Citation Nr: 18154100
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 14-41 389A
DATE:	November 29, 2018
ORDER
Entitlement to service connection for bilateral foot callouses is denied.
Entitlement to service connection for an ingrown toenail left great toe is denied.
Entitlement to service connection for bilateral hearing loss is denied.
Entitlement to service connection for glaucoma is denied.  
Entitlement to service connection for a disability manifested by fatigue, claimed as chronic fatigue syndrome, is denied.
Entitlement to service connection for a cardiovascular condition is denied.
Entitlement to service connection for a neurological disorder is denied.
Entitlement to service connection for a gastrointestinal condition is denied.
Entitlement to service connection for abnormal weight loss is denied.
Entitlement to an initial compensable rating for service-connected pseudofolliculitis barbae is denied.
Entitlement to an initial compensable rating for service-connected hyperhidrosis is denied.
REMANDED
Entitlement to service connection for tinnitus is remanded.
Entitlement to service connection for onychomycosis is remanded.
Entitlement to service connection for a respiratory disability, including allergic rhinitis and pharyngitis is remanded.
Entitlement to service connection for a dental condition, to include on the basis for eligibility for outpatient dental treatment, is remanded.
Entitlement to service connection for a bone and joint condition of both upper and lower extremities is remanded.
Entitlement to service connection for a disability manifested by muscle pain is remanded.  
Entitlement to service connection for a low back condition is remanded.  
Entitlement to an overall or combined rating of 70 percent prior to September 29, 2010 is denied.
FINDINGS OF FACT
1. The preponderance of the evidence is against a finding that the Veteran’s current bilateral foot callouses and ingrown toenails were incurred during or as a result of his military service.   
2. The most competent, credible, and probative evidence of record weighs against a finding that the Veteran’s bilateral hearing loss was incurred during or as a result of his service and hearing loss did not manifest to a compensable degree within one year of the Veteran’s discharge from service.
3. The preponderance of the evidence is against a finding that the Veteran’s current glaucoma was incurred during or as a result of his military service.  
4. The Veteran’s fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms are attributable to a known diagnosis, and are not shown to be etiologically related to service, to include as manifestations of an undiagnosed illness attributable to the Veteran’s service in the Southwest Asia Theater of operations; nor are his gastrointestinal symptoms shown to have been manifest within one year of service.
5. The lay and medical evidence of record does not establish that the Veteran has manifested abnormal weight loss during the current appeal period or at any time in close proximity to the appeal period.
6.  The preponderance of the evidence reflects that the Veteran’s service-connected pseudofolliculitis barbae has not been manifested by any observable or compensable symptoms during the appeal period.
7. The preponderance of the evidence reflects that the Veteran’s service-connected hyperhidrosis does not prevent the ability to handle paper or tools after therapy.
CONCLUSIONS OF LAW
1. The criteria for service connection for bilateral foot calluses have not been met.  38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2018).
2. The criteria for service connection for ingrown toenails have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2018).
3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2018).
4. The criteria for service connection for glaucoma have not been met.  38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2018).
5. The Veteran’s current fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms were not incurred in or aggravated by active service, nor may those disabilities be presumed to have been incurred during service as chronic diseases or manifestations of an undiagnosed illness. 38 U.S.C. §§ 1110, 1117, 1131 (West 2012); 38 C.F.R. §§ 3.303, 3.317 (2018).
6. The criteria for service connection for abnormal weight loss have not been met.  38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2018).
7. The criteria for an initial compensable rating for service-connected pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.118, DC 7829 (2018).
8. The criteria for an initial compensable rating for service-connected hyperhidrosis have not been met.  38 U.S.C. §§ 1155, 5103, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.118, DC 78032(2018).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active service from October 1983 to May 1991.  This matter is on appeal from rating decisions issued in August 2009 and November 2012.  
Service Connection
Generally, establishing service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. 3.303.
1. Entitlement to service connection for bilateral foot callouses
2. Entitlement to service connection for an ingrown toenail left great toe
The Veteran is seeking service connection for bilateral foot callouses and ingrown toenails, both of which are shown to have been diagnosed and treated during the appeal period.  See August 2010 VA treatment record; see also January 2007 VA treatment record.
