Citation Nr: A22020724 Decision Date: 10/13/22 Archive Date: 10/13/22 DOCKET NO. 191108-42475 DATE: October 13, 2022 ORDER 1. Entitlement to service connection for coronary artery disease is granted. 2. Entitlement to service connection for right eye cataract and left eye pseudophakia is granted. 3. Entitlement to service connection for left knee degenerative joint disease is granted. 4. Entitlement to service connection for right knee degenerative joint disease is granted. 5. Entitlement to service connection for glaucoma is granted. 6. Entitlement to service connection for hypercholesterolemia is denied. 7. Entitlement to service connection for obstructive sleep apnea (OSA) is granted. 8. Entitlement to service connection for hypertension is granted. 9. Entitlement to an initial compensable rating for bilateral hearing loss is denied. 10. Entitlement to an effective date prior to February 16, 2017, for the grant of service connection for bilateral hearing loss is denied. REMANDED 11. Entitlement to service connection for fingernail fungus is remanded. 12. Entitlement to service connection for tinea versicolor is remanded. 13. Entitlement to an initial rating in excess of 30 percent for Parkinson's disease with hemiballismus status post transient ischemic attacks (TIAs) is remanded. 14. Entitlement to a compensable rating prior to February 6, 2017, for non-proliferative diabetic retinopathy with left eye macular edema is remanded. 15. Entitlement to a rating in excess of 30 percent since February 6, 2017, for nonproliferative diabetic retinopathy with left eye macular edema is remanded. 16. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II to include whether separate compensable ratings are warranted for onychomycosis of the toenails and nephropathy is remanded. 17. Entitlement to an effective date prior to February 6, 2017, for the grant of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. 18. Entitlement to an effective date prior to February 6, 2017, for the grant of Dependents' Educational Assistance (DEA) under 38 U.S.C. Chapter 35 is remanded. 19. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance is remanded. FINDINGS OF FACT 1. The Veteran's coronary artery disease is presumed under law to have been caused by Agent Orange exposure in Vietnam. 2. The Veteran's right eye cataract and left eye pseudophakia are proximately due to his service-connected diabetes mellitus. 3. The Veteran's left knee degenerative joint disease is proximately due to his service-connected diabetes mellitus. 4. The Veteran's right knee degenerative joint disease is proximately due to his service-connected diabetes mellitus. 5. The Veteran's glaucoma is proximately due to by his service-connected diabetes mellitus. 6. The Veteran's hypercholesterolemia does not constitute a disability for VA benefits purposes. 7. The Veteran's OSA is proximately due to by his service-connected diabetes mellitus. 8. The Veteran's hypertension is presumed under law to have been caused by Agent Orange exposure in Vietnam. 9. Veteran's bilateral hearing has been manifested by hearing acuity of no worse than Level II hearing in the right ear and no worse than Level II hearing in the left ear. 10. There is no evidence prior to February 16, 2017, of a formal or informal claim for service connection for hearing loss. CONCLUSIONS OF LAW 1. The criteria for service connection for coronary artery disease presumed to have been caused by exposure to herbicides have been met. 38 U.S.C. §§ 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309(e). 2. The criteria for service connection for right eye cataract and left eye pseudophakia as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for left knee degenerative joint disease as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for right knee degenerative joint disease as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for glaucoma as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for hypercholesterolemia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.30. 7. The criteria for service connection for OSA as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 8. The criteria for service connection for hypertension presumed to have been caused by exposure to herbicides have been met. 38 U.S.C. §§ 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309(e). 9. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 10. The criteria for an effective date earlier than February 16, 2017, for the award of service connection for bilateral hearing loss have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active-duty service from June 1969 to March 1973 with service in Vietnam from April 1970 to March 1971. In the November 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the Statement of the Case as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. The Board notes that the Veteran's claim for service connection included irregular heart rhythm and chondromalacia or runner's knee. The Agency of Original Jurisdiction (AOJ) recharacterized the claims as service connection for arrythmia and chondromalacia of both knees. To encompass all diagnoses of record, the Board has recharacterized these issues as a cardiac disability to include coronary artery disease and arrhythmia and a knee disability to include chondromalacia and degenerative joint disease. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). An inferred claim for SMC has been raised. In a December 2019 letter, the Veteran's attorney noted that VA granted service connection for Parkinson's disease and hemiballismus and that a June 2015 CCHT Initial Assessment stated that the Veteran was dependent upon his wife for cleaning, chores, driving, meal preparation, medicine administration, and that he required assisting dress and on occasion when having difficulty with ambulation and unsteadiness required assistance using the restroom. The attorney's statements in December 2019 are sufficient to raise an inferred claim for SMC. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (entitlement to SMC is part of an increased rating claim, and VA should consider the issue when it is reasonably raised by the record, regardless of whether a veteran has specifically pled it). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as cardiovascular-renal disease including hypertension, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury pursuant to 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Certain diseases associated with exposure to herbicide agents in service are presumed to be service connected if the disease is manifested to a compensable degree within a specified time period. 38 C.F.R. §§ 3.307, 3.309(e). If a Veteran was exposed to a herbicide agent, including Agent Orange, during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 U.S.C. § 1116 ; 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307 (d) are also satisfied. Veterans who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a)(6)(iii). 1. Entitlement to service connection for a cardiac disability to include coronary artery disease and arrhythmia The Veteran contends that he has a heart disability related to his active-duty service. Exposure to Agent Orange is conceded by virtue of his service in the Vietnam from April 1970 to March 1971. The Veteran has a current diagnosis of coronary artery disease as evidenced by a March 2017 VA examination. Coronary artery disease is an enumerated condition under 38 C.F.R. § 3.309(e). As the Veteran is presumed to have been exposed to herbicides and that he has been diagnosed coronary artery disease, service connection for coronary artery disease is warranted. 38 U.S.C. §§ 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309(e). 2. Entitlement to service connection for cataracts The Veteran contends that his cataracts are related to his service-connected diabetes mellitus. The Veteran has a current diagnosis of right eye cataract and left eye pseudophakia as evidence by VA treatment records. The Veteran underwent VA examination in March 2013 at which time the examiner opined that the Veteran's cataracts were at least as likely as not to be complicated by his diabetes. The Veteran underwent VA examination in March 2017 at which time the examiner opined that age-related nuclear cataract of the right eye and presence of intraocular lens were less likely as not caused by or a result of diabetes mellitus type II. In support of his claim, the Veteran submitted a letter authored by Dr. Aliya Ali in December 2019. Dr. Ali noted that she had reviewed the pertinent in-service and post-service medical records as well as any relevant compensation and pension examinations from the Veteran's VA claims file. Dr. Ali opined that it was more likely than not that the Veteran's service-connected diabetes resulted in the development of his cataracts. Dr. Ali noted that the Veteran was a brittle diabetic and had many decades of uncontrolled blood sugars. Dr. Ali stated that diabetes, and especially prolonged hyperglycemia, could independently affect the eye and lead to the development of cataracts. Dr. Ali stated that she disagreed with the VA examiner's 2017 opinion that the Veteran's diabetes did not contribute to the development of his cataracts. Dr. Ali included a November 2013 medical article entitled, Diabetes and Cataracts, which stated that people with diabetes were more likely to develop vision stealing cataracts compared to non-diabetics. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's right eye cataract and left eye pseudophakia are related to his service-connected diabetes mellitus, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. Here, there are legitimate reasons for accepting Dr. Ali's favorable medical opinion over the VA examiner's unfavorable medical opinion. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. In this case, Dr. Ali provided an opinion and supported such opinion with detailed rationale and medical articles. Accordingly, the Board finds that the competent medical evidence of record, supports a finding that the Veteran's right eye cataract and left eye pseudophakia are related to his diabetes mellitus; thus, service connection for right eye cataract and left eye pseudophakia is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a left knee disability to include chondromalacia and degenerative joint disease 4. Entitlement to service connection for a right knee disability to include chondromalacia and degenerative joint disease The Veteran contends that his knee disabilities are related to his service-connected diabetes mellitus. The Veteran has a diagnosis of bilateral knee degenerative joint disease as evidence by VA treatment records. The record indicates that the Veteran was seen in September 2007 for knee pain; he indicated that his knees were fatigued mostly at night and that he was a