Citation Nr: A22012475 Decision Date: 07/05/22 Archive Date: 07/05/22 DOCKET NO. 191217-54095 DATE: July 5, 2022 ORDER Entitlement to service connection for a disability manifested by vertigo and dizziness to include benign paroxysmal positional vertigo (BPPV) and Meniere's syndrome) is granted. Entitlement to service connection for an acquired psychiatric disorder to include major depressive disorder (MDD) and anxiety is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to an effective date prior to August 31, 2015, for the assignment of a 20 percent rating for lumbar spine DDD is denied. Entitlement to an effective date prior to August 31, 2015, for the grant of service connection and assignment of an initial 10 percent rating for left lower extremity radiculopathy is denied. Entitlement to a rating in excess of 20 percent for lumbar spine degenerative disc disease (DDD) is denied. Entitlement to a rating in excess of 20 percent for radiculopathy of the right lower extremity is denied. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity is denied. REMANDED Entitlement to service connection for hemochromatosis is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran's disability manifested by vertigo and dizziness is related to exposure to jet fuel while on active duty. 2. The Veteran's acquired psychiatric disorders are proximately due to his service-connected disabilities. 3. The evidence of record persuasively weighs against finding that GERD began during active service or is otherwise related to an in-service injury or disease. 4. Prior to August 31, 2015, a claim for an increased rating for the Veteran's lumbar spine DDD was on appeal; a June 2017 rating decision effectuated a February 22, 2017, Board decision which granted service connection for lumbar spine DDD and assigned a 10 percent rating effective from June 13, 2008; the Veteran did not appeal the June 2017 rating decision and did not submit new and material evidence within a year of the notification of that decision. 5. Prior to August 31, 2015, a claim for service connection for left lower extremity radiculopathy was not filed or pending. 6. Since August 31, 2015, the Veteran's lumbar spine DDD has not been manifested by limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less or ankylosis of the entire thoracolumbar spine. 7. Since August 31, 2015, the Veteran's right lower extremity radiculopathy has been manifested by, at most, moderate incomplete paralysis of the sciatic nerve. 8. Since August 31, 2015, the Veteran's left lower extremity radiculopathy has been manifested by, at most, mild incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability manifested by vertigo and dizziness have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for an acquired psychiatric disability 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 GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for an effective date prior to August 31, 2015, for the assignment of a 20 percent rating for lumbar spine DDD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 5. The criteria for an effective date prior to August 31, 2015, for the grant of service connection and the assignment of a 10 percent rating for left lower extremity radiculopathy have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 6. Since August 31, 2015, the criteria for a rating in excess of 20 percent for lumbar spine DDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5237. 7. Since August 31, 2015, the criteria for a rating in excess of 20 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 8. Since August 31, 2015, the criteria for an initial rating in excess of 10 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1988 to May 1992 and from May 1, 2007 to May 21, 2007; he also served in the Air Force Reserves from May 1994 to April 2011 with periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). The Appeals Modernization Act (AMA) became effective February 19, 2019. This law creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review and applies to all decisions issued after the effective date of the law. Veterans under the old Legacy appellate system had the opportunity to opt into the AMA system in two ways. Under the AMA pilot program, the Rapid Appeals Modernization Program (RAMP), a Veteran could, before February 2019, elect into RAMP by invitation. In the December 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 RAMP supplemental claim decision on appeal, as well as any evidence submitted by the Veteran or his attorney with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. Historically, the Veteran's original application for compensation was received in June 2008. An April 2009 rating decision denied service connection for, inter alia, lumbar spine DDD, hemochromatosis, hearing loss, tinnitus, and right leg numbness; and a higher rating for hypertension. The Veteran appealed the March and April 2009 rating decisions. In May 2011, the Veteran testified at a Travel Board hearing with respect to the issues of service connection for, inter alia, lumbar spine DDD, hemochromatosis, hearing loss, tinnitus, and right leg numbness as well as for a higher rating for