Citation Nr: 18160491
Decision Date: 12/27/18	Archive Date: 12/26/18

DOCKET NO. 10-19 306
DATE:	December 27, 2018
ORDER
Entitlement to an increased evaluation for residuals of a fracture of the distal end of the right second metacarpal, rated as noncompensably disabling prior to May 15, 2017, and 10 percent disabling thereafter is denied.
Entitlement to a compensable evaluation for right ear hearing loss is denied.
Entitlement to an increased evaluation for hemorrhoids, rated as noncompensably disabling prior to March 16, 2005; 10 percent disabling from March 16, 2005, to May 14, 2017; and 20 percent disabling beginning May 15, 2017, is denied.
Entitlement to an increased evaluation of 60 percent for hiatal hernia is granted.
REMANDED
Entitlement to service connection for diabetes mellitus is remanded.
Entitlement to service connection for an eye disability, to include as secondary to diabetes mellitus, is remanded. 
Entitlement to service connection for a neurological disability, to include as secondary to diabetes mellitus, is remanded. 
Entitlement to a total disability rating due to individual employability (TDIU) resulting from service-connected disability is remanded.
FINDINGS OF FACT
1. Prior to May 15, 2017, the residuals of a fracture of the distal end of the right second metacarpal were manifested by pain and no gap between the index finger and the proximal transverse crease of the right hand. 
2. Beginning May 15, 2017, the residuals of a fracture of the distal end of the right second metacarpal were manifested by pain and a 7.5 cm gap between the index finger and the proximal transverse crease of the right hand.
3. The service-connected right ear hearing loss disability is shown to have been productive of no more than a Level V designation in the right ear that combines with the Level I designation in the non-service connected left ear, resulting in a noncompensable rating under 38 C.F.R. § 4.85, Table VII. 
4. For the period prior to March 15, 2017, the Veteran’s hemorrhoids manifested as large, bleeding, and painful without thrombosis, secondary anemia, or fissures.
5. For the period beginning March 15, 2017, the Veteran’s hemorrhoids manifested as persistently bleeding, small or moderate reducible external hemorrhoids, with excessive redundant tissue.
6.  The Veteran’s hiatal hernia manifested dysphagia, regurgitation, substernal pain, epigastric pain, vomiting, and some hematemesis.
CONCLUSIONS OF LAW
1. The criteria for an increased evaluation for residuals of a fracture of the distal end of the right second metacarpal, rated as noncompensably disabling prior to May 15, 2017, and 10 percent disabling thereafter, have not been met.  38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a Diagnostic Code 5003, 5229.
2. The criteria for a compensable evaluation for right ear hearing loss have not been met.  38 U.S.C. § 1155; 38 C.F.R. §§ 3.383, 4.85, 4.86, Diagnostic Code (DC) 6100.
3. The criteria for an increased evaluation for hemorrhoids, rated as noncompensably disabling prior to March 16, 2005; 10 percent disabling from March 16, 2005, to May 14, 2017; and 20 percent disabling beginning May 15, 2017, have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7336.
4. The criteria for an increased 60 percent evaluation for hiatal hernia have been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7346.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the United States Navy from January 1961 to January 1970.  These matters come before the Board of Veterans’ Appeals (Board) on appeal from September 2004 and July 2005 rating decisions.
In his December 2006 and April 2010 substantive appeals (VA Form 9) and November 2007 notice of disagreement (VA Form 21-4138), the Veteran requested hearings before a hearing officer and a Veterans Law Judge.  These hearing requests were subsequently withdrawn.
Increased Rating
Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  When a question arises as to which of two ratings apply under a particular diagnostic code (DC), the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating.  38 C.F.R. § 4.7.  After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran.  38 C.F.R. § 4.3.
The veteran’s entire history is reviewed when making disability ratings.  See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. “Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings.”  Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (citation omitted).  VA accordingly concentrates on the evidence that establishes the state of the veteran’s disability in the period one year before the veteran files his claim through the date VA makes a final decision on the claim.  Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). 
