where less than the maximum benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Thus, the issues have been characterized accordingly. The Board recognizes that a 90-day extension request letter was received by the Board in April 2021 from the Veteran's attorney. However, there has been no specific allegation as to why an extension would be warranted in this case. Instead the Board has received a generic letter only without clarification. This letter indicated that the Veteran's attorney was waiting on additional medical evidence and opinions. However, none of these reported records or opinions were identified. Without any specific indication as to why an extension is warranted in this specific case the Board will not consider this request further. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease, injury, or event and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied, "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Entitlement to service connection for a heart disorder. The Veteran seeks service connection for a heart disorder. The Veteran's service treatment records are absent complaints of or treatment for a heart disorder. The Veteran underwent a VA examination in March 2020. The Veteran denied having a history of myocardial infarction, coronary artery disease, cardiac catheterization, stent placement, coronary bypass grafting, cardiac arrhythmias, valvular heart disease, and congestive heart failure. He also reported that he did not take any heart medication other than his hypertension medication. The physical examination revealed normal findings. The examiner determined that there was no pathology to render a diagnosis of the Veteran's heart disorder. The examiner noted that the Veteran's VA problem list did not include a heart disorder. Upon consideration of the evidence above, the Board finds that the preponderance of the evidence is against service connection for a heart disorder. The evidence demonstrates that the Veteran has not had a heart disorder at any point during the period of the claim. In this regard, the Board finds it highly probative that the VA examiner opined that the Veteran does not have a heart disorder based upon a thorough examination. There are no medical findings to the contrary. Accordingly, the Board finds that the weight of the evidence does not establish a diagnosis of a heart disorder at any time during the period on appeal. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To the extent that the Veteran contends that he has a diagnosis of a heart disorder, the Board finds that such opinion is more suited to the realm of medical, rather than lay, expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). There is no indication that the Veteran has had any specialized education, training, or experience in determining the diagnosis of heart disorders. Accordingly, his opinion as to the diagnosis of such is not competent medical evidence. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. Therefore, service connection for a heart disorder is denied. 2. Entitlement to service connection for hypertension. The Veteran seeks service connection for hypertension. The Veteran's service treatment records are absent for complaints of or treatment for hypertension. The Veteran's June 1972 separation examination showed that his blood pressure was 136/88. Post-service medical records include a January 1975 treatment record with a blood pressure reading of 136/74. Thereafter, treatment records showed blood pressure readings of 140/86 in December 1981, 130/90 in January 1982, and 144/104 in February 1982. A February 1983 VA treatment record noted that the Veteran was treated for hypertension a few years prior. The assessment was hypertension. The Veteran was afforded a VA examination in March 2020. The examiner confirmed a diagnosis of hypertension. The Veteran reported that he received a diagnosis of hypertension when he was 30 years old and that he received a diagnosis of diabetes mellitus in 2009 or 2010. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by service. The rationale was that the Veteran's blood pressure readings were normal at the time of separation from service and within a few years thereafter. The examiner also noted that there was no diagnosis of hypertension in the service treatment records. It was noted that a March 1989 private medical record indicated that the Veteran had a history of hypertension. The examiner also opined that the Veteran's hypertension was less likely than not caused or aggravated by his service-connected diabetes mellitus. The examiner explained that the Veteran's hypertension predated his diabetes mellitus. Moreover, the Veteran's hemoglobin A1c indicated that his diabetes mellitus is well controlled with his current regimen. Per medical literature, diabetes mellitus may cause or aggravate hypertension if there is a chronic kidney disorder due to diabetes mellitus. The Veteran's eGFR is 94.7, which indicates good kidney function. Therefore, the Veteran's diabetes mellitus and his other service-connected disorders do not impact his hypertension. Upon consideration of the evidence above, the Board finds that the preponderance of the evidence is against service connection for hypertension. Significantly, the only competent medical opinion of record was provided by the March 2020 VA examiner. The Board affords significant probative value to the opinions provided by the March 2020 VA examiner. The medical opinions were supported by adequate rationale, included a thorough review of the evidence, and discussed medical literature. Additionally, presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty or on the basis of continuity of symptomology is not warranted in this case. The evidence demonstrates that the Veteran's hypertension was diagnosed more than one year after the Veteran's discharge from service. 38 C.F.R. § 3.307 (a). Moreover, any allegation of a continuity of hypertension symptomatology since service is inconsistent with the evidence of record. As such, presumptive service connection, to include on the basis of continuity of symptomatology is not warranted for his hypertension. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. To the extent that the Veteran contends that his hypertension is related to service, the Board finds that such an opinion is more suited to the realm of medical, rather than lay, expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). There is no indication that the Veteran has had any specialized education, training, or experience in determining the etiology of hypertension. Accordingly, his opinion as to the diagnosis or etiology of his hypertension is not competent medical evidence. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. Therefore, service connection for hypertension is denied. 3. Entitlement to service connection for obstructive sleep apnea. The Veteran seeks service connection for obstructive sleep apnea. The Veteran's service treatment records are absent for complaints of or treatment for a sleep disorder. Post-service medical records include an October 2013 polysomnography report. The Veteran reported excessive daytime somnolence and had a body mass index of 31.09. The diagnosis was severe obstructive sleep apnea. The Veteran was afforded a VA examination in March 2020. The Veteran mentioned that he had a problem with sleep in service, but nothing was done at that time. The examiner noted that the Veteran's neck size is 18 inches. He was described as having a short and stout neck with excessive fatty tissue at his neck area. The examiner opined that the Veteran's sleep apnea was less likely than not incurred in or caused by service. The rationale was that there was no diagnosis of or treatment for sleep apnea during service. There were also no complaints of sleep disturbances, including snoring, during service. The examiner noted the Veteran's report that he was diagnosed with sleep apnea in 2010, which was almost 40 years after his separation from service. The examiner also opined that the Veteran's obstructive sleep apnea was less likely than not proximately due to or the result of his service-connected post-traumatic stress disorder (PTSD). The examiner highlighted the most important risk factors for sleep apnea, including advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. Medical conditions that increased the risk of sleep apnea included pregnancy, congestive heart failure, end-stage renal disease, chronic lung disease, stroke, acromegaly, hypothyroidism, and polycystic ovary syndrome. The examiner explained that sleep apnea is a common disorder in which people have one or more pauses in breathing or shallow breaths while sleeping. The most common type of sleep apnea is obstructive sleep apnea. With obstructive sleep apnea, the airway collapses or becomes blocked during sleep. Obstructive sleep apnea is more common in people who are overweight, but it can affect anyone. The examiner also provided examples of common physical characteristics of people with obstructive sleep apnea, such as when your tongue and tonsils are large compared with the opening into your windpipe. It was explained that the extra soft tissue can thicken the wall of the windpipe. The shape of the head and neck may cause a smaller airway size in the mouth and throat area. The examiner found that the Veteran's moderate obesity, 18-inch neck circumference, excessive soft tissue in his neck, and male gender were associated with a higher risk of sleep apnea. Additionally, the medical literature did not establish a relationship between sleep apnea and PTSD. Upon consideration of the evidence above, the Board finds that the preponderance of the evidence is against service connection for obstructive sleep apnea. Significantly, the only competent medical opinion of record was provided by the March 2020 VA examiner. The Board affords significant probative value to the opinions provided by the March 2020 VA examiner. The medical opinion was supported by adequate rationale, included a thorough review of the evidence, and discussed medical literature. To the extent that the Veteran contends that his obstructive sleep apnea is related to service, the Board finds that such an opinion is more suited to the realm of medical, rather than lay, expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). There is no indication that the Veteran has had any specialized education, training, or experience in determining the etiology of sleep disorders. Accordingly, his opinion as to the diagnosis or etiology of his obstructive sleep apnea disorder is not competent medical evidence. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 and Schafrath v. Derwinski, 1 Vet. App. at 589, the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities under appeal. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities under review. In addition, the Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). As such, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's claim. 4. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus. Under Diagnostic Code 7913, a 20 percent disability evaluation is assigned for diabetes mellitus requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet. A 40 percent disability evaluation is contemplated for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent disability evaluation is warranted for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is contemplated for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus progressive loss of weight and strength or complications that would be compensable if separately evaluated. The Court has held that, in order to demonstrate a regulation of activities, "medical evidence" is required to show that both occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The phrase "regulation of activities" means "avoidance of strenuous occupational and recreational activities." Camacho, 21 Vet. App. at 362 (quoting 38 C.F.R. § 4.119, Diagnostic Code 7913 (defining the term within the criteria for a 100 percent rating)). Successive rating criteria, such as Diagnostic Code 7913 for diabetes mellitus, is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). For example, the diagnostic code for diabetes mellitus (Diagnostic Code 7913) is successive because each higher evaluation requires the elements of the lower evaluation: the 10 percent evaluation requires a restricted diet; the 20 percent evaluation requires a restricted diet and insulin or oral hypoglycemic agent, the 40 percent evaluation requires insulin, restricted diet, and regulation of activities; and so forth. Camacho, 21 Vet. App. at 366. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a higher rating for type II diabetes mellitus. The evidence establishes that the Veteran's diabetes mellitus required insulin and a restricted diet, but not a regulation of his activities. The treatment records do not show that the Veteran had any medical need to avoid strenuous activity. The March 2020 VA examination report indicated that the Veteran did not require regulation of activities as part of medical management for his diabetes mellitus. Thus, the Board finds that the Veteran's type II diabetes mellitus has required insulin and a restricted diet, but not a regulation of activities. As stated in Camacho, the phrase "regulation of activities" means "avoidance of strenuous occupational and recreational activities." Here, the evidence of record simply does not show that Veteran's occupational and recreational activities had been restricted by any medical provider. Accordingly, the Board finds that the criteria for the next higher rating of 40 percent have not been met or approximated at any point during the appeal period. See 38 C.F.R. § 4.119, Diagnostic Code 7913. 5. Entitlement to a disability rating in excess of 20 percent for left lower extremity peripheral neuropathy of the femoral nerve. Please see discussion in paragraph 8. 6. Entitlement to a disability rating in excess of 20 percent for right lower extremity peripheral neuropathy of the femoral nerve. Please see discussion in paragraph 8. 7. Entitlement to a disability rating in excess of 40 percent for left lower extremity peripheral neuropathy of the sciatic and common peroneal nerves. Please see discussion in paragraph 8. 8. Entitlement to a disability rating in excess of 40 percent for right lower extremity peripheral neuropathy of the sciatic and common peroneal nerves. In a March 2017 rating decision, the AOJ granted service connection for the Veteran's bilateral lower extremity peripheral neuropathy involving the sciatic and common peroneal nerves as secondary to his service-connected coccygectomy with post-operative recurrent pilonidal cyst. In a May 2020 rating decision, the AOJ granted service connection for bilateral lower extremity peripheral neuropathy involving the femoral nerve as secondary to his service-connected diabetes mellitus. The Veteran's bilateral lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is currently rated pursuant to Diagnostic Code 8620 for neuritis of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8620. His bilateral lower extremity peripheral neuropathy of the femoral nerve is currently rated under Diagnostic Code 8626. 38 C.F.R. § 4.124a, Diagnostic Code 8626. Under Diagnostic Code 8520, mild incomplete paralysis of the sciatic nerve, as well as neuritis (Diagnostic Code 8620) and neuralgia (Diagnostic Code 8720) of that nerve, warrants a 10 percent rating. Moderate incomplete paralysis is assigned a 20 percent rating, and moderately severe incomplete paralysis is warranted for a 40 percent rating. Severe incomplete paralysis of the sciatic nerve with marked muscular atrophy warrants a 60 percent rating. With complete paralysis of the sciatic nerve, which warrants an 80 percent rating, the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. Under Diagnostic Code 8521, mild incomplete paralysis of the common peroneal nerve, as well as neuritis (Diagnostic Code 8621) and neuralgia (Diagnostic Code 8721) of that nerve, warrants a 10 percent rating. Moderate incomplete paralysis is assigned a 20 percent rating, and severe incomplete paralysis of the common peroneal nerve warrants a 30 percent rating. Complete paralysis of the common peroneal nerve, involving foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes, is assigned a 40 percent rating. Under Diagnostic Code 8526, mild incomplete paralysis of the femoral nerve, as well as neuritis (Diagnostic Code 8626) and neuralgia (Diagnostic Code 8726) of that nerve, warrants a 10 percent rating. Moderate incomplete paralysis is assigned a 20 percent rating, and severe incomplete paralysis of the femoral nerve warrants a 30 percent rating. Complete paralysis of the femoral nerve, involving paralysis of quadriceps extensor muscles, is assigned a 40 percent rating. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. 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 "severe" by VA examiners and others, although an element of 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. Neurological disorders are ordinarily to be rated in proportion to the impairment of motor, sensory, or mental function. In rating peripheral nerve injuries and their residuals, attention is given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to increased ratings for his bilateral lower extremity peripheral neuropathy of the sciatic, common peroneal, and femoral nerves. During A March 2017 VA peripheral nerves examination, the Veteran reported coccygeal pain, numbness, and neuralgia with radiation to the bilateral extremities. His pain was exacerbated by sitting or standing from a seated position. The examiner confirmed a diagnosis of coccygodynia and bilateral sciatic nerve damage secondary to coccyx pilonidal surgeries. His symptoms were moderate constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. The physical examination revealed full strength, no muscle atrophy, and hypoactive deep tendon reflexes of the knees and ankles. There was decreased sensation for light touch in the thighs/knees, lower leg/ankles, and feet/toes. The examiner noted trophic changes and an abnormal gait attributable to his peripheral neuropathy. The Veteran reported constant use of a cane for regular support. The examiner determined that the Veteran had moderately severe incomplete paralysis of the sciatic nerve and moderate incomplete paralysis of the common peroneal nerve. His peripheral neuropathy impacted his ability to work due to pain, tingling, and numbness. The Veteran was afforded another VA peripheral nerves examination in March 2020. The