Despite the evidence showing a current diagnosis of bilateral foot callouses, the Veteran has not identified any in-service event, injury, or disease to which his bilateral foot callouses may be related.  His service treatment records (STRs) also fail to show any complaints or treatment for foot callouses and the post-service treatment records that document the presence of his current bilateral foot callouses do not contain any lay statements or medical evidence indicating that his callouses began during service or are otherwise related thereto.  
With respect to the ingrown toenails, the STRs reflect that the Veteran received treatment for an ingrown toenail on his right great toe in July 1986.  However, the evidence reflects that the Veteran requested the toenail be removed and there is no evidence of any subsequent complaints or treatment for ingrown toenails for the remainder of his military service.  Additionally, while the Veteran received treatment for ingrowing toenails after service, the first time this condition is shown is more than 10 years after service and, notably, neither the Veteran nor the examining clinician indicated that this condition had persisted since service or was otherwise related to any in-service event.  See VA treatment records dated June 2006 and January 2007.
Given the lack of credible lay evidence or competent medical evidence providing a nexus between the Veteran’s current bilateral foot callouses and ingrown toenails, the Board finds a VA examination and opinion are not needed in this case and that the evidence of record preponderates against a finding that the claimed disabilities are related to his military service.  Therefore, the Veteran’s claims of service connection for bilateral foot callouses and an ingrown toenail of the left great toe are denied.  
3. Entitlement to service connection for bilateral hearing loss
The Veteran was diagnosed with bilateral sensorineural hearing loss at the July 2008 VA examination, which sufficiently establishes the presence of the currently claimed disability.
With respect to service incurrence, the Veteran has asserted that his hearing loss was incurred as a result of noise exposure during service. In this regard, the Veteran has attributed his hearing loss to the duties he performed while assigned to infantry and artillery units. The Board concedes that the Veteran was exposed to acoustic trauma during service, as his service personnel records (SPRs) indicate that he was assigned to an artillery unit during service.  Therefore, the Veteran’s report of noise exposure is consistent with the nature and circumstances of his service and, hence, credible and in-service incurrence is established.
Nevertheless, the Board finds that the evidence does not establish a nexus or causal connection between the Veteran’s military noise exposure and current hearing loss.
The Veteran’s service treatment records (STRs) do not contain any complaints, treatment, or findings related to hearing loss or tinnitus. In fact, the Veteran’s hearing was normal on audiograms conducted throughout his period of service, including during his pre-induction and separation examinations.  See STRs dated June 1983, September 1985, October 1987, April 1991.
Moreover, there is no medical evidence showing complaints or treatment for hearing loss until May 2005 and a confirmed diagnosis of bilateral sensorineural hearing loss is not shown until the December July 2008 VA examination. See October 2005 VA treatment record.  In this regard, the Board notes that there is no lay or medical evidence of record that identifies the date of onset of the Veteran’s hearing loss; nor is there any indication or allegation that his hearing loss began in service or continued thereafter. Instead, the Veteran has only provided a general statement that he believes his hearing loss is related to his military service.   
The Board acknowledges the Veteran’s military noise exposure; however, there is no competent lay or medical evidence showing that he actually manifested an identifiable hearing impairment during service or within his first post-service year or evidence. Nor is there any medical evidence or opinion that relates the Veteran’s current hearing loss to service. 
During the July 2008 VA examination, the examiner noted the Veteran’s reports of in-service noise exposure, as well as his minimal post-service occupational or recreational noise exposure, but following a physical examination, interview of the Veteran, and review of the claims file, the VA examiner opined that the Veteran’s current hearing loss is not due to his military service. In making this determination, the examiner noted the Veteran’s entrance and separation audiograms were within normal limits and did not reflect any degradation of pure-tone thresholds during service.  The examiner also cited a landmark medical study of military noise exposure which found there is no scientific basis for delayed or late onset noise-induced hearing loss and explained that, in cases where entrance and separation audiograms and such tests were normal, there is no scientific basis for concluding that hearing loss that develops 20 or 30 years later is related to military noise exposure.   
The July 2008 VA opinion is considered competent and credible evidence addressing the etiology of the Veteran’s hearing loss, as the examiner provided a clear conclusion and supporting data in support thereof.  The Board also finds particularly probative that there is no contrary medical opinion of record. 