When weighing evidence, lay statements that describe the features or symptoms of an injury or illness are considered competent evidence. Falzone v. Brown, 8 Vet. App. 398 (1995). A lay person is also competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Once evidence is determined competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”)).
1. Entitlement to an increased evaluation for residuals of a fracture of the distal end of the right second metacarpal, rated as noncompensably disabling prior to May 15, 2017, and 10 percent disabling thereafter
Entitlement to service connection for residuals of a fracture of the distal end of the right second metacarpal was granted in a June 1970 rating decision.  An initial noncompensable evaluation was assigned effective January 13, 1970.  The Veteran filed the current claim for an increased rating in March 2005.  A July 2005 rating decision continued the noncompensable rating.  In an August 2018 rating decision, the evaluation was increased to 10 percent effective May 15, 2017.  The Veteran contends that a compensable rating is warranted for residuals of a fracture of the distal end of the right second metacarpal as his symptoms are more severe than what is contemplated by the current evaluation. 
The Veteran’s residuals of a fracture of the distal end of the right second metacarpal are rated as noncompensably disabling and 10 percent disabling under DC 5229: limitation of motion of the index or long finger.  This DC provides for a 10 percent rating when there is a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or with extension limited by more than 30 degrees. A gap of less than one inch, or where extension is limited by no more than 30 degrees, is noncompensable.
For the period prior to May 15, 2017, the Veteran’s residuals of a fracture of the distal end of the right second metacarpal are rated as noncompensably disabling.  At a May 2005 VA examination, the Veteran reported constant pain in the index and middle fingers of the right hand as well as on the medial aspect of the dorsal surface of the hand.  The Veteran was able to lay all fingers across the proximal transverse crease of the palm with no gaps.  Extension was not limited by more than 30 degrees.  
The May 2005 VA examination found mild degenerative changes of the distal interphalangeal joint spaces of the first through fifth digits but the remainder of the joint spaces were within normal limits. This VA examination found it at least as likely as not that the service-connected fracture of the second metacarpophalangeal (MCP) joint was contributing to the pain in his index finger; however, the pain in the remaining fingers was not due to the fracture.  Instead, the pain of the remaining fingers was secondary to degenerative joint disease of the distal interphalangeal (DIP) joints noted on x-ray. The May 2005 VA examination also noted that “a fracture of a single distal MCP will not result in degenerative changes is [sic] all of the joints in another part of the hand while leaving others spared.”  Accordingly, although arthritis is shown in the right hand, it is in the DIP joints, not the MCP joint fractured in service.  Thus, the Board does not consider the appropriateness of a rating under the criteria for arthritis.
In a December 2006 VA medical center (VAMC) record, the Veteran stated that the fingers of his right hand “are more stiff and starting to bend laterally.”  In the December 2006 substantive appeal, the Veteran wrote that he was unable to close his fingers tightly and that he did “have a gap between the fingertip and palm.”  The Veteran did not state how large the gap was.  In a statement received in September 2016, the Veteran reported that his right hand had reduced strength, pain, and the fingers locked “sometimes.”  
Considering this evidence, the Board finds the Veteran’s residuals of a fracture of the distal end of the right second metacarpal most nearly approximate a noncompensable rating.  Although there are reports of pain, and the Veteran noted a gap between his finger and his palm, the Veteran did not state how large the gap was.  Because the gap can be up to one inch before it reaches a compensable level, the Board finds that a noncompensable rating is appropriate for the period prior to May 15, 2017.
Beginning May 15, 2017, the Agency of Original Jurisdiction (AOJ) assigned a 10 percent rating.  A May 2017 VA examination found no ankylosis or related scars.  It also found no nerve injury related to the service-connected fracture, attributing the Veteran’s right hand neuropathy instead to a combination of the 1980s repair of the brachial artery, diabetic neuropathy, and polyneuropathy.  The Veteran reported flare-ups of the hand, finger, or thumb joint, stating “When it starts, [he] can’t hardly bear it”; the Veteran also reported having functional loss or impairment in that he “Can’t close hand, can’t grip, can’t open jar, can’t open bottle of water.” The May 2017 VA examination noted that the Veteran had a 7.5 cm gap between his index finger and the proximal transverse crease of the hand.  This warrants an increased evaluation of 10 percent.
