Citation Nr: 21032322 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 19-34 972 DATE: May 26, 2021 ORDER 1. New and material evidence has not been received to reopen the previously denied claim of entitlement to service connection for a bilateral hearing loss disability; therefore, the application to reopen is denied. 2. New and material evidence having been received, the application to reopen the claim for service connection for tinnitus is granted. The appeal is granted to this extent only. 3. The reopened claim of entitlement to service connection for tinnitus is denied. 4. Entitlement to a compensable disability rating for scar of the anterior chest is denied. REMANDED 5. Entitlement to a disability rating in excess of 30 percent for ischemic heart disease (IHD) is remanded. 6. Entitlement to service connection for left lower extremity peripheral neuropathy, is remanded. 7. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. 8. Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran did not appeal the October 2015 rating decision that denied the claim for service connection for bilateral hearing loss disability based on there being no nexus between the current disability and service; and no new and material evidence was received during the one year appeal period. 2. Evidence received since the October 2015 rating decision that denied the claim for service connection for a bilateral hearing loss disability does not relate to an unestablished fact necessary to substantiate the claim for service connection for a bilateral hearing loss disability. 3. The Veteran did not appeal the October 2015 rating decision that denied the claim for service connection for tinnitus based on there being no nexus between the current disability and service; and no new and material evidence was received during the one year appeal period. 4. Evidence received since the October 2015 rating decision that denied the claim for service connection for tinnitus, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim for service connection for a tinnitus and raises a reasonable possibility of substantiating the claim. 5. The Veteran's current tinnitus did not have its onset in service, it did not manifest within one year following service discharge, and is not otherwise related to service. 6. The Veteran's anterior chest scar has not been shown to be unstable or painful, at least 6 square (sq.) inches (39 sq. centimeters) in size, or otherwise disabling. CONCLUSIONS OF LAW 1. The October 2015 rating decision rating decision denying service connection for bilateral hearing loss disability is final. New and material evidence has not been received to reopen the claim for service connection for bilateral hearing loss disability. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 2. The October 2015 rating decision that denied the claim of entitlement to service connection for tinnitus is final. As evidence received since the October 2015 rating decision is new and material, the criteria for reopening the claim of entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for an initial compensable evaluation for scar of the anterior chest have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.114, 4.118, Diagnostic Codes 7801-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to July 1969, with additional reserve duty. In January 2021, the Veteran provided testimony in a virtual Board hearing before undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. The Veteran's representative requested additional time to submit a post-hearing memorandum and additional evidence. The undersigned VLJ informed the Veteran and his representative that the record would be left open for 60 days, until March 30, 2021, for the Veteran and/or his representative to submit any additional evidence. In March 2021, the Veteran's representative submitted a post hearing memorandum and a February 2021 report from a private physician. As neither the Veteran nor his representative requested a subsequent extension to submit records, the Board will proceed with adjudication below. Additionally, in a December 2020 letter from the Veteran's representative, she wrote that VA relied on VA examinations in connection with the appeal and that she was unable to determine from the record the qualifications of the examiners. At the January 2021 hearing, the undersigned discussed the facts addressed in this letter with the Veteran and his representative. The Veteran, through his representative, agreed that there were three examinations that related to the current claims on appeal. The undersigned noted that two of the examinations performed in connection with the Veteran's claim for an increased rating for ischemic heart disease were performed by medical doctors/physicians, and the audiology examination performed in connection with the Veteran's claims for service connection for bilateral hearing loss disability and tinnitus was performed by an audiologist. The undersigned explained that the examiners' curricula vitae were not at the Board and it would have to remand the claims to get them. The representative stated she did not want to delay the appeal and agreed she would go through the examinations after the hearing and if she and/or the Veteran had concerns or a problem with the examination report(s), she would address it in a post-hearing memorandum. See Transcript on pages 2-3. The post hearing memorandum