As noted, the Veteran has not asserted that his hearing loss actually began during service or persisted since that time. Instead, he has only stated that he believes that his hearing loss is related to the duties he performed during service. While the Veteran is competent to report that he experienced decreased hearing, the determination as to the etiology of his hearing loss is a complex medical question, as the diagnosis of hearing loss requires clinical observation and testing. It is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the relationship between his claimed disability and service. In addition, the Veteran has only offered conclusory statements regarding the relationship between his military service and hearing loss. By contrast, the July 2008 VA examiner took into consideration all the relevant facts in providing her opinion, which was based upon all relevant facts in this case, as well as her medical expertise. As such, the Veteran’s statements regarding a nexus between his military service and current hearing loss is outweighed by the July 2008 VA opinion and, as such, are not considered competent or probative evidence favorable to his claim.
As a final matter, the Board notes that because the medical evidence does not show a confirmed diagnosis of bilateral hearing loss until July 2008, more than 17 years after the Veteran was discharged from service, presumptive service connection, to include on the basis of continuity of symptomatology, is not warranted in this case. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Based on the foregoing, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for bilateral hearing loss. While the evidence of record shows the Veteran has current bilateral hearing loss, the probative evidence of record weighs against a finding that his disabilities were incurred in or are otherwise related to his military service. Because the evidence preponderates against the Veteran’s claim, the benefit-of-the-doubt doctrine is not for application and his claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
Service Connection – Mustard Gas Exposure and Undiagnosed Illness due to Gulf War service 
The Veteran has asserted that several of his claimed disabilities are due to his exposure to mustard gas during service, particularly given his duties as a Petroleum Supply Specialist.  While the Veteran’s DD Form 214 confirms his military occupational specialty (MOS) was a Petroleum Supply Specialist for part of his military service, VA has confirmed that he is not included on the list of individuals who were exposed to mustard gas during service and his other SPRs do not provide any indication that he was exposed to mustard gas during service.  See May 2008 Internal VA Email.  Additionally, there is no medical evidence or opinion of record that attributes the Veteran’s claimed disabilities to exposure to mustard gas.  Therefore, service connection is not warranted for any of the claimed disabilities on the basis of mustard gas exposure.  
Nevertheless, the Veteran has also asserted that several of his claimed disabilities are due to his service in Southwest Asia during the Gulf War.  See September 2010 Veteran statement.  The Veteran’s DD Form 214 reflects that he served in Southwest Asia from August 1990 to March 1991.  Therefore, he is considered a Persian Gulf War Veteran.  
In this regard, Service connection may also be granted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317 (a)(1).
For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317 (a)(4).
4. Entitlement to service connection for glaucoma, claimed as visual disturbance and burning
The Veteran has asserted that he was first diagnosed with glaucoma during service; however, the STRs do not reflect any complaints, treatment, or diagnosis of glaucoma during service.  Instead, the post-service treatment records reflect that he was initially diagnosed with glaucoma in March 2004.  See June 2004 VA treatment record.  Notably, neither the Veteran nor the examining physician noted that the post-service diagnosis of glaucoma was incurred during or as a result of his military service at that time.  
In fact, the evidentiary record does not contain any medical evidence or opinion of record that attributes the Veteran’s glaucoma ot any event, injury, or disease in service and the Veteran has only offered conclusory statements regarding the relationship between his military service and glaucoma – statements which are not supported by the service or post-service medical evidence of record.  In this regard, the Board notes the Veteran is not qualified through specialized education, training, or experience to offer an opinion on the relationship between his claimed disability and service and, as such, his statements are not considered competent or probative evidence favorable to his claim.
Based on the foregoing, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for glaucoma. While the evidence of record shows the Veteran has glaucoma, the probative evidence of record weighs against a finding that his disability was incurred in or is otherwise related to his military service. Because the evidence preponderates against the Veteran’s claim, the benefit-of-the-doubt doctrine is not for application and his claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
5. Entitlement to service connection for chronic fatigue syndrome
6. Entitlement to service connection for a cardiovascular condition
7. Entitlement to service connection for a neurological disorder
8. Entitlement to service connection for a gastrointestinal condition
The Veteran has variously sought to establish service connection for the aforementioned disabilities as undiagnosed illnesses or medically unexplained chronic multisystem illness due to his Gulf War service; however, after review of the evidence, the Board finds service connection is not warranted as each of the foregoing signs and symptoms have been attributed to specific diagnoses that are not shown to be due to his military service.  
Review of the record reveals the Veteran has complained of experiencing fatigue at various times during the appeal period.  See October 2008 VA treatment record; December 2009 VA treatment record; September 2013 VA treatment record.  