The May 2017 VA examination recorded arthritis of the hand documented by x-ray but did not state which joints were involved.  Resolving reasonable doubt in the Veteran’s favor, the Board will consider whether an increased rating is warranted for arthritis of the right second metacarpal.  Diagnostic code 5003 (arthritis, degenerative), provides two rating options for x-ray-established degenerative arthritis. The first is based on limitation of motion (as classified under the DC for the joint involved) objectively confirmed by findings such as swelling, muscle spasm, or painful motion. The second option under DC 5003 applies where there is no limitation of motion; this option allocates either a 10 percent rating if two or more major joints (or minor joint groups) are involved or a 20 percent rating if the criteria for a 10 percent rating are met and there are occasional incapacitating exacerbations.  The Veteran’s 10 percent rating is already based on limitation of motion of the joint involved — the index finger — and a 20 percent rating is not warranted under DC 5003 because two or more major joints (or minor joint groups) are not involved. 
In sum, the current noncompensable rating prior to May 15, 2017, and 10 percent rating thereafter are appropriate and a higher evaluation is not warranted.
2. Entitlement to a compensable evaluation for right ear hearing loss
Service connection for right ear hearing loss was granted in a June 1970 rating decision; a noncompensable evaluation was assigned effective January 13, 1970.  The Veteran contends that a compensable rating is warranted because the level of hearing loss is not represented by the current evaluation.
Evaluations of hearing loss range from noncompensable to 100 percent, based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz.  38 C.F.R. § 4.85.  To evaluate the degree of disability for service-connected hearing loss, the Rating Schedule establishes eleven auditory acuity levels, designated from Level I through Level XI, for profound deafness.  38 C.F.R. § 4.85, Diagnostic Code 6100.  
The Rating Schedule also provides for rating exceptional patterns of hearing impairment.  38 C.F.R. § 4.86 (2015).  If the puretone threshold is greater than 55 decibels at each of four specified frequencies (1000 Hertz, 2000 Hertz, 3000 Hertz, and 4000 Hertz), VA must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral, with each ear evaluated separately.  38 C.F.R. § 4.86(a).  If the puretone threshold is 30 decibels or less at 1000 Hertz and simultaneously 70 decibels or more at 2000 Hertz, VA must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next highest numeral for consideration, with each ear evaluated separately.  38 C.F.R. § 4.86(b).
As an initial matter, the Board will discuss VAMC audiological evaluation results as well as the August 2016 VA examination results to explain why these results are not being considered in the rating of the Veteran’s hearing loss disability.  September 2004, March 2006, March 2007, October 2013, August 2015, and July 2016 VAMC audiological evaluation results are not valid for rating purposes because they did not use the Maryland CNC speech discrimination test, as required by 38 C.F.R. § 4.85.  
The Board additionally notes that the August 2015 and July 2016 VAMC audiological evaluations did not perform any speech discrimination test because the Veteran could not be tested.  The August 2015 VAMC record found the Veteran’s evaluation results indicated “poor reliability since the [V]eteran was able to answer open-ended questions without the use of his hearing aids at normal conversational levels”; in addition, the clinician noted that the Veteran “did not even indicate vibrotactile responses which are present at high levels regardless of hearing loss.”  The July 2016 VAMC audiological evaluation made comparable findings, stating that the “Veteran was asked open ended questions through talk-forward function at 60dB and veteran responded without any hesitation” and the Veteran “did not even indicate vibrotactile responses which are present at high levels regardless of hearing loss.”
