Citation Nr: 22015477 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 18-00 902 DATE: March 17, 2022 ORDER Service connection for insomnia, to include as due to service-connected posttraumatic stress disorder (PTSD), is denied. An initial rating in excess of 50 percent for PTSD is denied. An initial 10 percent rating for right wrist scar residuals is granted. REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for nosebleeds, to include as due to herbicide exposure, is remanded. Entitlement to an initial compensable rating for bilateral hearing loss prior to December 1, 2018, is remanded. Entitlement to a rating in excess of 40 percent for bilateral hearing loss from December 1, 2018, to July 27, 2021, is remanded. Entitlement to a rating in excess of 50 percent for bilateral hearing loss from July 28, 2021, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The evidence supports a finding that the Veteran does not have an insomnia diagnosis that is separate from the PTSD diagnosis, and any sleep impairment symptoms are a symptom of the PTSD. 2. The severity, frequency, and duration of the Veteran's symptoms do not more closely approximate occupational and social impairment with deficiencies in most areas at any point during the period of appeal. 3. For the entire period of appeal, the evidence is in approximate balance on whether the right wrist scar is painful. The scar is also linear and stable, and does not result in limitation of motion or limitation of function. CONCLUSIONS OF LAW 1. The criteria for service connection for insomnia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for an initial 10 percent rating for the right wrist scar residuals are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Marine Corps from August 1967 to August 1971. His decorations include a Combat Action Ribbon, Vietnam Service Medal, and Vietnam Cross of Gallantry with Palm. In June 2020, the Veteran testified at a virtual hearing before the undersigned, and a transcript of that hearing is of record. The Board remanded the issues in June 2021 for further development. With regard to claim for service connection for insomnia and the increased ratings for PTSD, the AOJ was instructed to associate outstanding VA treatment records. With regard to the increased rating for the right wrist scar residuals, the AOJ was instructed to schedule the Veteran for a VA examination to determine the nature and severity of the disability. VA treatment records were subsequently associated with the record and the Veteran had a VA scars examination in July 2021. The Board therefore finds there has been substantial compliance with the remand directives with regard to the insomnia, PTSD, and right wrist scar claims. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). 1. Service connection for insomnia. The Veteran contends that he has insomnia due to his PTSD. He takes medication to treat the insomnia, and he also has nightmares about his combat experiences in Vietnam. Other sleep symptoms included getting up at night and yelling, and having difficulty going back to sleep. Before medication, he was sleeping for only three hours a night for 50 years. Since starting medication, he can sleep about five hours a night. The Veteran's representative asserts that there is a "significant interrelationship" between the PTSD and the insomnia. See the June 2020 Board hearing transcript. VA treatment records indicate that in a November 2016 mental health evaluation, the Veteran reported having problems of chronic sleep disturbance since returning home from Vietnam such that he was not able to sleep for more than four hours at a time. He self-medicated with Tylenol PM. Other symptoms included anxiety, depression, trouble concentrating, fits of emotion, and getting fidgety and defensive when his neighbor slammed the door. The evaluating psychologist diagnosed primary insomnia disorder and other specified trauma and stressor disorder. VA treatment records dated since then consistently note "insomnia" and PTSD or other trauma and stressor-related disorder in the list of active problems. In a February 2017 VA PTSD examination, the Veteran again reported ongoing sleep problems since returning from Vietnam due to intrusive memories that kept him awake, nightmares, and waking up off-and-on for most of the night. Other symptoms included increased startle response, becoming especially irritated and hyper-aroused with loud noises, irritability and anger, and road rage. The examiner diagnosed PTSD with delayed expression, and did not note any other diagnoses, including insomnia or any other sleep disorder. In a February 2017 VA medication management and psychotherapy appointment, the Veteran reported having problems with sleep and anger. He was assessed as having PTSD and dysthymia, and was prescribed mirtazapine for sleep and PTSD and prazosin for nightmares. In an April 2018 VA PTSD examination, the Veteran reported that he took quetiapine and over-the-counter Unisom before bedtime, which allowed him to initiate and maintain sleep. Without the medication, he was having delayed onset sleep and early morning awakening. The examining physician indicated that the Veteran's PTSD symptoms included chronic sleep impairment. The examiner opined that the Veteran's "primary insomnia diagnosis" was incorrect, and that his sleep problems were included in the diagnosis of PTSD. The examiner specified that "one of the cardinal symptoms of PTSD is 'sleep