was received in March 2021. In the memorandum, the representative wrote that the attached medical opinion she was submitting should be accepted over the VA examiners' opinions "whose qualifications are unknown." The Board finds that such statement is not a challenge to the competency of the examiners, but rather an assertion that (1) the opinion being submitted is more probative and/or (2) the relevant examinations may be inadequate. The Board will address these assertions within the decision. Thus, a remand for VA to provide the Veteran and/or his representative the qualifications of the examiners, who performed the three examinations, is not warranted. A claim for a TDIU rating had been reasonably raised by the record in conjunction with the increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Specifically, the Veteran's representative has contended that the Veteran is totally disabled and was unable to secure or follow a substantially gainful occupation as the result of the service-connected disabilities on appeal. See March 2021 post-hearing memorandum and February 2021 private physician's report. Thus, the claim of entitlement to a TDIU rating is before the Board. New and Material Evidence Prior unappealed decisions of the Regional Office (RO) are final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.160(d), 20.302(a), 20.1103. The Board does not have jurisdiction to consider a claim that has become final before it determines that new and material evidence has been presented, irrespective of what the regional office may have determined with respect to new and material evidence. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). If, however, new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. An appeal consists of a timely filed Notice of Disagreement (NOD), and after a Statement of the Case (SOC) has been furnished, a timely filed Substantive Appeal. 38 C.F.R. § 20.200. A Substantive Appeal consists of a properly completed VA Form 9 (Appeal to the Board of Veterans' Appeals) or correspondence containing the necessary information. 38 C.F.R. § 20.202. As a general rule, a substantive appeal must be filed within 60 days of the mailing of the SOC or within one year of the notice of the decision being appealed, whichever is later. 38 U.S.C. § 7105(d)(1); 38 C.F.R. § 20.302(b). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. New and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof; the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 1. Whether new and material evidence has been received to reopen the previously denied claim for service connection for a bilateral hearing loss disability. Entitlement to service connection for a bilateral hearing loss disability was denied in a March 2015 rating decision. In July 2015, the Veteran requested reconsideration of the claim and a subsequent October 2015 rating decision confirmed the previous denial of the claim. The Veteran was notified of the denial and his appellate rights. In the one-year appeal period that followed, the Veteran submitted neither a notice of disagreement nor any additional evidence. This rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The October 2015 rating decision denied service connection for a bilateral hearing loss disability on the basis that there was no medical link between the Veteran's bilateral hearing loss disability and military service and that there was no evidence that hearing loss manifested to a compensable degree within one year of service. Since the October 2015 rating decision, a February 2018 VA examination for hearing loss and tinnitus (contracted Disability Benefits Questionnaire (DBQ)) has been performed and the report was associated with the file. The February 2018 audiologist opined that the Veteran's bilateral hearing loss disability was not as likely as not (50 percent probability or greater) caused by or a result of an event in military service. The audiologist noted the Veteran's military occupational specialty (MOS) of infantry conceded noise exposure and that the Veteran reported military noise exposure from duty in Korea on the Demilitarized Zone (DMZ), artillery, mortars, machine guns, and firefights nightly. The examiner indicated that the Veteran's hearing thresholds at entrance examination in October 1967 and separation examination on June 1969 were within normal limits without significant threshold shifts. After considering the Veteran's in-service noise exposure and the American College of Occupational Medicine Noise and Hearing Conservation Committee finding that, "a noise induced hearing loss will not progress once it is stopped," the examiner concluded that it is less likely than not that the Veteran's hearing loss was caused by such military noise exposure. The February 2018 examiner's opinion is consistent with the opinion offered by the VA examiner in January 2015, which was considered in the October 2015 rating decision. Additionally, a December 2014 VA audiology consultation was associated with the record, which reflects the Veteran's chief complaint of gradual decreased hearing bilaterally. There is no etiology opinion offered in this consultation record. During the January 2021 Board hearing, the Veteran testified to noise exposure from firefights at the DMZ in service and training for the reserves in 1970. Subsequently, in March 2021, the Veteran's representative proffered a post hearing