The Veteran was afforded a VA examination in July 2013, during which he reported having low energy and low interest in participating in activities.  The VA examiner noted that laboratory tests were ordered to rule out a rheumatological reason for the Veteran’s fatigue but the examiner stated that all of the tests were normal and that there were no findings to suggest or support a diagnosis of chronic fatigue syndrome.  Instead, the VA examiner noted the Veteran was actively being treated by mental health for depression and posttraumatic stress disorder (PTSD).  In this regard, the Board notes that, in October 2008, the Veteran attributed his feelings of fatigue to his depression.  See October 2008 VA treatment record.
Given this evidence, the Board finds the preponderance of the evidence shows the Veteran’s fatigue is related to his mental health disability, which has been variously diagnosed as PTSD, depression, and anxiety.  
Similarly, in April 2006, the Veteran reported having chest pain with associated paresthesias in his hands and feet, which he reported had been present for one month.  After examining the Veteran, the clinician diagnosed the Veteran with atypical chest pain which he opined was more likely related to his anxiety and panic attacks.  See April 2006 VA treatment record.  During the December 2008 VA examination, the Veteran also reported having chest pain during service; however, the VA examiner stated that his chest pain was non-cardiac in nature and opined that it is likely the result of his anxiety.  See December 2008 VA Gulf War examination.  
Notably, the other medical evidence of record does not contain any complaints, treatment, or diagnoses related to any other cardiovascular signs or symptoms.  Therefore, the preponderance of the evidence reflects the Veteran’s chest pain has also been attributed to his mental health disability.  
The April 2006 VA clinician did not address the Veteran’s reported neurologic complaints at that time; however, the evidence shows the Veteran subsequently complained of left shoulder and neck pain.  See January 2011 VA treatment record.  The January 2011 VA clinician questioned if the Veteran’s complaints of left arm pain were neurologic in nature but he noted the distribution of the Veteran’s pain was non-anatomic and a separate record reflects that the Veteran was diagnosed with cervical radiculopathy.  See May 2010 VA treatment record.  Notably, the post-service medical evidence does not otherwise reflect that the Veteran has complained of neurologic signs or symptoms.  
Therefore, the Board finds the preponderance of the evidence reflects that the Veteran’s neurologic signs and symptoms have been attributed to a clinical diagnosis: cervical radiculopathy.  
Finally, during the December 2008 VA examination, the Veteran reported feeling a pulling sensation in his abdomen with bubbling noises, upset stomach, bloody stools, and nausea, all of which were attributed to gastritis.  See December 2008 VA Gulf War examination.  During the July 2013 VA examination, the Veteran reported having occasional indigestion but was otherwise unable to recall specifics of gastritis at the examination. Notably, the other medical evidence of record does not reflect any additional complaints or treatment for gastrointestinal problems.  Therefore, the Veteran’s gastrointestinal symptoms have been attributed to a diagnosis of gastritis.  
As the Veteran’s fatigue, chest pain, neurologic complaints, and gastrointestinal symptoms are not undiagnosed illnesses or medically unexplained chronic multisystem illnesses, but instead have been attributed to specific diagnoses/disabilities, they are not qualifying chronic disabilities for purposes of service connection based on Persian Gulf veteran status, and cannot be found service-connected on that basis.
The Board has considered whether service connection can be granted for the Veteran’s claimed disabilities on a direct basis.  However, the STRs do not contain any complaints, treatment, or diagnoses related to disabilities manifested by fatigue, chest pain (or other cardiovascular symptoms), neurologic complaints, or gastrointestinal symptoms.  Indeed, during examinations conducted in June 1983 and October 1987, the Veteran denied having palpitations or pounding heart, heart trouble, neuritis, frequent indigestion, or stomach or intestinal trouble.   See STRs dated June 1983 and October 1987.
In fact, the Board finds probative that the Veteran has never asserted that his symptoms actually began in or in close proximity to his active military service and that his reported symptoms are not shown for many years after service. 
In evaluating these claims, the Board finds probative that there is no medical evidence or opinion of record that suggests the Veteran’s fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms are related to his military service. While VA has not obtained a medical opinion that addresses direct service connection with respect to these disabilities, the Board finds that a VA examination/opinion is not needed. As noted, while there is evidence of current fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms, there is no evidence of any injury or disability in service to which the current disabilities may be related. Moreover, there is no competent lay or medical evidence of record establishing, or even indicating, an etiologic relationship between the Veteran’s current disabilities and his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, the Board finds that a VA examination/opinion is not necessary to decide the claims of service connection for the Veteran’s fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms.