hypertension and entitlement to a TDIU. A transcript of that hearing is of record. Also in May 2011, the Veteran filed a claim for service connection for Meniere's syndrome, an acquired psychiatric disability to include anxiety and depression, GERD, and sinusitis. A September 2011 rating decision denied those claims. The Veteran appealed the September 2011 rating decision. A December 2011 Board decision remanded the claims of, inter alia, a rating in excess of 10 percent for hypertension; service connection for lumbar spine DDD, hemochromatosis, hearing loss, tinnitus, and right leg numbness; and entitlement to a TDIU. In July 2013, the Board denied, inter alia, the issues of service connection for lumbar spine DDD, hemochromatosis, hearing loss, tinnitus, and right leg numbness. The issue of entitlement to a TDIU was again remanded. In August 2014, the Veteran testified at a Travel Board hearing with respect to the issues of service connection for Meniere's syndrome, an acquired psychiatric disability to include anxiety and depression, GERD, and sinusitis. A transcript of that hearing is of record. A December 2014 Board decision remanded the claims of service connection for Meniere's syndrome, an acquired psychiatric disability to include anxiety and depression, GERD, and sinusitis. On February 13, 2015, the United States Court of Appeals for Veterans Claims (Court) granted the parties' Joint Motion for Partial Remand (JMPR), remanding the parts of the Board's July 2013 decision which denied service connection for lumbar spine DDD, hemochromatosis, hearing loss, tinnitus, and right leg numbness as well as a rating in excess of 10 percent for hypertension. In March 2015, the Board remanded those issue for compliance with the terms of the JMPR. Service connection for hearing loss and tinnitus was granted in a February 2016 rating decision which assigned 10 percent ratings for each issue. On February 21, 2017, the Board remanded the issues of service connection for an acquired psychiatric disorder, GERD, sinusitis, and an ear disorder to include Meniere's syndrome. On February 22, 2017, the Board granted service connection for lumbar spine DDD and right lower extremity radiculopathy; denied a rating in excess of 10 percent for hypertension; and remanded the issues of service connection for hemochromatosis and entitlement to a TDIU. A June 2017 rating decision effectuated the February 22, 2017, Board decision and assigned a 20 percent rating for right lower extremity radiculopathy effective from June 5, 2012, and a 10 percent rating for lumbar spine DDD effective from June 13, 2008. In April 2018, the Veteran submitted his RAMP Opt-In Election for all eligible issues on appeal. In July 2018, the Veteran was informed that his appeal had been withdrawn with respect to the issues of service connection for hemochromatosis, Meniere's syndrome, sinusitis, GERD, and MDD as well as entitlement to a TDIU. As such, the Veteran had two separate Legacy appeal streams which were merged when he chose to opt into the AMA from a legacy appeal prior to February 19, 2019. A February 2019 rating decision denied service connection for hemochromatosis, Meniere's syndrome, sinusitis, GERD, and MDD as well as entitlement to a TDIU. That decision also increased the rating for the Veteran's lumbar spine DDD from 10 percent to 20 percent from August 31, 2015, granted service connection for left lower extremity radiculopathy and assigned a 10 percent rating effective August 31, 2015, and denied entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy,. On December 17, 2019, VA received the VA Form 10182 wherein the Veteran requested evidence submission review which permitted him 90 days from the date that the VA Form 10182 was received by VA to submit additional evidence in support of his claims. On January 22, 2020, the Board acknowledged receipt of the Veteran's VA Form 10182 and reiterated that the Veteran had 90 days from the date of the Board's receipt of the VA Form 10182 to submit new evidence. The Board notes that the Agency of Original Jurisdiction (AOJ) in its February 2019 rating decision denied service connection for GERD, hemochromatosis, major depression, Meniere's syndrome, and sinusitis on the basis that new and relevant evidence had not been submitted; however, the AOJ noted that in support of the claim, VA had presumed the receipt of new and relevant evidence for GERD, hemochromatosis, major depression, Meniere's syndrome, and sinusitis and noted that the claims were reconsidered. These findings are internally inconsistent; however, as the Board is bound by the AOJ's favorable findings, the Board will not address whether the issues of service connection for GERD, hemochromatosis, major depression, Meniere's syndrome, and sinusitis may be readjudicated. 