disturbance' (e.g., difficulty falling or staying asleep or restless sleep." In a November 2018 VA PTSD examination, the Veteran again reported that his sleep symptoms including difficulty going to sleep, restless, nightmares two times per week, and getting approximately six hours of sleep per night. The examiner indicated that the Veteran's PTSD symptoms included chronic sleep impairment, and the examination report is silent for mention of any separately diagnosed sleep condition. As noted above, VA treatment records dated since November 2016 note "insomnia" among the Veteran's list of active problems. However, the same treatment records also consistently note diagnoses of PTSD and/or other trauma and stressor-related disorder, and it appears that the separate diagnosis of insomnia stopped being listed among the noted diagnoses in 2019. The Veteran continued to be treated for sleep problems, including changing medication dosages at times and discussing nightmares increasing and/or decreasing with the medication changes, but "insomnia" is not listed as a diagnosis or assessment in VA mental health treatment dated between February 2019 and June 2021. The Board finds that the April 2018 VA examiner's opinion is competent and credible, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinion was rendered after reviewing the Veteran's STRs and other medical records, and soliciting a medical history from the Veteran, and conducting a physical examination and clinical testing of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The VA examiner provided facts and rationale on which he based his opinions, including expressly considering and discussing the diagnosis of primary insomnia disorder, explaining why it was an incorrect diagnosis. Furthermore, neither the Veteran nor his representative has produced a medical opinion to contradict the conclusions of the VA examiner. As such, the evidence supports a finding that any sleep problems, including insomnia, are symptoms of the Veteran's PTSD, and not a separately diagnosed disorder. The Veteran contends that service connection is warranted for his insomnia, but the Board cannot rely on his assertions regarding medical diagnoses. The issue is medically complex, as it requires specialized medical education and knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make a competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. As such, the Board finds the Veteran's statements probative with regard to establishing his current symptoms, but finds little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has medical expertise and training pertinent to mental health and sleep disorder diagnoses. Without competent evidence of a relevant diagnosed disorder, service connection for the claimed disability cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 2. Increased rating for PTSD. The rating criteria for rating mental disorders, including anxiety disorder and PTSD, reads as follows: a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. The Board notes that the DSM-5 states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court's holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores; however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board will not afford any GAF scores mentioned in the record any probative value in cases where the DSM-5 applies. See also Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. February 23, 2018) (finding that the Board provided an inadequate statement of its reasons or bases for relying on GAF scores in its decision when the appeal was certified after August 4, 2014, and the DSM-5 applied to the claim). In this case, the Veteran's appeal was certified to the Board in 2018. As such, the DSM-5 applies, and the Board will not afford GAF scores any probative value. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit explained that the frequency, severity, and duration of the symptoms also played an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. The Board finds that for the entire period of appeal, the Veteran's PTSD does not more closely approximate the schedular criteria for a rating in excess of 50 percent under Diagnostic Code 9411 at any point during the period of appeal (from November 5, 2016). VA treatment records indicate that in a November 2016 mental health evaluation, the Veteran reported symptoms of anxiety, fits of emotion, getting fidgety and defensive when his neighbor slammed the door, insomnia, and anger reactions, and denied having any suicidal or homicidal ideation. He reported living with his wife in a condo, and had been employed as a clergy until retiring/resigning two years ago. The treating psychologist indicated that the Veteran was neatly groomed, cooperative, and engaged. His mood was euthymic with a full range affect. As noted above, the evaluating psychologist diagnosed primary insomnia disorder and other specified trauma and stressor disorder, with symptoms of anxiety, depression, trouble concentrating/memory problems, difficulty falling asleep, frequent awakenings, difficulty returning to sleep, waking too early, bad dreams/nightmares, and a history of substance use problems. The Veteran started individual therapy and medication management appointments at VA in December 2016 and continued through at least June 2021, attending approximately one session therapy and/or medication management per month in 2017 and 4-6 times per year between 2018 and 2020. He was prescribed