The Board has considered the Veteran’s lay assertions of a nexus between his period of military service and current fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms. However, it is not argued or shown that the Veteran is qualified through specialized education, training, or experience to offer an opinion on the relationship between his claimed disabilities and service. While lay persons are competent to provide opinions on some medical matters (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the etiology of his fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms are complex medical matters that fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran’s statements regarding a nexus between his current fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms and military service are outweighed by the other evidence of record, and, as such, are not considered competent or probative evidence favorable to his claims.
Therefore, based on the foregoing, the Board finds the preponderance of the evidence is against the grant of service connection for the claimed fatigue, chest pain, neurologic complaints, or gastrointestinal symptoms on a direct basis. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims and, as such, that doctrine is not applicable in the instant appeal and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.
9. Entitlement to service connection for abnormal weight loss
The Veteran has sought to establish service connection for abnormal weight loss as an undiagnosed illness or medically unexplained chronic multisystem illness due to his Gulf War service; however, after review of the evidence, the Board finds service connection is not warranted for abnormal weight loss.
During the December 2008 VA examination, the examiner noted the Veteran’s weight had been variable over the previous couple of years and ranged between 140 and 205 pounds, while also noting that he had been seeing a dietician because he was unable to drop the weight.  See December 2008 VA examination.  In this regard, the post-service treatment records generally note the Veteran is overweight and has been encouraged to lose weight.  Indeed, the treatment records reflect that any weight loss the Veteran has experienced was attributed to diet and exercise as opposed to as due to an undiagnosed illness or medically unexplained chronic multisystem illness.  See June 2004 VA treatment record; February 2005 VA treatment record; April 2005 VA treatment record; December 2008 VA treatment record.
The Veteran has not submitted any lay or medical evidence showing he has experienced abnormal weight loss during the appeal period or in the time period just prior to the filing of this claim.  Accordingly, in the absence of a current disability, the Veteran’s claim must be denied and the benefit of the doubt doctrine does not apply.  
Increased Rating
10. Entitlement to an initial compensable rating for service-connected pseudofolliculitis barbae 
The Veteran’s service-connected pseudofolliculitis barbae (PFB) is rated noncompensable (zero percent disabling) pursuant to 38 C.F.R. § 4.118, DC 7829, which provides the rating criteria for chloracne.  
During the July 2012 VA skin examination, the Veteran was diagnosed with PFB.  However, the examiner explained that the Veteran’s PFB was not active and that his beard prevented observation of any scars.  The examiner noted that the Veteran’s various skin disabilities, including PFB, was not manifested by scarring, disfigurement, systemic manifestations, or debilitating or non-debilitating episodes.  He also noted the Veteran’s skin disabilities, including PFB, did not require treatment with oral or topical medications.  See July 2012 VA Skin examination.  
The evidentiary record does not contain any additional lay or medical evidence regarding the severity of the Veteran’s PFB.  In fact, the Veteran has not asserted that his PFB has worsened or has been manifested by any observable or compensable symptoms since the July 2012 VA examination.  Instead, he has only asserted that his disability warrants a compensable rating.  
Given the foregoing, the Board finds the Veteran’s service-connected PFB does not warrant an initial compensable rating under DC 7829 or any other potentially applicable diagnostic code, as the evidence of record reflects that his disability is not manifested by any observable or compensable symptoms.  See 38 C.F.R. § 4.31. 
11. Entitlement to an initial compensable rating for service-connected hyperhidrosis 
The Veteran’s service-connected hyperhidrosis is rated noncompensable (zero percent disabling) pursuant to 38 C.F.R. § 4.118, DC 7832.  Under that code, a noncompensable rating is warranted when the Veteran is able to handle paper or tools after therapy, while a 30 percent rating is warranted when the Veteran is unable to do so.  
During the July 2012 VA skin examination, the Veteran was diagnosed with hyperhidrosis, which the examiner stated was not active.  In this regard, the examiner noted the Veteran had dry skin residuals on his bilateral hands which were not related to any activity or season.  The examiner also specifically noted the Veteran was able to handle paper or tools after treatment.  See July 2012 VA Skin examination.  