heating and air conditioning specialist who crawled around on his knees all day. X-rays revealed mild spurring bilaterally. In December 2009, the Veteran was seen for knee pain related to his construction job. In May 2011, the Veteran was diagnosed as having bilateral knee arthritis and was issued knee braces to decrease pain. In June 2011, the Veteran was seen for orthopedic consultation for bilateral knee pain. X-rays revealed essentially normal knees; and he was diagnosed as having bilateral knee pain, extremely mild degenerative disease without signs of inflammation. Subsequently, the Veteran underwent Hyalgan injections atraumatically at the lateral, suprapatellar pouches in October and November 2011. In May 2012, it was noted that the Veteran received excellent result from Hyalgan injections; x-rays again showed very mild osteoarthritis. Dr. Ali opined in December 2019 that it was more likely than not that the Veteran's service-connected diabetes and peripheral neuropathy resulted in the development of bilateral knee degenerative joint disease. Dr. Ali noted that hyperglycemia has been shown to have a direct effect on development of osteoarthritis by affecting the cartilage and that peripheral resulted in the development of his cataracts. Dr. Ali included a medical article which noted that diabetes mellitus seemed to have a direct impact on osteoarthritis as hyperglycemia promoted deposition of advanced glycation end-products and affected cartilage health and that hyperglycemia also contributed to peripheral neuropathy which could contribute to muscle weakness, joint instability, and consequent osteoarthritis of weight-bearing joints. There is no conflicting evidence regarding the etiology of the Veteran's bilateral knee degenerative joint disease. Accordingly, the Board finds that service connection for left and right knee degenerative joint disease is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for glaucoma The Veteran contends that his glaucoma is related to his service-connected diabetes mellitus. The Veteran has a current diagnosis of glaucoma as evidence by March 2017 VA examination at which time the examiner opined that primary open-angle glaucoma was less likely as not caused by or a result of diabetes mellitus. The examiner noted that glaucoma often happens in people without diabetes mellitus type II but in the same age population as the Veteran. Dr. Ali opined in December 2019 that it was more likely than not that the Veteran's service-connected diabetes resulted in the development of his glaucoma. Dr. Ali noted that the Veteran was a brittle diabetic and had many decades of uncontrolled blood sugars. Dr. Ali stated that diabetes, and especially prolonged hyperglycemia, could independently affect the eye and lead to the development of cataracts. Dr. Ali stated that she disagreed with the VA examiner's 2017 opinion that the Veteran's diabetes did not contribute to the development of his glaucoma. Dr. Ali included a January 2015 medical article from the American Academy of Ophthalmology entitled, Who is at Risk for Glaucoma? which stated that people with diabetes were more at risk of developing glaucoma as well as a March 2004 medical article entitled, Diabetes mellitus as a risk factor for primary open-angle glaucoma: a meta-analysis, which concluded that diabetic patients were at significantly increased risk of developing primary open-angle glaucoma. The Board notes that there is a difference of opinion among the medical professionals. Here, there are legitimate reasons for accepting Dr. Ali's favorable medical opinion over the VA examiner's unfavorable medical opinion. In this case, Dr. Ali provided an opinion and supported such opinion with detailed rationale and medical articles. Accordingly, the Board finds that the competent medical evidence of record, supports a finding that the Veteran's glaucoma is related to his diabetes mellitus; thus, service connection for glaucoma is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for hypercholesterolemia Hypercholesterolemia, or high cholesterol, does not constitute a disability for VA purposes but is essentially a laboratory finding. VA has in its rulemaking capacity indicated that high cholesterol does not fall within VA's definition of disability for which compensation is warranted. 61 Fed. Reg. 20440, 20445 (May 7, 1996) (supplementary information preceding revisions to criteria for evaluating endocrine system indicating that hyperlipidemia, elevated triglycerides, and elevated cholesterol "are actually laboratory test results, and are not, in and of themselves, disabilities"). In addition, the evidence does not show that the Veteran's hypercholesterolemia causes functional impairment or impairs earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (holding that the term "disability" for VA compensation purposes refers to functional impairment of earning capacity); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that pursuant to 38 C.F.R. § 4.1, the term disability "should be construed to refer to impairment of earning capacity due to disease, injury, or defect, rather than to the disease, injury, or defect itself"). Thus, the evidence does not support that the Veteran has a diagnosable condition for which high cholesterol is the primary symptom. As such, there is no competent evidence of a current disability upon which to predicate a grant of service connection and the first element of service connection the existence of a present disability has not been met. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection is warranted for hypercholesterolemia. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is, therefore, not for application as to this claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 7. Entitlement to service connection for OSA The Veteran contends that his OSA is related to his service-connected diabetes mellitus. The Veteran has a diagnosis of OSA as evidence by VA treatment records which indicate polysomnographic findings of moderate OSA from sleep study conducted on October 4, 2016. Dr. Ali opined in December 2019 that it was more likely than not that the Veteran's service-connected diabetes caused the development of OSA. Dr. Ali noted that diabetes, especially uncontrolled blood sugars, can lead to sleep disordered breathing and that individuals with sleep disordered breathing caused by diabetes, such as the Veteran, are less likely to have the typical symptoms of OSA. Dr. Ali included a June 2013 medical article from the American Academy of Sleep Medicine which stated that overwhelming clinical evidence has shown that patients suffering from two very common illnesses type II diabetes and hypertension are at much higher risk for OSA; a February 2011 medical article entitled, Diabetes and sleep: A complex cause-and-effect relationship, which stated that sleep disorders favor the development of type II diabetes or exacerbate the metabolic control of both types of diabetes, whereas diabetes itself when associated with poor metabolic control is often followed by sleep disorders; and a June 2011 medical article entitled, Prevalence of sleep apnoea in diabetic patients, which concluded that the prevalence of sleep disordered breathing is increased in patients with diabetes mellitus and that most of these patients had no typical clinical symptoms of OSA. There is no conflicting evidence regarding the etiology of the Veteran's OSA. Accordingly, the Board finds that service connection for OSA is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Entitlement to service connection for hypertension The Veteran contends that he has hypertension related to his active-duty service. The Veteran has a current diagnosis of hypertension as evidenced by VA treatment records. The Veteran underwent VA examination in August 2007 at which time the examiner noted that he had had hypertension since 1995 and since he had no kidney problems, hypertension was not due to his diabetes mellitus type II. The Veteran underwent VA examination in May 2011 at which time the examiner noted that the Veteran's hypertension was not a complication of diabetes as there was no renal vascular disease, no nephrotic syndrome, and no biopsy suggesting diabetic nephropathy. The Veteran underwent VA examination in March 2013 at which time the examiner determined that hypertension was not at least as likely as not due to or permanently aggravated by diabetes mellitus. The Veteran underwent VA examinations in October 2014 and April 2015; neither examiner found conditions other than peripheral neuropathy and retinopathy to be at least as likely as not due to or permanently aggravated by his diabetes mellitus. The Veteran underwent VA examination in March 2017 at which time the noted that peripheral neuropathy, nephropathy, retinopathy, and stroke to be the complications of or conditions due to his diabetes mellitus. Dr. Ali opined in December 2019 that it was more likely than not that the Veteran's hypertension was etiologically due to his diabetes mellitus. Dr. Ali noted that the Veteran's high blood pressure was common at the time of diagnosis of diabetes mellitus because at that time he had been diagnosed as having hyperinsulinemia and insulin resistance which had been present for a while. Dr. Ali noted that the 2007 VA examiner was incorrect that an individual must have renal problems or nephropathy from diabetes in order to link the hypertension to the diabetes. Dr. Ali noted that hypertension often manifested prior to the development of nephropathy and is thought of as a contributor to renal disease. Dr. Ali included a May 1992 medical article entitled, Diabetes mellitus and hypertension, which noted that the etiology of hypertension in the majority of diabetic patients could not be explained by underlying renal disease and remained "essential" in nature; that the hallmark of hypertension in type I and type II diabetes appeared to be increased peripheral vascular resistance; that there was increasing evidence that insulin resistance/hyperinsulinemia could play a key role in the pathogenesis of hypertension in both subtle and overt abnormalities of carbohydrate metabolism; and that population studies suggest that elevated insulin levels, which often occur in type II diabetes mellitus, was an independent risk factor for cardiovascular disease. Dr. Ali also included a 2001 medical article entitled, Diabetes and Hypertension, which noted that the incidence of hypertension was increased in individuals with diabetes mellitus and that in these patients, high blood pressure was common at the time of diagnosis of diabetes but the development of diabetes often preceded by a period during which hyperinsulinemia and insulin resistance was already present. Dr. Ali further included a 1995 medical article entitled, From Diabetes Mellitus and Associated Hypertension, Vascular