For similar reasons, the August 2016 VA examination results are not valid.  The examiner felt the puretone threshold results were not valid because they did not give an accurate portrait of the Veteran’s hearing loss.  As stated by the examiner,
The [V]eteran entered the testing booth with his hearing aids in his ears.  The aids remained in his ears during the case history portion and while he did exhibit some difficulty understanding certain questions, he could answer my questions without incident.  He was counseled on how the test would go and he indicated that he understood.  During the pure tone portion, testing was stopped and re-explained.  The results were no different. After testing was completed, without his hearing aids, [the Veteran] was conversing with me quite well given his communication difficulty.  While I feel [the Veteran] does indeed have a hearing loss, I do not believe this test gives an accurate representation of his hearing ability.
The examiner also did not perform a speech discrimination test because it was found that the use of such a score would not be appropriate.
The Board acknowledges that its decision not to consider these VAMC results or the August 2016 VA examination means the Veteran’s disability evaluation will be based on a May 2005 VA examination.  VA attempted to give the Veteran a more recent examination when it scheduled the August 2016 VA examination; however, the Veteran failed to comply by declining to give full effort at the VA examination.  The Court has held that VA’s duty to assist the Veteran in developing the facts and evidence pertinent to a claim is not a one-way street.  See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).  It is the responsibility of Veterans to cooperate with VA.  See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992).  The Board finds that giving the Veteran an additional opportunity would be fruitless because the previous two VAMC evaluations also noted the Veteran’s lack of effort.  For the above reasons, the only audiological evaluation the Board will consider is the May 2005 VA examination.
The May 2005 VA examination indicated pure tone thresholds, in decibels, as follows:  
			HERTZ		
	500	1000	2000	3000	4000
RIGHT	50	50	60	70	80

The average pure tone threshold at 1,000, 2,000, 3,000, and 4,000 Hertz was 65 decibels.  Speech recognition ability was 72 percent.  These findings do not qualify as an exceptional pattern of hearing impairment and translate to Level V hearing impairment under Table VI.  Pursuant to 38 C.F.R. § 4.85(f), the hearing in the non-service-connected ear is assigned a Level I designation.  Level V hearing impairment in one ear with Level I non-service connected hearing in the other ear is considered noncompensably disabling.  38 C.F.R. § 4.85, Diagnostic Code 6100.  Thus, a compensable rating is not warranted for the Veteran’s hearing loss.
In exceptional cases an extraschedular rating may be provided.  38 C.F.R. § 3.321.  The Court of Appeals for Veterans Claims (Court) has set out a three-part test (based on the language of 38 C.F.R. § 3.321(b)(1)) for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice.  Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009).  
The Veteran reported dizziness and bleeding in his right ear at the May 2005 VA examination.  With respect to dizziness, this symptom is not contemplated in the rating schedule to be a symptom associated with hearing loss, but is specifically indicated by the rating schedule to be a separately ratable disability.  These symptoms are recognized in the rating schedule as symptoms of cholesteatoma (DC 6200), peripheral vestibular disorders (DC 6204), or Meniere’s syndrome (DC 6205), which are separately compensable disabilities distinct from hearing impairment (DC 6100) (and not to be combined with hearing impairment in the case of Meniere’s syndrome), and would be rated in accordance with the schedular criteria under the applicable Diagnostic Code, provided it is present in the Veteran and determined to be service connected.
At the May 2005 VA examination, the Veteran reported dizziness around December 2004 “but the problem significantly improved after adjustments to his medications. He is taking oral medications for diabetes, neuropathy, arthritis, and hypertension.”  An August 2015 VAMC record also addressed the Veteran’s dizziness, stating “[The Veteran’s complaints of imbalance and dizziness appear to be related to possible orthostatic hypotension combined with peripheral neuropathy. He does not present with any [complaints of] true vertigo or symptoms consistent with a peripheral vestibular disorder.”  Thus, the Board finds that the Veteran’s dizziness is not related to his hearing loss disability.