examiner diagnosed diabetic polyneuropathy of the bilateral lower extremities. He reported leg weakness, tingling, and numbness. He stated that he was unable to drive for short and long distances because of his peripheral neuropathy. The Veteran also had difficulty with prolonged walking and standing. His symptoms were moderate constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. Muscle strength was decreased in ankle dorsiflexion, deep tendon reflexes were decreased in the knees and ankles, light touch was decreased in the ankles/lower legs and feet/toes, vibration sensation was decreased, and cold sensation was decreased. The Veteran had trophic changes, described as dry, shiny, and hairless legs. He did not have muscle atrophy. The examiner determined that the Veteran had moderately severe incomplete paralysis of the sciatic nerve and moderate incomplete paralysis of the femoral nerve. The Veteran's bilateral lower extremity radiculopathy impacted his ability to work. The examiner stated that the Veteran was unable to lift, carry, or move heavy objects. He could not stand or walk for long periods or drive long or short distances. The Veteran is currently assigned a 40 percent rating for his bilateral lower extremity peripheral neuropathy of the sciatic and common peroneal nerves. This is the highest schedular rating available under Diagnostic Code 8521 for paralysis of the common peroneal nerve. He is also assigned a 20 percent rating for his bilateral lower extremity peripheral neuropathy of the femoral nerve. As to higher ratings under Diagnostic Code 8520 for the sciatic nerve and Diagnostic Code 8526 for the femoral nerve, the medical evidence does not show severe incomplete paralysis or complete paralysis. Instead, the evidence of record demonstrates that there was no muscular atrophy, no complete paralysis, no foot drop, and no paralysis of the quadriceps extensor muscles of the bilateral lower extremities. Accordingly, the weight of the evidence of record does not demonstrate manifestations consistent with severe incomplete paralysis or complete paralysis of the sciatic or femoral nerves during the appeal period. Based on the foregoing, the evidence shows that the Veteran has no more than moderately severe incomplete paralysis of the sciatic nerve and no more than moderate incomplete paralysis of the femoral nerve. Therefore, the Board finds that the preponderance of the evidence is against a finding that higher ratings are warranted for bilateral lower extremity peripheral neuropathy affecting the sciatic, common peroneal, and femoral nerves. 9. Entitlement to a disability rating in excess of 10 percent for coccygectomy residuals with post-operative recurrent pilonidal cyst. The Veteran's coccygectomy residuals with post-operative recurrent pilonidal cyst is rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5298 for removal of the coccyx. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Under Diagnostic Code 5298, a noncompensable disability rating is assigned for partial or complete removal of the coccyx, without painful residuals, and a maximum 10 percent evaluation is assigned for removal of the coccyx with painful residuals. 38 C.F.R. § 4.71a, Diagnostic Code 5298. The Board notes that the Veteran is rated at the highest schedular rating possible under Diagnostic Code 5298. Therefore, a rating in excess of 10 percent is not warranted on a schedular basis under Diagnostic Code 5298. The Board has considered whether any other pertinent Diagnostic Code was potentially applicable to the Veteran's coccygectomy residuals with recurrent pilonidal cyst. In this regard, the Veteran is separately rated for bilateral lower extremity peripheral neuropathy, a scar of the coccyx area, and post-operative ano-rectal canal displacement and stenosis, all secondary to his service-connected coccygectomy residuals. The Board has considered whether the case should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for each disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the pain associated with the Veteran's service-connected coccygectomy residuals with recurrent pilonidal cyst, is contemplated by the schedular criteria. There is no indication in the record that the average industrial impairment from the individual disability would be in excess of that contemplated by the assigned rating. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321 (b) is not in order. Accordingly, there is no higher schedular rating available for the Veteran's coccygectomy residuals with recurrent pilonidal cyst, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 10. Entitlement to an initial disability rating in excess of 10 percent for a painful scar of the coccyx area. The Veteran is assigned a 10 percent disability rating for his service-connected coccyx scar pursuant to Diagnostic Code 7804. Diagnostic Code 7801 indicates that for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), a 10 percent rating is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7801. Note (1) provides that a deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Id. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. Pursuant to Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. Id. A 20 percent rating is warranted for three to four scars that are unstable or painful, and a 30 percent rating is warranted for five or more scars that are unstable or painful. Id. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note (1). If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Id., Note (2). Scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an additional rating under Diagnostic Code 7804, when applicable. Id., Note (3). Under Diagnostic Code 7805, other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. Id. The Board notes that amendments were made to the criteria for rating the skin, effective August 13, 2018. See 83 Fed. Reg. 32, 592 (July 13, 2018). The amendments did not change the criteria for rating scars under Diagnostic Codes 7800 and 7804. With regard to Diagnostic Codes 7801 and 7802, the terms deep, nonlinear, and superficial, were replaced with "underlying soft tissue damage." The revisions also divided the previously referenced body parts into various zones of the body and indicated that separate evaluations may be assigned for each affected zone. The Veteran was afforded a VA examination in November 2012. The examiner diagnosed a well healed surgical scar with residual complaints of tenderness on palpation. The examiner described a painful linear scar in the coccyx region that measured 7.5 cm. The scar was not unstable with frequent loss of covering of the skin. The Veteran underwent another VA examination in March 2020. The Veteran reported that his scar worsened, especially with prolonged walking and standing. The scar measured 7 cm. x 3 cm. The examiner found the scar was associated with 10 square centimeters of underlying tissue damage. Based on a review of the evidence, the Board finds that a disability rating in excess of 10 percent is not warranted for the Veteran's coccyx area scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. The evidence does not show that the scar was greater than 39 square centimeters with associated underlying soft tissue damage, thus, a rating under Diagnostic Code 7801 is not appropriate. There is also no evidence that the scar was greater than 929 square centimeters, thus, a rating under Diagnostic Code 7802 is not appropriate. There is no indication that the scar is both painful and unstable, thus, the Veteran is not entitled to an additional 10 percent rating under Diagnostic Code 7804. With regard to Diagnostic Code 7805, the evidence of record does not indicate, and the Veteran does not contend, that there are any other disabling effects resulting from the coccyx area scar. Accordingly, the coccyx area scar is appropriately rated as noncompensable under Diagnostic Code 7805 and 10 percent disabling under Diagnostic Code 7804. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The claim of entitlement to an increased rating for the Veteran's painful coccyx area scar must be denied. 11. Entitlement to a TDIU for the period beginning on July 9, 2014. The Veteran contends that he is entitled to TDIU benefits. After reviewing the evidence of record, the Board finds that TDIU benefits are warranted for the period beginning on July 9, 2014. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A TDIU may be assigned when the schedular rating for service-connected disabilities is less than 100 percent when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, it is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. A finding of total disability is appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340 (a)(1), 4.15. "Substantially gainful employment" is that employment, "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16 (a). Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop). Id. In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Throughout the period on appeal, service connection has been in effect for PTSD, rated as 50 percent disabling; migraine headaches, rated as 50 percent disabling; bilateral peripheral neuropathy affecting the sciatic and common peroneal nerves, rated as 40 percent disabling for each lower extremity; diabetes mellitus, rated as 20 percent disabling; bilateral lower extremity femoral nerve peripheral neuropathy, rated as 20 percent disabling for each lower extremity; coccygectomy with post-operative recurrent pilonidal cyst, rated as 10 percent disabling; painful coccyx area scar, rated as 10 percent disabling; degenerative arthritis of the lumbar spine, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; post-operated ano-rectal canal displacement and stenosis, rated as noncompensable; coccyx area scar, rated as noncompensable; and left ear hearing loss, rated as noncompensable . In November 2012, the Veteran was afforded a VA examination to evaluate his coccygectomy residuals. The Veteran was limited to standing 15 to 30 minutes. The VA examination report indicated that the Veteran retired after thirty years of employment as a machinist. He was eligible for retirement by age or duration of work. It was noted that the Veteran's duties as a machine worker required him to sit, stand, and lift heavy 20-pound objects. In November 2012, the Veteran stated that the pain medicine used to treat his service-connected disorders slowed him down significantly and that the pain prevented him from doing many things. A June 2013 VA psychiatric examination report indicated that the Veteran retired in 2002 from his job where he worked packaging parts. At the time of the examination he worked as a parttime minister at a small church. In June 2013, the Veteran reported that his coworkers assisted him so that he could keep working until he qualified for retirement in 2002. He also completed seminary school in 1980. In January 2014, the Social Security Administration (SSA) concluded that the Veteran was disabled as a result of chronic pain syndrome, chronic abdominal pain, lumbar spine arthritis, fibromyalgia, and anxiety. The SSA noted that the Veteran's medical provider stated that his abdominal pain failed to significantly improve with ongoing conservative treatment. The August 2014 VA audiology examination report indicated that the Veteran's word recognition ability was poor at elevated conversational speech levels. His tinnitus did not impact ordinary conditions of daily life. A March 2015 headaches disability benefits questionnaire indicated that the Veteran treated his headache symptoms with Maxalt, morphine, Percocet, and Tylenol. His headache symptoms included sensitivity to sound, nausea, and sensitivity to light. The symptoms lasted one to two days and occurred three times per week. The physician noted that the Veteran's prostrating attacks of migraine headache pain occurred more frequently than once per month. His headache disorder impacted his ability to work due to nausea, tunnel/blurred vision, and trouble focusing. The physician concluded that the Veteran would not be able to sustain gainful employment and that he would need to leave the workplace early twice a week and would miss more than three days per week. It was also noted that the medications used to treat his headache disorder caused drowsiness, memory loss, and loss of concentration. A March 2017 VA peripheral nerves examination