memorandum with a report from a private Orthopaedic surgeon, Dr. Frank Graf, that she proports to opine that it is at least as likely as not that the Veteran's tinnitus and hearing loss are service-connected. Dr. Graf noted that in 1970, the Veteran went to a training camp for the reserves, and the Veteran described being exposed to an exploding device followed by as much as two hours of not being able to hear. Dr. Graf indicated that the problems of tinnitus and hearing loss requiring sensory neural hearing aids was documented in the Veteran's medical records, however, Dr. Graf does not directly provide an opinion of a causal connection between the Veteran's in-service noise exposure and his current hearing loss disability or that it manifested within one year of service discharge. The Board has considered the allegation by the Veteran's representative in the post-hearing memorandum that Dr. Graf's report must be accepted over the VA examiner's because their qualifications are unknown. Initially, as stated above, the Board finds that the statement that the examiner's "qualifications are unknown" is not a challenge to the competency of the audiologist, but rather an allegation that the examination may not be adequate. The Board finds that VA has satisfied its duty to assist when it provided medical examinations performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or physician's assistant. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). The Board may assume a that VA medical examiner is competent. See Cox, 20 Vet. App. at 569; Hilkert v. West, 12 Vet. App. 145, 151 (1999) (VA may presume the competence of an examiner, and an appellant bears the burden of persuasion to show that the Board's reliance on an examiner's opinion was in error). The February 2018 opinion was provided by state-licensed audiologist who performed an audiological examination, reviewed the Veteran's claims file, and provided an opinion that included a discussion of the facts in this case, medical principles, and a thorough rationale. The Veteran and his representative have not offered competent and probative evidence in support of their assertions to persuade the Board that the February 2018 examinations performed were inadequate. Thus, in the absence of clear evidence of irregularity to question the examiner's qualifications, the Board finds the examination, findings, and opinion provided to be adequate. The additional evidence of VA treatment records, a February 2018 VA examination report, lay testimony, and private medical report, while new in that these records were not previously of record, is not material, as it does not show that the Veteran's current bilateral hearing loss disability had its onset in service or within one year of service discharge or is otherwise related to service. Instead, it confirms facts that were already of record at the time of the October 2015 rating decision, which is that the Veteran had a diagnosis of a bilateral hearing loss disability for VA purposes and had in-service noise exposure, but without competent evidence of a nexus between the current bilateral hearing loss disability and service. Accordingly, the Board finds that new and material evidence has not been received to reopen the claim for service connection for bilateral hearing loss disability. Therefore, the application to reopen the previously denied claim is denied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. Whether new and material evidence has been received to reopen the previously-denied claim for service connection for tinnitus. Entitlement to service connection for tinnitus was denied in a March 2015 rating decision. In July 2015, the Veteran requested reconsideration of the claim and a subsequent October 2015 rating decision confirmed the previous denial of the claim. The Veteran was notified of the denial and his appellate rights. In the one-year appeal period that followed, the Veteran submitted neither a notice of disagreement nor any additional evidence. This rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The October 2015 rating decision denied service connection for tinnitus on the basis that it was neither occurred in nor was caused by service. The Veteran has since reported that the onset of tinnitus in service, including during an examination in February 2018 and in testimony provided at the January 2021 Board hearing. Given that the threshold for substantiating a claim to reopen is low, this evidence, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim for service connection for tinnitus and raises a reasonable possibility of substantiating the claim. The Board finds that this new evidence is also material. Thus, the claim of entitlement to service connection for tinnitus is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as tinnitus (as an organic disease of the nervous system), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for tinnitus. The Veteran contends that service connection for tinnitus is warranted because it was incurred in service or otherwise caused by his in-service noise exposure given his military occupational specialty (MOS) as a reconnaissance intelligence specialist. During the January 2021 Board hearing, the Veteran testified to noise exposure from firefights at the DMZ in service and training for the reserves in 1970. See also July 2015 statement. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the grant of service connection for tinnitus. The reasons follow. The Veteran has tinnitus or ringing in the ears, as documented in the January 2015 VA examination report and February 2018 DBQ. There is no medical test for tinnitus; thus, evidence of tinnitus symptoms is highly subjective. Tinnitus is a condition capable of lay observation and diagnosis; therefore, the Veteran is competent to report that he has tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Accordingly, the first element of a service-connection claim is met. The Veteran was exposed to hazardous noises during service. The Veteran's Certificate of Release or Discharge from Active Duty (DD Form 214) shows that the Veteran had an MOS of light weapons infantryman in the U.S. Army, which is noted as having a "high" probability of hazardous noise exposure, in which case, the exposure to hazardous noise should be conceded. As discussed above, the Veteran has reported his military noise exposure of artillery fire at the Korean DMZ, including mortars and small machine guns without ear plugs. Military personnel records reflect that the Veteran was awarded an Expert Marksmanship Qualification Badge for the M-14 rifle. Although the Veteran's service treatment records do not show symptoms or complaints of tinnitus or other ear problems, there is ample indication that he was exposed to acoustic trauma in service due to his MOS in the Army. The Board finds that the Veteran was exposed to hazardous noise during his service, meeting the second element of a service-connection claim. While the Veteran has a current diagnosis of tinnitus and was exposed to in-service acoustic trauma, the Board finds that the preponderance of the evidence is against a link, or nexus, between the current disability and service. The February 2018 VA examiner noted that the Veteran reported the onset of his tinnitus during service and denied a coinciding event. During the January 2021 Board hearing, the Veteran testified that he recalled ringing in his ears after firefights in service and after a grenade simulator was rolled into his tent in a training maneuver in 1970. The evidence does not support a finding that the Veteran's current tinnitus was incurred coincident with active service and had been continuous since his July 1969 service separation. For example, the Veteran's June 1969 Report of Medical Examination for purposes of separation reflects a normal clinical evaluation of "ears general" and a "1" rating was assigned assessing hearing under the "PULHES" profile system indicating that the Veteran's hearing was in a high level of fitness. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). In the June 1969 Report of Medical History for purposes of separation, the Veteran denied that he ever had or had at the time, "ear, nose, or throat trouble;" "running ears;" "hearing loss;" and "wear a hearing aid." The Veteran signed this document, wherein he attested that the information he provided in this form was "true and complete to the best of my knowledge." The Board accords high probative value and credibility to this document, as the Veteran completed it contemporaneously with service. The Veteran's first report of tinnitus is in the November 2014 VA 21-526EZ, Fully Developed Claim, seeking entitlement to service connection for tinnitus. A December 2014 VA audiology consultation reflects a positive history for bilateral constant tinnitus with the Veteran reporting an onset of 10 years prior, thus, in approximately 2004. This report of tinnitus from the Veteran reflects an onset of almost 35 years after service separation. Moreover, during the January 2015 VA examination, the Veteran reported an onset of tinnitus of "many years ago," which is consistent with the December 2014 VA medical record. It was specifically noted by the examiner that the Veteran could not provide a "more specific time frame." The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service, which resulted in any chronic or persistent disability. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). Thus, the Board finds that the Veteran's current tinnitus disability did not manifest in service or within one year of separation from active duty, and a presumption of service connection based on chronicity is not appropriate. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, the January 2015 VA examiner opined that the Veteran had a diagnosis of clinical hearing loss and his tinnitus is at least as likely than not (50 percent probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss. The February 2018 examiner provided the opinion that tinnitus is less likely than not (less than 50 percent probability) caused by or a result of military noise exposure. She explained that although the Veteran reported an onset of tinnitus during service, there is conflicting evidence including the December 2014 VA audiology consultation where the Veteran reported an onset of "10 years ago" and the January 2015 examination where the Veteran reported an onset of "many years ago," as discussed above. The examiner also noted the lack of evidence in the record of tinnitus and hearing loss during service and opined based on this and the conflicting evidence that it is less likely than not that the Veteran's tinnitus was caused by military service. The Board finds that the February 2018 opinion is highly probative, as the examiner based her opinion on