As for the bleeding, at the May 2005 VA examination the Veteran complained of soreness and bleeding in his right ear for the last few months.  The VA examination stated that the Veteran “attributed the bleeding to the effect of blood thinners he is taking” but the VA examination did not offer an opinion as to etiology.  There is no competent evidence in the record to suggest that the Veteran’s bleeding in the right ear is related to his hearing loss.
Moreover, considering Thun, for both dizziness and bleeding, even if the dizziness and bleeding were related to hearing loss, the Board notes that the second element of the analysis — indicia of an exceptional or unusual disability picture — is not met.  The record does not reflect marked interference with employment or frequent periods of hospitalizations due to dizziness or bleeding in the right ear.  For these reasons, the Board finds that the record does not establish that Veteran’s hearing loss is so exceptional or unusual as to warrant referral for extraschedular consideration.
Finally, entitlement to a TDIU is an additional element to be considered for all claims for an increased rating.  Rice v. Shinseki, 22 Vet. App. 447 (2009).  Although the Veteran reported at the August 2016 VA examination that he “can’t hear,” the record does not indicate that the Veteran is unemployable due to his right ear hearing loss and the Veteran has not made such a claim.  The Veteran could work in an environment that does not require hearing for safety purposes and could rely on his left ear for hearing.  Thus, remand of a TDIU claim is not necessary.
3. Entitlement to an increased evaluation for hemorrhoids, rated as noncompensably disabling prior to March 16, 2005; 10 percent disabling from March 16, 2005, to May 14, 2017; and 20 percent disabling beginning May 15, 2017
Entitlement to service connection for hemorrhoids was granted in a June 1970 rating decision.  An initial noncompensable evaluation was assigned effective January 13, 1970.  The Veteran filed the current claim for an increased rating in March 2005.  A July 2005 rating decision continued the noncompensable rating but a November 2006 rating decision increased the evaluation to 10 percent, effective March 16, 2005.  In August 2018, the evaluation was increased to 20 percent effective May 15, 2017.  The Veteran contends that a higher rating is warranted for his hemorrhoids.
The Veteran’s hemorrhoid disability is evaluated under DC 7336.  Pursuant to DC 7336, a noncompensable rating is warranted where the hemorrhoids are found to be mild or moderate in nature.   A 10 percent rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences.  A 20 percent rating, the highest rating available pursuant to DC 7336, is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures.  38 C.F.R. § 4.114.
The Veteran was assigned a 10 percent evaluation for hemorrhoids effective March 16, 2005.  Although the Board considers evidence in the year prior to the date of claim, in this case there was no relevant evidence prior to March 16, 2005.  Thus, the date of claim for increased rating is the appropriate date for the increase.  38 C.F.R. § 3.400.
As for the period beginning March 16, 2005, the Veteran reported at a May 2005 VA examination that he had bleeding and burning pain with each bowel movement, though the Veteran denied any thrombosis.  The May 2005 examination identified two hemorrhoids: a “Single large external nonthrombosed hemorrhoid in the anal area” and a “Small internal hemorrhoid.”  
In a December 2006 substantive appeal, the Veteran stated that he had fissures “as much as 2 – 3 times per week.”  Although the Veteran is competent to relate symptoms he has experienced, the Board finds his statement regarding fissures is not credible because it requires medical knowledge outside the lay experience of the difference between fissures and hemorrhoids.  Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999).  The Veteran has not demonstrated such knowledge; therefore, the statement is not competent and is given little weight.
A March 2007 VAMC record noted that the Veteran’s hemorrhoids ‘bleed persistently at times and at times burst.”  In a statement received in September 2016 the Veteran reported that he had “hemorrhoids, pain [and] sometimes blood.”
Considering this evidence, the Board finds that the current 10 percent rating is appropriate.  Although the Veteran reported burning pain and bleeding with every bowel movement at the May 2005 VA examination, there was no reference to secondary anemia or fissures.  The later medical and lay evidence also recorded bleeding “persistently at times” and “sometimes,” again without reference to anemia.  In addition, the Veteran’s medical record does not contain any reference to fissures and the Veteran is not competent to make such a finding.  Accordingly, a 10 percent rating is appropriate for the period prior to May 15, 2017. 