Disease, and Nephropathy, An Update, which noted that hypertension was about twice as frequent in individuals with diabetes as in those without and that hypertension often antedates and likely contributed to the development of nephropathy in many diabetic individuals. The Board notes that there is a difference of opinion among the medical professionals. Here, there are legitimate reasons for accepting Dr. Ali's favorable medical opinion over the VA examiners' unfavorable medical opinions. In this case, Dr. Ali provided an opinion and supported such opinion with detailed rationale and medical articles. The Board also notes that although VA regulations do not yet include hypertension as a presumptive disability associated with herbicide exposure; legislation has recently been passed that added hypertension to the presumptive list. See H.R. 3967: Honoring our PACT Act of 2022. In addition, the National Academy of Sciences (NAS), in 2006 and 2008 updates, concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). In a recent 2018 update, the NAS found that there was "sufficient" evidence of an association between hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Thus, even assuming for the sake of argument that the Veteran's hypertension could not be etiologically linked to his service-connected diabetes mellitus, it is at least as likely as not linked to his Vietnam service. Accordingly, the Board finds that the competent medical evidence of record, supports a finding that the Veteran's hypertension is related to his diabetes mellitus; thus, service connection for hypertension is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 9. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. The Veteran is appealing the original assignment of a disability rating following an award of service connection for bilateral hearing loss. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran contends that he is entitled to a higher rating for his hearing loss. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). On the authorized audiological evaluation in March 2017, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 30 60 65 70 LEFT 10 30 60 65 65 Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 88 percent in the left ear. Applying the results to Table VI, the findings yield a numeric designation of Level II in the right ear and Level II in the left ear. Entering the resulting bilateral numeric designation of Level II for the right ear and Level II for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a zero percent (noncompensable) disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran's assertion that he has to say, "huh?" a lot of the time and that the family says he keeps the television sound too loud. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Ross v. Shulkin, 29 Vet. App. 142, 145 (2017). For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether a compensable rating is warranted for bilateral hearing loss. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is, therefore, not for application as to this claim. Lynch, 21 F.4th at 776. Earlier Effective Date 10. Entitlement to an effective date prior to February 16, 2017, for the grant of service connection for bilateral hearing loss Under governing law, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose, if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155. The Veteran's original claim for service connection for hearing loss was received by VA on February 16, 2017, more than one year beyond his release from service. In this case, prior to February 16, 2017, there was no claim, formal or informal, received by VA for service connection for any type of hearing impairment. As such, the Veteran's request for an earlier effective date cannot be sustained. The Board notes that in conjunction with a claim for increased rating for diabetes mellitus, VA received a letter from the Veteran's wife on March 1, 2013, at which time she noted, "His hearing is also diminished. I know the eyes and the hearing changes are also associated with having diabetes." To the extent that the Veteran contends that his wife's March 1, 2013, statement should be construed by VA as an informal claim for disability benefits for hearing loss, an informal claim can be raised when a veteran submits written evidence of an intent to file a claim for specific benefits. In this case, even with liberal construction, the Court has held the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. See Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006), citing Brannon v. West, 12 Vet. App. 32 (1998). Moreover, in the absence of a sufficient manifestation of an intent to apply for benefits for a particular disease or injury, a document providing medical information which refers to a disability in and of itself is not an informal claim for VA benefit. Ellington v. Nicholson, 22 Vet. App. 141, 145-46 (2007). Therefore, the Board finds that the March 1, 2013, statement from the Veteran's wife cannot be construed as an informal claim because it does not reasonably demonstrate an intent from the Veteran to file an application for a benefit. Therefore, the Veteran's claim for an effective date prior to February 16, 2017, for the award of service connection for heart disease is denied. Even assuming for the sake of argument that a claim for service connection for hearing loss was pending since March 1, 2013, the record is absent any clinical evidence of hearing impairment until the March 2017 VA examination. As noted above, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2). Entitlement to service connection did not arise until the May 2017 VA examination. The legal criteria pertaining to the assignment of an effective date for service connection are controlling. As a claim of entitlement to service connection for hearing loss was not submitted to VA prior to February 16, 2017, entitlement to an earlier effective date for the grant of service connection for bilateral hearing loss cannot be assigned. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. The correct effective date for the grant of service connection for bilateral hearing loss is February 16, 2017, the date the Veteran submitted his claim for service connection for hearing loss. REASONS FOR REMAND 11. Entitlement to service connection for fingernail fungus The issue is remanded to correct a duty to assist error that occurred prior to the September 2019 Statement of the Case. The Veteran underwent VA examination for fungus of the toenails and fingernails in March 2017 at which time he was diagnosed as having onychomycosis/tinea pedis. The examiner noted that the Veteran's great toenails were discolored and thickened; however, the examiner failed to address fingernail fungus. This constitutes a pre-decisional duty to assist error which necessitates an additional VA examination. 38 C.F.R. §§ 20.301, 20.802. The Board notes that Dr. Ali opined in December 2019 that the Veteran's fingernail fungus was more likely than not etiological due to his service-connected diabetes; however, there is no indication that Dr. Ali examined the Veteran and, therefore, cannot make a competent diagnosis of fingernail onychomycosis. 12. Entitlement to service connection for a skin disability to include tinea versicolor The issue is remanded to correct a duty to assist error that occurred prior to the September 2019 Statement of the Case. The Veteran underwent VA examination in March 2017 at which time he was diagnosed as having tinea versicolor, a flaky, scaly, salmon-colored rash, located on his inner thigh area, his inner arm area, on the chest, and on the upper mid back area. The VA examiner, however, failed to provide an etiology opinion for the tinea versicolor. This constitutes a pre-decisional duty to assist error which necessitates an additional VA examination. 38 C.F.R. §§ 20.301, 20.802. The Board notes that Dr. Ali opined in December 2019 that it was more likely than not that the Veteran's versicolor began while in service and noted that there was documentation from 2006 as well as the 2017 VA examination that the Veteran first noticed skin discoloration while in service. Dr. Ali, however, did not discuss the absence of any skin disorders in service, the Report of Medical Examination in March 1973 which clinically evaluated the Veteran's skin as normal, and the Report of Medical History completed in March 1973 in conjunction with his separation physical in which he denied ever having any skin diseases. 13. Entitlement to an initial rating in excess of 30 percent for Parkinson's disease with hemiballismus status post TIAs The issue is remanded to correct a duty to assist error that occurred prior to the September 2019 Statement of the Case. Under 38 C.F.R. § 4.124a, Diagnostic Code 8004, corresponding to paralysis agitans, a minimum 30 percent rating is assigned when there are "ascertainable residuals" of the disability. However, VA is required to consider whether any of these residuals may otherwise be rated under separate Diagnostic Codes. If there are ascertainable residuals that can be rated under a separate Diagnostic Code, and the combined disability rating resulting from these residuals exceeds 30 percent, then these separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. The Veteran underwent VA examination in March 2017 at which time he diagnosed as having Parkinson's Disease with a date of diagnosis of 2015. Motor manifestations indicated moderate stooped posture, moderate balance impairment, and tremors in all extremities with mild tremors on the right and moderate tremors on the left. Additional manifestations include severe sexual dysfunction. There were no slowed movement, loss of automatic movements, speech changes, mental manifestations, loss of sense of smell, sleep disturbance, difficulty chewing or swallowing, urinary problems, or constipation. The Veteran also underwent VA Central Nervous System and Neuromuscular Diseases examination that same day with the same VA examiner who noted that the Veteran had a right sided stroke after three previous TIAs leaving him with left sided weakness, greater in the arm than the leg, that the Veteran went to the ER for several visits after the stroke for "shaking all over" was initially diagnosed with Parkinsonism by the ER doctor but later diagnosed with hemiballismus due to the stroke by his neurologist. The Board notes that VA treatment records are replete with notations of Parkinson's disease in past medical history and active medical problems. These records, however, are absent a clinical diagnosis of Parkinson's disease. In fact, two VA neurologists and one private neurologist found that the Veteran did not have a diagnosis of Parkinson's disease. VA treatment records also indicate that the Veteran informed his medical providers that he did not have