noted that his peripheral neuropathy pain was exacerbated by sitting or rising from sitting. A May 2019 VA examination report noted that his ano-rectal canal displacement caused recurring pain. His only symptom was recurring severe pain. The examiner explained that the severe pain was due to the amount of surgical procedures which caused adhesions, scarring, and recurrence. He treated his pain with Percocet taken three times per day. The examiner determined that the Veteran's disorder did not impact his ability to work. It was noted that he was able to drive to the appointment, walked without difficulty, had a normal gait, sat for 30 minutes without difficulty, and was able to stand and sit without apparent difficulty. A February 2020 VA audiology examination report documented the Veteran's complaints that his hearing loss interfered with communication. In March 2020, the Veteran was afforded a VA psychiatric examination. The examiner determined that his PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran reported lack of socialization, anxiety in public places, and difficulty communicating with others. He reported enjoyment in his church and learning new information on the computer. His daily activities involved being active, completing tasks, involvement with family activities, and spending time alone in his room. He was a pastor, attended Sunday church services, and participated in activities with other churches three to four times a year. The examiner found that the Veteran had moderate limitation in his ability to complete a normal workday without interruptions from psychological symptoms, to maintain attention and concentration for extended periods, to understand and remember detailed instructions, to carry out detailed instructions, to remember location and work-like procedures, and to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. He had mild limitation in his ability to perform activities within a schedule, to maintain regular attendance, to sustain an ordinary routine without special supervision, to interact appropriately with the general public, to work in coordination with or proximity to others without being distracted by them, to accept instruction and respond appropriately to criticism from supervisors, to understand and remember very short and simple instructions, to carry out and remember very short and simple instructions, to travel to unfamiliar places or use public transportation, and to respond to changes in the work setting. There was no limitation in his ability to set realistic work-related goals or make plans independently of others, to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, to make simple work-related decisions, to ask simple work-related questions, and to be aware of normal hazards and take appropriate precaution. A March 2020 VA back examination report noted that the Veteran used a cane when needed, typically with prolonged walking and standing. He reported difficulty kneeling, squatting, heavy lifting, and prolonged walking and standing. The examiner determined that his service-connected lumbar spine disorder impacted his ability to work. The examiner determined that the Veteran was unable to lift, carry, or move heavy objects. His back impacted his ability to walk or stand for prolonged periods and drive long distances. The examiner stated that the Veteran's lumbar spine disorder impacted his ability to perform physical and sedentary employment. In March 2020, the Veteran reported that his coccyx scar worsened with prolonged walking and standing. The examiner determined that the coccyx scar did not impact his ability to work. A March 2020 VA examination report indicated that the Veteran was prescribed oxycodone with acetaminophen for his ano-rectal stenosis. The examiner stated that the disorder did not impact his ability to work. A March 2020 VA peripheral nerves examination noted bilateral leg weakness, tingling, and numbness. He was unable to drive for short or long distances. He also had difficulty with prolonged walking and standing. The examiner determined that his disorder impacted his ability to work. He was unable to lift, carry, or move heavy objects. He also had difficulty with prolonged standing or walking. The examiner stated that the Veteran's bilateral lower extremity peripheral neuropathy impacted his ability to secure and maintain substantially gainful employment with any kind of occupational environment, including physical and sedentary employment. In February 2021, the Veteran reported that he was currently worked two hours per week as a pastor. He explained that his pay was rationed based on what the church could afford to pay him. He stated that there were times that he couldn't attend church service due to his service-connected disorders. He stated that he earned $1,200 over the past 12 months and that he was paid $300 in December 2020. The Veteran also reported that the church was very flexible and worked around his issues. Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that the service-connected disorders rendered him unable to maintain substantially gainful employment consistent with his education and occupational background for the period beginning on July 9, 2014. The Veteran was employed by an automobile manufacturer in the parts department from 1972 to August 2002. Thereafter, he was employed as a pastor, working between one and six hours per week and making no more than $500 per month. The Board finds that the Veteran's employment as a pastor is marginal in nature and does not constitute "substantially gainful employment." The VA examination reports indicated that his service-connected disorders significantly limited his physical activities. His service-connected disorders also impacted his ability to perform sedentary activities due to the side effects of medications used to treat his headache disorder and ano-rectal displacement. His PTSD also caused limitations in his ability to get along with coworkers or peers, maintain attention and concentration, and carry out detailed instructions. In sum, the Board is satisfied that the service-connected disabilities have been so severe as to render the Veteran unable to maintain any form of substantially gainful employment consistent with his education and occupational background. Accordingly, a TDIU for the period beginning on July 9, 2014, is warranted. Effective Date Generally, the effective date of an award based on an original claim for compensation benefits, if received more than one year after the claimant's discharge from service, shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i). The effective date, "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefore." 