The evidentiary record does not contain any additional lay or medical evidence regarding the severity of the Veteran’s hyperhidrosis, except for the September 2008 VA examination during which he was noted to have callouses and peeling on his hands.  The September 2008 VA examiner did not provide any information regarding any functional impairment caused by the Veteran’s hand callouses.  See September 2008 VA examination.  Additionally, the Veteran has not asserted that his PFB has worsened or resulted in any functional limitation since the July 2012 VA examination.  Instead, he has only asserted that his disability warrants a compensable rating.  
Given the foregoing, the Board finds the Veteran’s service-connected hyperhidrosis does not warrant a compensable rating, as the preponderance of the evidence does not reflect that his disability renders him unable to handle paper or tools after treatment.  Therefore, the Veteran’s increased rating claim must be denied and the benefit of the doubt doctrine is not for application in this case.  
REASONS FOR REMAND
1. Entitlement to service connection for tinnitus is remanded.
During the July 2008 VA audiological examination, the examiner did not provide a medical opinion regarding the etiology of the Veteran’s claimed tinnitus because the Veteran denied having a history of tinnitus during the examination.  However, the Veteran has reported having tinnitus at various times during the appeal period.  See December 2007 VA treatment record; September 2009 VA treatment record.  
Given the Veteran’s competent and credible report of tinnitus and his military noise exposure, a remand is required to obtain a medical opinion regarding the likely etiology of his tinnitus.
2. Entitlement to service connection for onychomycosis
In April 2008, the Veteran filed a claim seeking service connection for residuals of onychauxis; however, in the August 2009 rating decision, the RO denied service connection for onychomycosis.  However diagnosed, review of the evidence reveals the Veteran has received treated for onychauxis throughout the appeal period and he was also diagnosed with onychomycosis involving all 10 toenails and tinea pedis during the July 2012 VA Skin examination.  The VA examiner did not provide any medical history or nexus statement regarding the Veteran’s onychomycosis or tinea pedis; however, the STRs reflect that he received treatment for tinea pedis during service and the Veteran has asserted that his onychomycosis and onychauxis are residual conditions of that which was manifested in service.  See January 1986 STR; June 2008 Veteran statement.  
Based on the foregoing, the Board finds a medical opinion is needed to address the likelihood that the Veteran’s current onychomycosis, onychauxis, and or tinea pedis are related to his military service.  
3. Entitlement to service connection for a respiratory disability, including allergic rhinitis and pharyngitis, is remanded.
In July 2012, the Veteran was afforded a VA sinus and respiratory examination.  During the sinus examination, the Veteran was diagnosed with allergic and non-allergic rhinitis; however, a diagnosis was not rendered during the respiratory examination.  Nevertheless, the Veteran reported having shortness of breath which he attributed to oil burns and dust from his service in Southeast Asia.  Despite the Veteran’s assertions and the diagnoses of allergic and non-allergic rhinitis, an opinion was not rendered as to whether the Veteran’s current respiratory disabilities are related to his exposure to oil burns and dust during the Gulf War.  Therefore, the Board finds an addendum opinion is needed regarding the likely etiology of his current respiratory disability. 
4. Entitlement to service connection for a bone and joint condition of both upper and lower extremities
5. Entitlement to service connection for a disability manifested by muscle pain
6. Entitlement to service connection for a low back condition
The Veteran has sought to establish service connection for a joint condition, low back condition, and a disability manifested by muscle pain as due to an undiagnosed illness or medically unexplained chronic multisystem illnesses due to his Gulf War service.
VA treatment records show the Veteran has variously reported having body aches, pain in multiple joints, including his low back, and muscle aches throughout the appeal period.  Notably, none of the Veteran’s examining clinicians attributed his various complaints to a specific diagnosis.  See e.g., January 2007 VA treatment record; VA treatment records dated September 2009, December 2010, July 2011; September 2013 VA treatment record.  Nevertheless, the December 2008 VA examiner stated that the Veteran’s muscle tension and pain were a likely residual of his anxiety, without any explanation or rationale in support thereof, and he did not address the likely etiology of the Veteran’s joint and/or low back pain.  
Given the conflicting evidence of record regarding the nature and etiology of the Veteran’s various joint, muscle, and low back problems, the Board finds an addendum opinion is needed.    
7. Entitlement to service connection for a dental disability, to include on the basis of eligibility for outpatient dental treatment, is remanded. 