mirtazapine, prazosin, quetiapine, and/or sertraline, which were adjusted as needed throughout the period of appeal. In a February 2017 VA PTSD examination, the Veteran reported that after separation from service, he worked for a number of years in sales and then changed to ministry for 13 years before his recent retirement. Since retirement, he had more problems with increasing intrusive memories and thinking about what happened during his combat experiences. The Veteran lived with wife, had two adult sons, and spent time with family and grandchildren. His other symptoms included irritability, anger, increased startle response, becoming especially irritated and hyper-aroused with loud noises, increasing social isolation, ongoing sleep problems, and road rage. He reported having one incident of suicidal ideation and attempt in his 20s after return from combat, and approximately 10 times since then of experiencing suicidal ideation. The Veteran was taking prescribed medication and attending therapy appointments, which he found helpful. On examination, the Veteran was noted to be clean and well-groomed, oriented in all spheres, and memory was intact. His responses were appropriate and coherent, speech was normal, and there was no indication of psychosis or delusions. He denied any suicidal or homicidal ideation at the time of the examination. The examiner diagnosed PTSD with delayed expression, including symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships. The symptoms caused occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. The Veteran was capable of managing his financial affairs. In an April 2017 VA mental health appointment, the Veteran reported that he quit taking the mirtazapine because it was causing him to hear voices and have suicidal ideation. He was prescribed quetiapine instead. In an April 2018 VA PTSD examination, the Veteran reported having no major family, marital, or social changes or stressors since the last VA examination. Because he was not working, he had started cutting the grass at his church and was doing tai-chi twice per week. Regarding his sleep, he took quetiapine and over-the-counter Unisom before bedtime, which allowed him to initiate and maintain sleep. On examination, the Veteran was noted to be wearing clean clothing, and he was alert, relaxed, and cooperative. His speech was normal, and he denied feeling depressed or having suicidal ideation. He also denied having significant symptoms of anxiety, and was noted to have a normal affect. The examiner indicated that the Veteran's symptoms included chronic sleep impairment and difficulty in adapting to stressful circumstances, including work or a worklike setting. As noted above, the examiner opined that the Veteran's "primary insomnia diagnosis" was incorrect, and that his sleep problems were included in the diagnosis of PTSD. The examiner also noted that "delayed expression" was incorrect, and that people did not develop PTSD "out of the blue, forty years or longer after the stressful events." Rather, PTSD was not known when the Veteran returned from Vietnam, and therefore the Veteran could not have been diagnosed or treated. The examiner concluded that the Veteran's PTSD symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although general functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was capable of managing his financial affairs. In a November 2018 VA PTSD examination, the Veteran reported having a good marriage with his wife of 44 years. They lived in a condo they purchased from his father-in-law, and he had good relationships with both of his adult sons who lived near him. He had eight grandchildren and described himself as a good grandfather. He liked to go golfing in the past, but had not been in two years, and he had not attended his grandson's sports events in the past five years. He had been doing tai chi for the past four years to alleviate stress. The Veteran was retired from the clergy, but was still involved with his church and attended Sunday services. He was in therapy once per month for symptoms of nightmares, Vietnam memories, anger, and short temper, and continued to take quetiapine, prazosin, and melatonin. Other reported symptoms included depressed mood, anxiety, suspiciousness, flashbacks, and impaired sleep. On examination, the Veteran was noted to be well-groomed, with normal speech, appropriate judgment, and no evidence of hallucinations or delusions. He reported having suicidal ideation in 2017, which lasted for a couple of weeks and improved when he volunteered and got busy with the church. The examining psychologist opined that the Veteran's PTSD symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances including work or a work like setting, and impaired impulse control resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although general functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was capable of managing his financial affairs. In a May 2019 VA therapy appointment, the Veteran reported that he continued to perform maintenance duties for his church approximately three days per week, which made him feel "competent" because he was giving back to his community. He also continued to participate in tai chi classes. The Veteran discussed how he resigned his position at the church due to a difference in belief regarding same-sex marriage, which led him to be less interested in church activities or meetings, but that had not negatively impacted his mood in other areas