Parkinson's disease. The Veteran was seen for a diabetic education consultation with a clinical dietitian in May 2007 at which time other health problems noted included, "neuropathy, parkinsons?" In October 2014, the Veteran was seen in Emergency Department (ER) for complaints of an episode of slurred speech and right sided weakness; assessment was TIA. A consultation for neurology was made by ER; and in November 2014, the Veteran was seen for Neurology Consultation with the impression of TIA versus hyperglycemic symptoms versus undefined entity. In January 2015, the Veteran was referred back to neurology clinic for provisional diagnoses due to his having five to six spells pretty much alike except the last one and he decline acute medical evaluation on most except for the ER visit in October 2014. Previous MRI of the brain and CT scan pictures were reviewed. The neurologist diagnosed the Veteran with TIAs without etiology or definite neuro-anatomical location. The Veteran was seen in ER in March 2015 with complaints of left-hand numbness, left lower extremity shakiness for two weeks; assessment was TIA. The Veteran underwent neurology follow up in March 2015 at which time the neurologist noted that the most likely cause of the movement disorder was psychogenic as his affect was unusual for an acute movement disorder, the immediate cessation on walking, excellent balance, and the unusual appearance of the foot movements fit a non-organic cause. When he was seen at the ER in April 2015, he denied a history of Parkinson's disease; assessment by ER physician in April 2015 was chorea form activity left side undergoing evaluation. That same month, the VA neurologist advised the Veteran that he believed that his movement disorder was not a serious neurodegenerative disease; and for whatever the reasons, it was psychogenic. The Veteran requested a consultation with a neurologist outside VA; in May 2015, the Veteran was seen by another VA neurologist for a second opinion. After review of the record and physical examination of the Veteran, the neurologist stated, Clinically this patient had an acute onset of positive movement disorder that would be concerning for hemiballismus with a head CT as described above. I am concerned that this abrupt onset of neurologic dysfunction is stroke leading to a hemiballismus with a degree of athetosis. The Veteran underwent MRI which support clinical diagnosis of stroke with resultant hemiballismus; he was started on topiramate. In November 2015, the Veteran's hemiballismus due to stroke was noted to be under control; and his symptomatology appeared to be greatly reduced. In July 2015, the Veteran saw a non-VA neurologist for an additional opinion at which time the neurologist stated that he concurred with the VA neurologist's assessment that the Veteran suffered choreic or ballistic movements affecting the left side on the basis of right cerebral infarction deep in the hemisphere involving the thalamus and subthalamic nucleus. The neurologist noted that stroke was the basis of this though hyperglycemia was a possible cause of the clinical picture as well. At his July 2016 Sleep Clinic consultation, the Veteran stated that although Parkinson's was listed as a problem, this was incorrect. In January 2017, the VA neurologist's attending note stated that the Veteran had a movement disorder, hemiballismus, which was secondary to a stroke that he suffered and that he had ataxia with this on one side of his body. As noted above, the March 2017 VA examiner diagnosed the Veteran as having Parkinson's disease; however, there is no indication what criteria she used to render such a diagnosis. It also appears that the Veteran was not initially diagnosed with parkinsonism by an ER physician as noted by the March 2017 VA examiner. Further, the March 2017 VA examination did not address the contrary opinions of the Veteran's two VA treating neurologists and the private neurologist. As such, the medical opinion does not provide an adequate rationale regarding the diagnosis of Parkinson's disease. Because of the inconsistencies in the March 2017 VA examination report, the Board is not convinced that the examiner adequately considered all of the Veteran's symptomology associated with hemiballismus and symptoms due to status post TIA and stroke. 14. Entitlement to a compensable rating prior to February 16, 2017, for non-proliferative diabetic retinopathy with left eye macular edema 15. Entitlement to a rating in excess of 30 percent since February 16, 2017, for nonproliferative diabetic retinopathy with left eye macular edema The issue is remanded to correct a duty to assist error that occurred prior to the September 2019 Statement of the Case. The record indicates that the Veteran receives treatment from an outside provider, Dr. Byrnes of VISTAR Eye Center. It appears that some records from Dr. Byrnes were received and could be viewed with Vista Imaging; however, it is unclear from the file if Vista Imaging includes all records from February 16, 2016, to September 11, 2019, from Dr. Byrnes. A remand is required to allow VA to obtain these records directly from Dr. Byrnes. 16. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II to include whether separate compensable ratings are warranted for onychomycosis of the toenails and nephropathy The issue is remanded to correct a duty to assist error that occurred prior to the September 2019 Statement of the Case. The Veteran underwent VA examination in March 2017 at which time treatment for diabetes mellitus included prescribed oral hypoglycemic agents and more than one injection of insulin was required per day; frequency of diabetic care was twice per month for episodes of ketoacidosis and weekly for hypoglycemia. No regulation of activities was required. Complications of diabetes mellitus included peripheral neuropathy, nephropathy, retinopathy, and stroke. The Board notes that at end-March 2017, closest to the time of the VA examination, the Veteran's A1C was 7.4. In August 2017, A1C was 8.3; in February 2018, A1C was 9.1; and in June 2018, A1C was 8.7. In February 2018, the Veteran's medication was changed to Lantus 60 units and Glipizide 10mg BID for meal coverage was added. A June 2018 letter from the Veteran's endocrinologist noted that the protein in his urine had increased from the last time. In August 2018, the Veteran's diabetes mellitus was noted to be not very well controlled; an August 2018 letter from the Veteran's endocrinologist recommended that he increase his Lantus from 60 to 65 units twice daily. As the VA treatment records which indicate a worsening of the Veteran's diabetes mellitus were of record prior to the September 2019 Statement of the Case, this constitutes a pre-decisional duty to assist error which necessitated an additional VA examination. 38 C.F.R. §§ 20.301, 20.802. In addition, as noted above, the Veteran underwent VA examination for fungus of the toenails and fingernails in March 2017 at which time he was diagnosed as having onychomycosis/tinea pedis. The examiner noted that the Veteran's great toenails were discolored and thickened; however, the examiner failed to address fingernail fungus which could change the percentage of body area affected. 17. Entitlement to an effective date prior to February 6, 2017, for the grant of entitlement to TDIU 18. Entitlement to an effective date prior to February 6, 2017, for the grant of Dependents' Educational Assistance (DEA) under 38 U.S.C. Chapter 35 Finally, because a decision on the remanded issue of entitlement to a compensable rating prior to February 16, 2017, for non-proliferative diabetic retinopathy with left eye macular edema could significantly impact a decision on these issues, the issues are inextricably intertwined. A remand of the claims for these issues are also required. 19. Entitlement to SMC based on the need for regular aid and attendance As noted above, in a December 2019 letter, the Veteran's attorney noted that VA granted service connection for Parkinson's disease and hemiballismus and that a June 2015 CCHT Initial Assessment stated that the Veteran was dependent upon his wife for cleaning, chores, driving, meal preparation, medicine administration, and that he required assisting dress and on occasion when having difficulty with ambulation and unsteadiness required assistance using the restroom. As entitlement to SMC is inextricably intertwined with the increased rating claim on appeal, it must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Schedule the Veteran for a skin and fingernail examination. The examiner must review the claims file. For each skin/nail disorder identified, the examiner is asked to provide a response to the following: (a) Is such skin/nail disorder at least as likely as not related to service, including exposure to Agent Orange during service in Vietnam? In providing the requested opinion, consider the Veteran's description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? (b) Is such skin/nail disorder at least as likely as not proximately due to service-connected disability? (c) Is such skin/nail disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected disability? Service connection has been established for coronary artery disease, right eye cataract, left eye pseudophakia, degenerative joint disease of the knees, glaucoma, obstructive sleep apnea, hypertension, retinopathy with macular edema of the left eye, Parkinson's disease and hemiballismus status post transient ischemic attacks, peripheral neuropathy of upper and lower extremities, diabetes mellitus type II with nephropathy and onychomycosis of the toenails, and bilateral hearing loss. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions above. Provide a rationale to support all opinions. 2. Schedule the Veteran for examination(s) by appropriate clinician(s) to determine the current severity of his service-connected conditions: (i) Parkinson's disease with hemiballismus status post transient ischemic attacks, (ii) non-proliferative diabetic retinopathy with left eye macular edema, (iii) diabetes mellitus type II, (iv) onychomycosis of the toenails, and (v) nephropathy. The examiner should provide a full description of each disability and report all signs and symptoms necessary for evaluating such disabilities under the rating criteria. It would be helpful if the examiner would comment on whether the Veteran has a diagnosis of Parkinson's disease or Parkinsonism; and if not, what the actual diagnosis is for the Veteran's complaints noted to be Parkinson's disease such as stooped posture, balance impairment, and tremors in all extremities. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to an effective date prior to February 16, 2017, for TDIU and DEA as well as the issue of entitlement to SMC. John R. Doolittle, II Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.