In April 2008, the Veteran filed a claim seeking service connection for outpatient dental care; however, the RO has not developed or adjudicated the issue of service connection for a dental disability on the basis of eligibility for outpatient dental treatment and only considered the Veteran’s claim on the basis of service connection for a dental disability for compensation purposes.  See August 2009 Rating Decision; July 2010 Statement of the Case.   
The Board is unable to proceed with this appeal until the AOJ completes the necessary development and adjudication. 38 C.F.R. § 17.161; Douglas v. Derwinski, 2 Vet. App. 435 (1992); Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  Therefore, a remand is necessary.  
8. Entitlement to an overall or combined rating of 70 percent prior to September 29, 2010
The Veteran’s claim of entitlement to a higher combined rating prior to September 29, 2010 is inextricably intertwined with the service connection claims being remanded herein, as the grant of service connection for any of the claims remaining on appeal may impact his overall disability rating.  Therefore, adjudication of this claim must be deferred pending resolution of those claims.   
The matters are REMANDED for the following action:
1. Return the claims file to the examiner who conducted the Veteran’s July 2008 VA audiological examination. If the July 2008 VA examiner is no longer available, request that another provider review the record and provide the requested opinions. 
After review of the record, the examiner is asked to provide the following opinions:
Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current tinnitus was incurred in or otherwise related to his military service? 
In answering the foregoing, the examiner should consider the Veteran’s credible reported in-service noise exposure, as well as the service and post-service treatment records. 
A rationale should be provided for each opinion offered.
2. Return the claims file to the examiner who conducted the Veteran’s July 2012 VA skin examination. If the July 2012 VA examiner is no longer available, request that another provider review the record and provide the requested opinions. 
After review of the record, the examiner is asked to provide the following opinions:
Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current onychomycosis, onychauxis, and/or tinea pedis were incurred in or as a result of his military service, including the treatment for tinea pedis in January 1986? 
In answering the foregoing, the examiner should consider the Veteran’s credible lay statements regarding the onset and nature of his current disabilities, as well as the service and post-service treatment records.   
A rationale should be provided for each opinion offered.
3. Return the claims file to the examiner who conducted the Veteran’s July 2012 VA sinus and respiratory examinations. If the July 2012 VA examiner is no longer available, request that another provider review the record and provide the requested opinions. 
After review of the record, the examiner is asked to provide the following opinions:
Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current diagnoses of allergic and non-allergic rhinitis were incurred in or as a result of his military service, including exposure to oil burns and dust during his service in Southeast Asia?
The examiner should also address if the Veteran has any respiratory or pulmonary signs or symptoms that are not attributable to his diagnosis of allergic and non-allergic rhinitis that represent an undiagnosed illnesses or medically unexplained chronic multisystem illnesses. 
In answering the foregoing, the examiner should consider the Veteran’s credible lay statements regarding the onset and nature of his current disabilities, as well as the service and post-service treatment records.   
A rationale should be provided for each opinion offered.
4. Obtain an addendum opinion to determine the nature and etiology of any disability manifested by joint pain, muscle pain, or low back pain.  The examiner must review the claims file and note that review in the report. A supporting rationale for all opinions must be provided. 
a. Is it at least as likely as not (i.e., probability of 50 percent) that the Veteran’s claimed joint pain, muscle pain, and/or low back pain are due to (1) an undiagnosed illness or (2) a medically unexplained chronic multisystem illness? If so, the examiner should comment on the severity of such symptomatology and report signs and symptoms necessary for evaluating the illness under the rating criteria. 
b. Are there objective indications that the Veteran is suffering from chronic disability manifested by joint pain, muscle pain, and/or low back pain? The examiner must determine whether these symptoms can be attributed to any known clinical diagnosis or to a chronic multi-symptom illness with a partially explained etiology.
c. With respect to any currently diagnosed disability manifested by joint pain, muscle pain, and/or low back pain, is it at least as likely as not (i.e., probability of 50 percent) that the disability was incurred in service?
(Continued on the next page)
 
The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 
5. Complete the necessary development for the dental treatment claim, to include referring it to VHA if deemed necessary.
 
R. FEINBERG
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A.J. Turnipseed, Counsel 

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

For More Information on Veterans Disability Compensation Benefits! Visit: DisableVeteran.org ~ A Non-Profit Non Governmental Agency


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