of his life. He was satisfied with his sleep on his medication regimen, and was overall satisfied with his current quality of life. He felt ready to terminate psychotherapy and schedule future appointments as needed. The treating psychologist agreed to terminate psychotherapy, but noted that the Veteran would continue to attend medication management appointments. In June 2020, the Veteran reported having an increase in nightmares since the beginning of the year. He was sleeping in a separate room from his wife because he kicked his wife during the nightmares. The Veteran was advised to increase the prazosin. In August 2020, the Veteran reported that his nightmares had decreased from twice per week to once every two weeks since increasing the prazosin. In November 2020, the Veteran again noted an increase in difficulty with sleep and increase in nightmares. His prazosin was increased again. In February and June 2021, the Veteran reported that his nightmares had improved on the new dosage of prazosin. The Board finds the VA examiners' opinion to be competent and credible, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinions were rendered after reviewing the Veteran's VA medical records, soliciting a medical history from the Veteran, and conducting a physical examination and clinical testing of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The VA examiner also provided facts and rationale on which the opinions and conclusions were based. The examination results are also consistent with VA treatment records dated between 2016 and 2021, which note similar symptoms and treatment with prescription medications and mental health therapy. The weight of the evidence shows that the Veteran's symptoms have been relatively consistent for the entire period of appeal, including depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships. The Board find that such symptoms more nearly approximate that of occupational and social impairment with reduced reliability and productivity, which warrants a 50 percent rating under Diagnostic Code 9411. As such, the Board also finds that the Veteran's symptoms have not more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood to warrant a higher 70 percent evaluation at any point during the period of appeal. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (stating that use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating). As noted above, the criteria for a 70 percent rating includes symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. In this case, the Veteran has not been found to have obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene. The Board acknowledges that in the February 2017 VA examination, the Veteran reported having one incident of suicidal ideation and attempt in his 20s after return from combat, and approximately 10 times since then of experiencing suicidal ideation; however, these incidents occurred prior to the period of appeal, and the Veteran denied having suicidal ideation at the time of the examination. The Board also acknowledges that the Veteran reported suicidal ideation in April 2017; however, that was attributed to the medication that the Veteran was prescribed, and that medication was discontinued. The Veteran consistently denied having suicidal or homicidal ideation in all subsequent VA treatment records and VA examinations. The Board also acknowledges that the Veteran was noted to have difficulty in adapting to stressful circumstances including work or a worklike setting in the April 2018 VA examination, and that he was found to have difficulty in adapting to stressful circumstances including work or a worklike setting and impaired impulse control in the November 2018 VA examination. However, the Board does not find these two symptoms to be so frequent and disabling as to result in occupational and social impairment with deficiencies in most areas at any point during the period of appeal. See Mauerhan v. Principi, at 442 (2002) (finding that symptoms contained in rating schedule criteria are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating."). Rather, the Veteran has remained married for the entire period of appeal and has indicated that the marriage is good, has two adult children and several grandchildren with whom he has good relationships, remains active in his church, and participates in tai chi classes. He was also noted in three VA examinations to be capable of completing his activities of daily living and managing his financial affairs. Although the Veteran was not working during the period of appeal, he indicated that he stopped working due to a difference in belief regarding same-sex marriage. The Board also finds it significant that all three VA examiners concluded that the Veteran's PTSD symptoms resulted in, at worst, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), which would warrant only a 30 percent rating. Accordingly, the Board finds that the Veteran's symptoms are not of such frequency, severity, and duration that they result in occupational and social impairment with deficiencies in most areas to warrant a higher 70 percent evaluation at any point during the period of appeal. 