the same facts that the Board finds are credible in that the Veteran did not have tinnitus in service, but rather experienced it decades after service discharge. In March 2021, the Veteran's representative proffered a post hearing memorandum with a report from a private Orthopaedic surgeon, Dr. Graf, that she proports to opine that it is at least as likely as not that the Veteran's tinnitus is service connected. Dr. Graf noted that in 1970, the Veteran went to a training camp for the reserves and the Veteran described being exposed to an exploding device followed by as much as two hours of not being able to hear. Dr. Graf indicated that the problems of tinnitus and hearing loss requiring sensory neural hearing aids was documented in the Veteran's medical records; however, Dr. Graf does not directly provide an opinion of a causal connection between the Veteran's in-service noise exposure and his current tinnitus. While Dr. Graf noted in his report that the Veteran's tinnitus began in service, this is based on the Veteran's statements which the Board has found not to be credible. The Board has considered the assertion by the Veteran's representative that Dr. Graf's report must be accepted over the VA examiner's because their qualifications are unknown. Again, the Board finds that the statement that the examiner's "qualifications are unknown" is not a challenge to the competency of the audiologist, but rather an allegation that the examination may not be adequate. The Board finds that VA has satisfied its duty to assist when it provided medical examinations performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or physician's assistant. See Cox, 20 Vet. App. at 563. The Board may assume a that VA medical examiner is competent. See Cox, 20 Vet. App. at 569; Hilkert, 12 Vet. App. at 151. The January 2015 and February 2018 opinions were provided by licensed audiologists. The Veteran and his representative have not offered competent and probative evidence in support of their assertions to persuade the Board that the January 2015 and February 2018 examinations performed were inadequate. Thus, in the absence of clear evidence of irregularity to question the examiners' qualifications, the Board finds the examinations, findings, and opinions provided to be adequate. The Board finds that the most probative evidence of record are the opinions of the January 2015 and February 2018 examiners. The examination reports and opinions collectively provide competent and probative evidence that weighs against the Veteran's claim because the examiners reviewed the claims file, interviewed the Veteran, performed audiological examinations, and provided medical opinions supported by well-reasoned rationale, which were based upon the specific facts and medical principles. Monzingo v. Shinseki, 26 Vet. App. 97, 105-106 (2012). The examiners considered the Veteran's report of military noise exposure, including grenades, Claymore mines, artillery, mortars, machine guns and firefights as noted in the respective examination reports. There is no competent evidence that refutes these opinions. The Veteran has attempted to establish a nexus through his own lay assertions that tinnitus is related to his in-service exposure to noise hazards; however, the preponderance of the evidence is against a finding of chronic tinnitus since service or tinnitus that is otherwise related to service. The Board has considered the more credible evidence, which shows that he did not have tinnitus until over three decades after service and the opinions from the January 2015 and February 2018 examiners, particularly that the Veteran's current tinnitus is related to his hearing loss, which is not service connected, are the most probative medical evidence, which is against the claim. The Veteran's DD Form 214 does not show that he received an award or decoration indicative of having engaged in hand-to-hand combat with the enemy versus being in a war zone. Thus, the provisions of 38 U.S.C. § 1154(b) are not for application. For all the reasons laid out above, the Board finds the preponderance of the evidence is against the claim of service connection for tinnitus, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to a compensable disability rating for scar of the anterior chest. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. See 38 C.F.R. § 4.7 (2018). When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. The Veteran contends that his scar of the anterior chest, currently assigned a noncompensable evaluation pursuant to 38 C.F.R. § 4.118, DC 7805, warrants a compensable rating. DC 7805 provides that scars and other effects of scars are to be evaluated under DCs 7800, 7801, 7802, and 7804, or under another appropriate code if such disabling effects are not considered under DCs 7800, 7801, 7802, or 7804. DC 7800 provides criteria for scars or disfigurement of the head, face, or neck, and is therefore inapplicable to the Veteran's scar on the anterior chest. DC 7801 provides ratings for burn or other scars (not on the head, face, or neck) that are deep and nonlinear. Deep and nonlinear scars involving an area or areas of at least 6 square inches (39 sq. cm) but less than 12 square inches (77 sq. cm.) are rated 10 percent. Scars in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) are rated 20 percent. Scars in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) are rated 30 percent. Scars in an area or areas of 144 square inches (929 sq. cm.) or greater are rated 40 percent. 