38 U.S.C. § 5110 (a). Effective March 24, 2015, a specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). Prior to March 24, 2015, a "claim" was defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-5 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). The essential elements for any claim, whether formal or informal, are: (1) an intent to apply for benefits; (2) an identification of the benefits sought; and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). 12. Entitlement to an effective date earlier than July 9, 2014, for the award of service connection for left ear hearing loss. On July 9, 2014, the RO received the Veteran's claim seeking entitlement to service connection for tinnitus. The AOJ inferred a claim of entitlement to service connection for hearing loss. In the September 2014 rating decision on appeal, the RO granted service connection for left ear hearing loss, effective July 9, 2014 The Board finds that July 9, 2014, is the proper effective date for the grant of entitlement to service connection for left ear hearing loss. The Veteran has not alleged that he filed a claim or had an informal communication asserting his entitlement to service connection for left ear hearing loss prior to July 9, 2014. 38 U.S.C. § 5101 (a); 38 C.F.R. §§ 3.1 (b), 3.151(a), 3.155. Accordingly, July 9, 2014, is the earliest effective date that can be assigned for the grant of entitlement to service connection for left ear hearing loss. As no earlier effective date is permitted by law, the benefit sought on appeal must be denied. REASONS FOR REMAND 1. The claim of entitlement to right ear hearing loss is remanded. The Veteran was afforded VA examinations in connection with his claim in August 2014 and February 2020. The VA examiners indicated that the Veteran's hearing was normal at all tested frequencies at the time of enlistment and separation. The examiners found that the service treatment records did not show any evidence of significant threshold shifts when comparing the enlistment and separation examinations. However, the absence of in-service evidence of a hearing disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Therefore, the Board finds that an additional medical opinion is needed in this case. 2. The claim of entitlement to service connection for bilateral cataracts is remanded. The Board notes that a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In June 2018, the Board remanded the claim and instructed the AOJ to obtain a VA medical opinion as to whether the Veteran's cataracts were caused or aggravated by his service-connected diabetes mellitus. Pursuant to the Board remand, a VA medical opinion was obtained in January 2021. The examiner stated that the Veteran's cataracts were nuclear, mild, and age appropriate. The examiner also stated that diabetics were more likely to get cortical cataracts. The examiner did not sufficiently address whether the Veteran's cataracts were caused or aggravated by his service-connected diabetes. Additionally, the examiner did not support the medical opinion with supporting rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). In this regard, the examiner did not provide a reason for his/her conclusion. Accordingly, a remand is required to obtain another VA medical opinion. 3. The claim of entitlement to a higher initial disability rating for PTSD, rated as 30 percent prior to October 14, 2013, and 50 percent, thereafter, is remanded. Pursuant to the June 2018 Board remand, the AOJ obtained outstanding treatment records from the Martinsburg Vet Center and a VA PTSD examination. Unfortunately, the January 2021 supplemental statement of the case (SSOC) addressed the issue of entitlement to a rating in excess of 30 percent for the period prior to October 14, 2013, but did not address the rating for the period beginning on October 14, 2013. To ensure due process, the Board finds that a remand is necessary for the issuance of an SSOC which specifically addresses entitlement to a higher rating for the entire period on appeal. See 38 C.F.R. § 19.31(c). 4. The claim of entitlement to an initial compensable rating for left ear hearing loss is remanded. The issue of entitlement to an initial compensable rating for left ear hearing loss is intertwined with the issue of entitlement to service connection for right ear hearing loss. Harris v. Derwinski, 1 Vet. App. 180 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Therefore, further consideration of the claim of entitlement to an initial compensable rating for left ear hearing loss must be deferred. 5. The claim of entitlement to a TDIU prior to July 9, 2014, is remanded. The schedular criteria for entitlement to a TDIU have not been met for the period prior to July 29, 2014. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § § 4.16 (b) (2018). Rating boards are required to submit to the Director, Compensation Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § § 4.16 (a). Where a veteran does not meet the schedular requirements of 38 C.F.R. § § 4.16 (a), the Board has no authority to assign a TDIU in the first instance and may only refer the claim to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § § 4.16 (b). The medical evidence indicates that his PTSD, coccygectomy residuals, and degenerative arthritis of the lumbar spine significantly limited the Veteran's ability to perform physical and sedentary employment. The March 2020 VA examiner stated that the Veteran's lumbar spine disorder impacted his ability to secure and maintain substantially gainful employment, including physical and sedentary employment. The Board finds referral to the Director, Compensation Services for extraschedular TDIU consideration is warranted. 38 C.F.R. § § 4.16 (b). 