3. Increased rating for right wrist scar residuals. The Veteran has been assigned an initial noncompensable rating for his lumbar spine scar under Diagnostic Code 7805. Under this diagnostic code, scars are rated based on any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. In a December 2016 VA examination, the Veteran was noted to have a scar on his right wrist from a ganglion cyst excision in 1968. The scar measured 5.5 centimeters (cm) in length and 0.2 cm in width, and was noted to be linear, horizontal, nontender, flesh-colored, nondepressed, nonelevated, and well healed. There were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with the scar. VA treatment records indicate that in February 2017, the Veteran reported having wrist pain and limited range of motion since surgery. In March 2017, the right wrist was noted to be tender with pressure from the sides. There was no swelling. In April 2017, the Veteran was again noted to have wrist pain. In the June 2020 Board hearing, the Veteran indicated that since the surgery in service, he had a poor grip, which limited activities such as holding a hammer and doing most work around the house. He also stated that the scar was painful, more so when it was cold outside, and he used a brace. In a July 2021 VA examination, the Veteran reported a lack of flexibility and pain on cold days. He was not receiving any treatment for the condition, and denied any impact on function. The examiner indicated that the right wrist scar was 5 cm long and 0.1 cm wide. The scar was not tender to palpation, unstable, or with underlying soft tissue damage. The scar also did not result in limitation of motion or limitation of function, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with the scar. In sum, the Board finds that, for the entire period of appeal (from October 28, 2016), the right wrist scar is subjectively painful, linear, and stable, and does not result in any limitation of function. As noted above, Diagnostic Code 7805 rates "other" scars based on any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. The Veteran is not entitled to a compensable rating under this diagnostic code because he has suffered no functional impairment as a result of the scar, as noted by VA examiners in December 2016 and July 2021. However, the Board finds that a 10 percent rating is warranted under Diagnostic Code 7804, which provides a 10 percent rating for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. In this case, the Veteran has reported that he has right wrist pain. It is unclear whether the scar itself is causing or contributing to the pain, but the Board finds that the evidence is in approximate balance on whether the scar residuals include pain. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2022). As such, a 10 percent rating based on pain is warranted. A rating in excess of 10 percent under an alternative or additional diagnostic code is not warranted. Diagnostic Code 7800 contemplates scars of the head, face or neck and is not here for consideration. Diagnostic Code 7801 contemplates scars not of the head, face, or neck that are deep and nonlinear. Diagnostic Code 7802 contemplates scars due to other causes not of the head, face, or neck, that are superficial and nonlinear. The Veteran is competent to report that he feels his scar is worse than evaluated and, by this decision, the Board is granting an evaluation of 10 percent, and no greater. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, neither the Veteran nor his representative are competent to make medical determinations as to the severity or nature of his right wrist scar. Thus, his testimony alone, without corroborating medical evidence, is insufficient to outweigh that of the 2016 and 2021 VA medical examiners. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The medical evidence presents no other findings, signs or symptoms, complications or conditions that are the result of the right wrist scar. As such, a 10 percent rating for the right wrist scar residuals is warranted for the entire period of appeal, and a rating in excess of 10 percent is not warranted at any point during the period of the appeal. REASONS FOR REMAND 1. Entitlement to service connection for a neck disability is remanded. In the June 2021 Board remand, the AOJ was instructed to obtain a medical opinion on the nature and likely etiology of the claimed neck disability. In rendering an opinion on whether it is at least as likely as not that any neck diagnosis is related to service, the examiner was directed to consider whether the diagnosis was due to Veteran's combat in Vietnam. The Veteran subsequently had a VA neck examination in July 2021. The examiner diagnosed degenerative arthritis, which she opined was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, as there were no service treatment records (STRs) showing any neck diagnosis during service. The earliest notation of any neck condition was in September 2017, which was 46 years after separation from service. The Board finds that the July 2021 VA examiner's opinion is not a sufficient basis on which to determine whether any diagnosed neck condition is related to the Veteran's active service, as the opinion was based, in essence, on the lack of treatment records between the Veteran's separation from service and September 2017. The mere fact that medical records do not establish chronicity is not, in and of itself, a sufficient basis on which to rest a medical conclusion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009), quoting Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The examiner did not consider the Veteran's lay reports of injuring his neck in Vietnam in combat, continued neck problems since service, and eventual diagnosis and treatment when he "finally couldn't take it." See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). The Board therefore finds that a medical opinion addendum is necessary. 