The Agency of Original Jurisdiction assigned a 20 percent rating effective May 15, 2017.  A 20 percent rating is the maximum rating available for hemorrhoids. The May 2017 VA examination found the Veteran had persistent bleeding, small or moderate external hemorrhoids, reducible external hemorrhoids, and excessive redundant tissue.  Accordingly, a 20 percent rating is warranted beginning May 15, 2017. 
Finally, entitlement to a TDIU is an additional element to be considered for all claims for an increased rating.  Rice v. Shinseki, 22 Vet. App. 447 (2009).  The May 2017 VA examination found that the Veteran’s hemorrhoids did not impact his ability to work and the Veteran has not argued that it affects his ability to work.  Thus, a remand for TDIU is not warranted.
4. Entitlement to an increased rating for hiatal hernia, rated as 30 percent disabling prior to August 3, 2018, and 60 percent disabling thereafter
Entitlement to service connection for hiatal hernia was granted in a June 1970 rating decision.  An initial 10 percent evaluation was assigned effective January 13, 1970.  In an April 2002 rating decision, a 30 percent rating was granted effective November 27, 2001.  The Veteran filed the current claim for an increased rating in March 2005.  A July 2005 rating decision continued the 30 percent rating. In August 2018, the evaluation was increased to 60 percent effective May 15, 2017.  The Veteran contends that a higher rating is warranted for his hiatal hernia.
The Veteran’s hiatal hernia is currently rated as 30 percent and 60 percent disabling under DC 7346.  Under DC 7346, a 10 percent rating is assigned for hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity.  A 30 percent evaluation contemplates hiatal hernia manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health.  A 60 percent rating is assigned for hiatal hernia manifested by symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health.  38 C.F.R. § 4.114.
After considering the record, the Board finds the Veteran’s disability warrants a 60 percent evaluation throughout the appeals period.  At a May 2005 VA examination, the Veteran reported that he experienced “indigestion with substernal [and] epigastric pain every time he eats” as well as “attacks of an aching substernal pain during his waking hours” that occured every 45 to 60 minutes and last 15 minutes.  The Veteran denied any “pure dysphagia” but reported experiencing the “sensation of solids [and] liquids getting ‘hung up’ in his esophagus every time he eats”; he also reported experiencing “regurgitation of food material with a sour liquid every time he eats anything.”  The Veteran noted that he experienced nausea an average of three times per day but he denied vomiting, hematemesis, or melena.   The Veteran also reported that his reflux pain awakened him every night and caused him to sleep on the couch.
A November 2005 VAMC record stated that the Veteran had been vomiting up blood in the morning for the past “several months.” June 2006 VAMC noted the Veteran had constant gas build up, regurgitation, and choking while eating and drinking as well as vomiting “sometimes.”  The Veteran recorded in his December 2006 substantive appeal that the hiatal hernia caused his weight to fluctuate, caused problems with strangulation and pain in the shoulders, and induced pain and vomiting.  In a March 2007 VAMC record the Veteran denied unintentional weight loss, reported “intermittent” dysphagia and reflux, and reported “sometimes” vomiting with “occasional[]” blood.  
In a June 2011 VAMC record, the VAMC noted that the Veteran had nausea after eating and vomiting “every morning.”  April 2014 lay statements from the Veteran’s wife and friends indicated that the Veteran had lost weight, had food regurgitating when he ate, and “usually” threw up when he ate out.  A December 2014 VAMC record reported that “when reflux occurs, he chokes and has difficulty breathing. He has been sleeping in a recliner in order to avoid these symptoms.”  