38 C.F.R. § 4.118. Note (1) specifies that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801 (effective from October 23, 2008). DC 7802 provides a maximum 10 percent rating for a burn or other scars that are superficial and nonlinear involving an area of 144 square inches (929 sq. cm) or greater. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802. DC 7804 provides a 10 percent rating for one or two scars that are unstable or painful, a 20 percent rating for three or four scars that are unstable or painful, and a 30 percent rating for five or more scars that are unstable of painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (3) provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. 38 C.F.R. § 4.118, DC 7804. Under DC 7805, disabling effects of scars not considered in a rating under DCs 7800 to 7804 are evaluated under other appropriate DC(s). 38 C.F.R. § 4.118, DC 7805. In every instance where the schedule does not provide a 0 percent rating for a DC, a noncompensable or 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 During the January 2021 Board hearing, the Veteran testified that his scar never healed properly and was sore all the time and bothered him every once in a while. The Board has reviewed the record and finds that the preponderance of the evidence is against a finding that the left hip scar is painful or unstable, greater than 6 sq. inches in size, or otherwise disabling. Upon VA examination in March 2017, the Veteran's scar was noted to be 23 cm. in length by 0.3 cm in width. The examiner documented that the scar was not painful or unstable, had a total area equal to or greater than 39 square cm. (6 square inches), or was located on the head, face or neck. In December 2017, a VA examiner made specific comments that the scar was "well healed, healthy looking, and non-tender." The Board has considered the Veteran's statements; however, it accords more probative value to the objective findings by the VA examiners following examination of the scar, which clinical findings are consistent with each other. Within the February 2021 letter from Dr. Graf, he did not provide clinical findings regarding the scar, but rather concluded that the Veteran's scarring should be rated at 10 percent without explaining upon what clinical findings he based this conclusion. A medical opinion without a rationale has no probative value. The Veteran has not proffered any other competent and probative evidence in support of a finding that the anterior chest scar is deep and nonlinear involving an area of at least 6 sq. inches (DC 7801); superficial and nonlinear involving an area of 144 sq. inches (DC 7802); unstable or painful (DC 7804); or is otherwise disabling (DC 7805). The preponderance of the evidence is against entitlement to a compensable disability rating for the Veteran's anterior chest scar. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. REASONS FOR REMAND 5. Entitlement to a disability rating in excess of 30 percent for ischemic heart disease (IHD) is remanded. The Veteran was last afforded a VA examination in December 2017 in order to evaluate the severity of his service-connected IHD. During the January 2021 Board hearing, the Veteran testified to worsening symptoms since his last examination. Thus, the Board finds that a remand is necessary to afford the Veteran an opportunity to undergo a VA examination to assess the current nature, extent and severity of his IHD. 6. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. 7. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. The Veteran contends that service connection for bilateral lower extremity peripheral neuropathy is warranted as secondary to his service-connected IHD. During the January 2021 Board hearing, the Veteran testified that he never had problems in his legs prior to 2014 and that the pain was worse after veins were harvested in his legs for his coronary artery surgery. The Veteran was afforded a VA examination for his claimed bilateral peripheral nerve disabilities in December 2017. The examiner confirmed a diagnosis of right peroneal neuropathy secondary to L4-L5 radiculopathy and congenital spina bifida and note that the left lower extremity was unremarkable. The examiner found that the Veteran's claimed bilateral peripheral neuropathy was less likely than not (less than 50 percent probability) proximately due to or the result of the service-connected IHD. She provided the rationale that IHD does not cause peripheral neuropathy, the Veteran's peripheral neuropathy was secondary to his lumbar spine condition, and the Veteran denied any history of diabetes mellitus. However, at the hearing, the Veteran had raised the issue of his symptoms in his lower extremities became worse after veins were harvested in his legs for his coronary artery surgery, which is a theory of entitlement that was not considered by the December 2017 VA examiner. Therefore, the Board finds that addendum VA medical opinions are warranted to address this allegation. VA medical records, including in August 2015, indicate that the Veteran had an electromyography (EMG) performed and was diagnosed with neuropathy and had been following a local neurologist, Dr. Hassan. An electroencephalogram (EEG) report from Dr. Syed Zaheer Hasan is associated piecemeal with the claims file, which indicates that potentially relevant records may be outstanding. The record also indicates that the Veteran was referred by Dr. Mark C. Nadaud, D.O. As such, the Veteran should be provided an opportunity to identify any additional outstanding relevant private medical records on remand. An effort must be made to locate and associate any outstanding private medical records with the Veteran's claims file. 8. Entitlement to a TDIU rating is remanded. A determination with respect to the claims for entitlement to service connection for right and left lower extremity peripheral neuropathy and an increased rating for service-connected IHD may have an impact upon consideration of the issue of entitlement to TDIU on appeal; the Board finds that these issues are inextricably intertwined. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. As such, Board consideration of the merits of the Veteran's TDIU claim is deferred pending adjudication of the Veteran's claims for service connection for right and left lower extremity peripheral neuropathy and an increase rating of his service-connected IHD on appeal. Additionally, in going through the record, the Board did not see that the Veteran had completed a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. While such form is not required, it assists VA with making a determination regarding entitlement to a TDIU rating when the past work history and educational history are all located in the form, and VA has the full name and address of the Veteran's employers to verify the facts regarding the Veteran's employment. The Veteran is asked to complete the form to assist VA with adjudicating this claim. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private medical records relevant to service connection claims for bilateral lower extremity neuropathy on appeal, to include but are not limited to records from the following medical professionals: Dr. Mark C. Naduad, D.O.; Dr. Syed Zaheer Hasan, neurologist; any other private medical professional for treatment of the claimed bilateral lower extremity neuropathy. 2. Provide the Veteran with a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, and request that he complete the form in its entirety. 3. Schedule the Veteran for a VA examination to evaluate the current severity of his service-connected ischemic heart disease (IHD). 4. Schedule the Veteran for a VA examination to address the likelihood that peripheral neuropathy in the lower extremities is related to harvesting of veins in connection with the heart surgery the Veteran underwent in April 2017. The examiner should be provided a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from December 1967 to July 1969. The Veteran is service connected for ischemic heart disease (coronary artery disease status post myocardial infraction and coronary artery bypass graft) and scar, anterior chest. The Veteran is mainly contending that bilateral lower extremity peripheral neuropathy was caused by or aggravated by his service-connected IHD and the coronary artery surgery where veins were harvested in his legs. In August 2014, the Veteran complained of right leg pain described at a level of 9 out of 10 severity. See VBMS entry with document type, "CAPRI," receipt date 04/03/2017, on pages 38-40 A January 2015 VA examination report for back conditions shows the Veteran reported that two years prior, he was determined to have osteopenia and arthritis of the lower back. He stated that he had pain on the right side of his lower back and hip that radiated into his upper leg. The examiner determined that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. See VBMS entry with document type, "C&P Exam," with "DBQ MUSC Back thoracolumbar spine" in the Subject field, receipt date 01/13/2015. A June 2015 private electroencephalogram (EEG) report shows that the testing was performed due to complaint of right upper and lower extremity numbness and tingling. As to the lower extremities, there was evidence of minimal to moderate right peroneal neuropathy. An S1 radiculopathy could not be excluded. There was evidence of right L4-L5 radiculopathy. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 07/30/2015. In August 2015 VA medical records, it is noted that an electromyography (EMG) was performed by a local neurologist, and the Veteran was diagnosed with neuropathy. See VBMS entry with document type, "CAPRI," receipt date 04/03/2017, on pages 13-17. In August 2015, the Veteran underwent coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending, reverse saphenous vein graft to second obtuse marginal, reverse saphenous vein graft to right coronary artery, median sternotomy, endoscopic vein harvest, and cardiopulmomary bypass. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 01/30/2017, on pages 4-5. The operative report notes that veins ended up having to be harvested from both legs in the greater saphenous system proximally from both things as it bifurcated in the distal thigh and became very small thereafter. Id. Of record is the March 2017 VA examination report for heart conditions. See VBMS entry with document type, "C&P Exam," receipt date 03/13/2017, with "DBQ CARDIO Heart" in the subject field. Of record is the December 2017 VA examination report for heart conditions. See VBMS entry with document type, "C&P Exam," receipt date 12/28/2017, with "DBQ CARDIO Heart" in the subject field, on pages 1-6. Of record is the December 2017 VA examination report for peripheral nerves conditions. The Veteran reported that he noticed tingling and numbness in both legs and feet worse on the right side for the preceding 3 years. He had an EMG done in June 2015 that confirmed right peroneal neuropathy and the left side was unremarkable. It was noted that the Veteran has a history of congenital spina bifida and lumbar disc degeneration with L4-L5 radiculopathy. He was taking Neurontin 300 mg three times daily since 2015. The Veteran denied any history of diabetes mellitus. He reported that he had 3 veins taken from the right leg and one from the left leg and believed neuropathy was due to striping of veins from his lower extremities. See VBMS entry with document type, "C&P Exam," receipt date 12/28/2017, with "DBQ CARDIO Heart" in the subject field, on pages 6-11. The examiner found that the Veteran's claimed bilateral peripheral neuropathy was less likely than not (less than 50 percent probability) proximately due to or the result of the service-connected IHD. She provided the rationale that IHD does not [cause] peripheral neuropathy, the Veteran's peripheral neuropathy was secondary to his lumbar spine condition and the Veteran denied any history of diabetes mellitus. See VBMS entry with document type, "C&P Exam," receipt date 12/28/2017, on page 14. Of record is a February 2021 report from a private physician. The physician noted that wound complications are common following leg vein harvest with paresthesias and swelling are common long-term complications type of study retrospective audit. He added that a complication of the use of saphenous vein graft in coronary bypass surgery is injury to the saphenous nerve and that this injury combined with peripheral neuropathy related to diabetes mellitus type II produce severe right and lower extremity neuropathy. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 03/30/2021, on pages 2-6. Additional records may have been associated with the claims file since May 2021, including a new VA examination report for the Veteran's service-connected IHD. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: Left lower extremity: a) Does the Veteran have a current left lower extremity peripheral neuropathy disability or any functional impairment due to pain of the left lower extremity? b) For each left lower extremity peripheral neuropathy disability (or functional impairment due to pain of the left lower extremity) offered, the examiner is asked to address whether it is at least as likely as not (50 percent probability or more) that such disability is caused by the service-connected ischemic heart disease (IHD)? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that left lower extremity peripheral neuropathy disability (or functional impairment due to pain of the left lower extremity) is aggravated by the service-connected IHD? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected IHD aggravates the Veteran's left lower extremity peripheral neuropathy disability (or functional impairment due to pain of the left lower extremity) the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the left lower extremity peripheral neuropathy disability (or functional impairment due to pain of the left lower extremity) prior to aggravation. If the examiner is unable to establish a baseline for the left lower extremity prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his IHD and the coronary artery surgery where veins were harvested in his legs caused and/or aggravate the pain. Please consider and discuss the relevant medical records, including but not limited to the February 2021 private physician report (locations above). Right lower extremity a) Does the Veteran have a current right lower extremity peripheral neuropathy disability or any functional impairment due to pain of the right lower extremity? b) For each right lower extremity peripheral neuropathy disability (or functional impairment due to pain of the right lower extremity) offered, the examiner is asked to address whether it is at least as likely as not (50 percent probability or more) that such disability is caused by the service-connected ischemic heart disease (IHD)? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that right lower extremity peripheral neuropathy disability (or functional impairment due to pain of the right lower extremity) is aggravated by the service-connected IHD? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected IHD aggravates the Veteran's right lower extremity peripheral neuropathy disability (or functional impairment due to pain of the left lower extremity) the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right lower extremity peripheral neuropathy disability (or functional impairment due to pain of the right lower extremity) prior to aggravation. If the examiner is unable to establish a baseline for the right lower extremity prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his IHD and the coronary artery surgery where veins were harvested in his legs caused and/or aggravate the pain. Please consider and discuss the relevant medical records, including but not limited to the February 2021 private physician report (locations above). Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. After all available evidence has been associated with the record, review the evidence and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.