38 U.S.C. § 5103A(d). 2. Entitlement to service connection for nosebleeds is remanded. In the June 2021 Board remand, the AOJ was instructed to obtain a medical opinion on the nature and likely etiology of the claimed nosebleeds. In rendering an opinion on whether it is at least as likely as not that any nosebleed condition is related to service, the examiner was directed to consider whether the diagnosis was due to exposure to mustard gas (dioxin) and/or Agent Orange. The Veteran subsequently had a VA examination in July 2021. The examiner diagnosed epistaxis (nose bleeds), which she opined was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, as there were no service treatment records (STRs) showing any diagnose of chronic nosebleeds during service. The earliest notation of any such condition was in September 2017, which was 46 years after separation from service. The Board finds that the July 2021 VA examiner's opinion is not a sufficient basis on which to determine whether any diagnosed neck condition is related to the Veteran's active service. First, as noted above, the mere fact that medical records do not establish chronicity is not, in and of itself, a sufficient basis on which to rest a medical conclusion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009), quoting Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The examiner did not consider the Veteran's lay reports that the nosebleeds started in 1970 in service and continued since that time. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). Furthermore, the examiner did not opine on whether the nosebleeds were due to exposure to mustard gas and/or Agent Orange. The Board therefore finds that a medical opinion addendum is necessary. 38 U.S.C. § 5103A(d). 3. Entitlement to an increased rating for bilateral hearing loss prior to December 1, 2018, is remanded. 4. Entitlement to an increased rating for bilateral hearing loss from December 1, 2018, to July 27, 2021, is remanded. 5. Entitlement to an increased rating for bilateral hearing loss from July 28, 2021, is remanded. VA treatment records indicate that the Veteran had audiological evaluations in October 2016, August 2018, and November 2019. The audiogram results, however, are noted to be located in the Computerized Patient Record System (CPRS) and/or VistA Imaging, neither of which the Board has access to view. As such, the Board finds that a remand is required to obtain all VA audiometric test results dated since September 2015 that are stored in CPRS or VistA Imaging. 6. Entitlement to a TDIU is remanded. The Board similarly finds that any decision with respect to the service connection and increased rating claims remanded herein may affect the Veteran's claim for a TDIU. Thus, the claims are inextricably intertwined. Final appellate review of the Veteran's claim for a TDIU must be deferred until the appropriate actions concerning the Veteran's claims for service connection for a neck disability and nosebleeds, and his initial increased rating claim for bilateral hearing loss are completed and the matters are either resolved or prepared for appellate review. The matters are REMANDED for the following action: 1. Contact the VA examiner who provided the July 2021 neck opinion (or if he or she is no longer available, a suitable replacement) and ask the examiner to review the record and prepare an addendum to the medical opinion. The examiner should opine on whether it is at least as likely as not (50 percent probability or greater) that any current neck condition had causal origins in active service. The examiner should specifically address the Veteran's contentions that his neck condition began with an injury in Vietnam in combat, and has continued since then. The examiner should explain the medical basis for the conclusions reached. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the Veteran should be scheduled for such an examination. 2. Contact the VA examiner who provided the July 2021 nosebleeds opinion (or if he or she is no longer available, a suitable replacement) and ask the examiner to review the record and prepare an addendum to the medical opinion. The examiner should opine on whether it is at least as likely as not (50 percent probability or greater) that any current nosebleed condition had causal origins in active service. The examiner should specifically address the Veteran's contentions that his nosebleeds began in Vietnam in service and have continued since then. The examiner should also specifically address and consider whether any nosebleed condition is due to mustard gas (dioxin) and/or Agent Orange. The examiner should note that it is inadequate to conclude that that any nosebleed condition is not related to service simply because it is not on VA's list of presumptive diseases associated with exposure to herbicides. The examiner should explain the medical basis for the conclusions reached. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the Veteran should be scheduled for such an examination. (Continued on the next page) 3. Associate with the claims file all relevant VA audiological treatment records dated from August 2015 to present, to include associating all audiogram results located in CPRS and/or scanned into VistA Imaging. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.