In a statement received in September 2016, the Veteran reported regurgitation of liquids and solids, vomiting “sometimes” with blood, pain and burning in his throat and chest, and lost weight.  The May 2017 VA examination noted that the Veteran had “symptoms productive of considerable impairment of health”; persistently recurrent epigastric distress; dysphagia; pyrosis; regurgitation; substernal pain; sleep disturbance caused by esophageal reflux (4 or more times a year); nausea (4 or more times a year); vomiting (for or more times a year); hematemesis (4 or more times a year).
Considering this evidence, the Board finds the Veteran qualified for a 60 percent rating from the beginning of the appeals period.  The Veteran had consistent dysphagia and regurgitation as well as substernal pain.  In addition, the Veteran had chest and epigastric pain, vomiting, and some vomiting of blood (hematemesis).  Accordingly, the Veteran’s condition warrants a higher 60 percent evaluation.
Finally, entitlement to a TDIU is an additional element to be considered for all claims for an increased rating.  Rice v. Shinseki, 22 Vet. App. 447 (2009).  The May 2017 VA examination found the Veteran’s hiatal hernia did affect his ability to work because “Veteran is capable of limited lifting, carrying, standing, and walking due to the severity of his symptoms due to hiatal hernia.”  Thus, the Veteran could work in a position with limited lifting, carrying, standing, and walking, such as working as an analyst.  In addition, the Board notes that the Veteran has not argued that his hiatal hernia impacts his ability to work.  The Board finds that remand is not warranted for TDIU. 
REASONS FOR REMAND
1. Entitlement to service connection for diabetes mellitus is remanded.
The Board cannot make a fully-informed decision on the issue of entitlement to service connection for diabetes mellitus because no VA examiner has opined whether the diabetes mellitus is due to exposure to chemicals (other than herbicide agents) or paint.
In addition, the AOJ must complete additional development with regards to herbicide-agent exposure.  The AOJ obtained from the Defense Personnel Records Information Retrieval System (DPRIS) information regarding the U.S.S.Proteus in 1968 but did not include information regarding the U.S.S. Proteus in 1969.  The Veteran served for a short time on the U.S.S Proteus in 1969.  Therfore information from 1969 should be obtained.
2. Entitlement to service connection for an eye disability, to include as secondary to diabetes mellitus, is remanded.
The Veteran contends that his eye disability is secondary to diabetes mellitus.  The issue of service connection for diabetes mellitus is being remanded for additional development, which could significantly impact a decision on the issue of entitlement to service connection for an eye disability.  A remand is therefore required.
3. Entitlement to service connection for a neurological disability, to include as secondary to diabetes mellitus, is remanded.
The Veteran contends that his neurological disability is secondary to diabetes mellitus.  The issue of service connection for diabetes mellitus is being remanded for additional development, which could significantly impact a decision on the issue of entitlement to service connection for a neurological disability.  A remand is therefore required.
4. Entitlement to a TDIU is remanded.
The Board finds that the Veteran has raised a claim for entitlement to TDIU as part of his increased rating claim for residuals of a fracture of the distal end of the right second metacarpal. See Rice v. Shinseki, 22 Vet. App. 447 (2009).  The May 2017 VA examination found that the Veteran’s condition limits his ability to perform occupational tasks: “[the] Veteran is capable of no handling and fingering when using the right upper extremity.”  The Veteran’s dominant hand is his right hand. Also, the Veteran and other lay people have stated that the Veteran has trouble gripping and holding items with his right hand.
Based on these reports, the Board finds the record raises the issue of whether the Veteran is able to secure or follow a substantially gainful occupation; a claim for TDIU has therefore been raised. 
The matters are REMANDED for the following action:
1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s diabetes mellitus is at least as likely as not related to exposure to chemicals (other than herbicide agents) or paint.
2. Contact the appropriate agency to obtain information regarding herbicide agent exposure on the U.S.S. Proteus for the period in 1969 in which the Veteran served thereon.
3. Adjudicate the claim for entitlement to TDIU based on residuals of a fracture of the distal end of the right second metacarpal.

 
M. H. HAWLEY
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	W. Ripplinger, Associate Counsel 

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