6. The claim of entitlement to an effective date prior to November 30, 2016, for the grant of service connection for left lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is remanded. Please see discussion in paragraph 7. 7. The claim of entitlement to an effective date prior to November 30, 2016, for the grant of service connection for right lower extremity peripheral neuropathy of the sciatic and common peroneal nerves is remanded. Generally, the effective date of an award based on an original claim for compensation benefits, if received more than one year after the claimant's discharge from service, shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i). The effective date, "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefore." 38 U.S.C. § 5110 (a). The general rule with respect to the effective date of an award of increased compensation is that the effective date of the award "shall not be earlier than the date of receipt of the application thereof." 38 U.S.C. § 5110 (a). This statutory provision is implemented by regulation that provides that the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (o)(1). An exception to that rule applies, however, under circumstances where the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. If an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." 38 U.S.C. § 5110 (b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400 (o)(1)(2); VAOPGCPREC 12-98 (1998). If the increase occurred more than one year prior to date of receipt of the claim, the increase is effective the date of receipt of the claim. If the increase occurred after the date of receipt of the claim, the effective date is the date of increase. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(1)(2). On September 10, 2012, the Veteran filed an informal claim for an increased rating for coccygectomy residuals. In a July 2013 rating decision, the AOJ denied his claim for an increased rating. The associated notification letter informed the Veteran that this was a provisional rating decision and that the AOJ would reconsider the decision if additional evidence was submitted. Thereafter, the AOJ reconsidered the decision in a March 2015 rating decision. The Veteran perfected an appeal as to the issue of entitlement to an increased rating for coccygectomy residuals. During the pendency of the appeal, in November 2016, the Veteran filed a claim of entitlement to service connection for sciatic nerve damage as secondary to his service-connected coccygectomy residuals. In March 2017, the AOJ granted service connection for bilateral lower extremity peripheral neuropathy of the sciatic nerve as secondary to the coccygectomy residuals. An effective date of November 30, 2016 was assigned. Service connection for bilateral lower extremity peripheral neuropathy of the sciatic nerve was granted as secondary to the Veteran's coccygectomy residuals during the course of the appeal for an increased rating for coccygectomy residuals, which was received on September 10, 2012. Thus, the grant of service connection for bilateral lower extremity peripheral neuropathy of the sciatic nerve is considered a component of the Veteran's September 2012 claim for an increased rating for the coccygectomy residuals. Accordingly, September 10, 2012, is the appropriate "date of claim". A September 2014 private treatment record noted worsening of his abdominal pain with pain radiation to the paraspinous region. The physician noted that his pain was managed by a pain management specialist, A.G., M.D., and that the office notes reflected lumbar pain with right lower extremity pain with paresthesias along the lateral aspect of the leg. The private medical records from Dr. G. at The Spine and Pain Center have not been obtained. Such records could shed light on when entitlement arose for service connection for bilateral lower extremity peripheral neuropathy of the sciatic and common peroneal nerves. It appears that the AOJ attempted to obtain the records from Dr. G. at the Spine and Pain Center, but the provider did not respond. However, the Veteran was not notified that that the AOJ was unable to obtain this evidence in accordance with 38 C.F.R. § 3.159 (e). Accordingly, a remand is required in order to comply with 38 C.F.R. § 3.159 (e) and to give the Veteran an opportunity to provide such records. The matters are REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims, to include private medical records from A.G., M.D. at The Spine and Pain Center. If the AOJ deems the records do not exist or that any additional attempts to obtain these records would be futile, the record should be annotated to reflect such and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). 2. Then, refer the claim to the Director, Compensation Service, for consideration of whether a TDIU on an extraschedular basis is warranted pursuant to 38 C.F.R. § § 4.16 (b). 3. The AOJ should refer the Veteran's claims file to a VA examiner with the appropriate training and expertise to determine the nature and etiology of his right ear hearing loss. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right ear hearing loss began in or are otherwise related to the Veteran's active duty service. The examiner is advised that the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. In rendering the opinion, the examiner should also discuss medically known or theoretical causes of hearing loss and describe how hearing loss which result from noise exposure generally present or develop in most cases, as distinguished from how hearing loss develop from other causes, in determining the likelihood that current right ear hearing loss was caused by noise exposure in service as opposed to some other cause. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. The AOJ should refer the Veteran's claims file to a VA examiner with the appropriate training and expertise to determine the nature and etiology of his bilateral cataracts. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's bilateral cataracts were caused or aggravated by his service-connected diabetes mellitus. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. McKinley, 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.