38 C.F.R. §§ 3.103 (f)(4), 3.104(c), 20.801(a) (2020). The Board also notes that on his VA Form 10182 received in December 2019, the Veteran appealed the effective dates and disability ratings for the Veteran's lumbar spine and bilateral lower extremity radiculopathy. As noted above, service connection for right lower extremity radiculopathy was granted in a June 2017 rating decision which assigned a rating of 20 percent effective from June 5, 2012. The effective date of a grant of service connection of a disability must be timely filed after the rating decision that grants the benefit. It may not later be claimed as a stand-alone claim after the statutory time limit to appeal has passed. A claim for an earlier effective date is a downstream element of a grant of service connection and the adjudication of a freestanding claim for an earlier effective date violates the rule of finality. See Rudd v. Nicholson, 20 Vet. App. 296, 299 (2006) (holding that stand-alone claims for earlier effective dates have no legal merit). Therefore, as the rating decision issued in June 2017 was not appealed, an appeal of the effective date of service connection or the initial 20 percent rating for right lower extremity radiculopathy at this current juncture would constitute a stand-alone claim, which violates the rule of finality. As such, the Board finds that there is no issue in controversy with regard to an effective date prior to June 5, 2012, for the grant of service connection for right lower extremity radiculopathy and the assignment of a 20 percent rating. The claim is, therefore, dismissed as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). 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 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 granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Only "veterans" are entitled to VA compensation. 38 U.S.C. § 1131. The term "veteran" means a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable. 38 U.S.C. § 101 (2); 38 C.F.R. § 3.1 (d). The term "active duty" includes full-time duty in the Armed Forces, other than ACDUTRA. 38 U.S.C. § 101 (21). "Active military, naval, and other air service" includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, cardiac arrest, or cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6 (b); see also Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). The fact that a claimant has established status as a "veteran" for other periods of service (active duty, etc.) does not obviate the need to establish that he is also a "veteran" for purposes of the period of ACDUTRA where the claim for benefits is premised on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). However, once a claimant has achieved veteran status for a single disability incurred or aggravated during that period of ACDUTRA, that status applies to all disabilities claimed to have been incurred or aggravated during that period of ACDUTRA. Hill v. McDonald, 28 Vet. App. 243, 252 (2016). Reserve and National Guard service generally means ACDUTRA and INACDUTRA; although it may also include active duty. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). Basically, this refers to the two weeks of annual training which each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. The Veteran's service personnel records indicate that subsequent to his active duty, he had an ACDUTRA periods from September 16-30, 1995; February 26-March 10, 1996; March 22, 1996; May 24-25, 1997; May 26-June 7, 1997; June 8-14, 1997; August 9-23, 1998; May 26, 2002; December 7-21, 2002; November 3-7, 2003; September 6-20, 2003; February 9-13, 2004; and March 20-24, 2004. The Veteran had no periods of ACDUTRA between May 26, 1992 and May 25, 1995; May 26, 1999 and May 25 2001; May 26, 2004 and May 25, 2005; and May 26, 2008 and May 25, 2010. The Board notes that the Veteran testified at both his Board hearings that he worked for the Air Force Reserve full-time as a military technician and had a "dual status" as a Reservist and civilian employee. A military technician (dual status) is a Federal civilian employee who is employed under section 3101 of Title 5 or section 709(b) of Title 31; is required as a condition of that employment to maintain membership in the Selected Reserve; and is assigned to a civilian position as a technician in the organizing, administering, instructing, or training of the Selected Reserve or in the maintenance and repair of supplies or equipment issued to the Selected Reserve or the armed forces. 10 U.S.C. § 10216. There is no legal basis upon which to establish service connection for diseases or injuries incurred during civilian employment. See, e.g., Venturella v. Gober, 10 Vet. App. 340 (1997) (holding that where a claimant has status as a Reserve/Guard member and as a civilian military employee, service connection is not in order for those diseases or injuries that were incurred during civilian employment). 1. Entitlement to service connection for a disability manifested by vertigo and dizziness (claimed as Meniere's syndrome) The Veteran contends that he has a disability manifested by vertigo and dizziness related to his active duty service. Specifically, the Veteran noted in a statement received in June 2016 that his military occupational specialty (MOS) was an aircraft structural maintenance specialist and that during that time, he was exposed to jet fuel on a daily basis as part of his job required him to work in fuel tanks and on parts that had not been cleaned before being brought in for repair. The Veteran noted that during his active duty service, he got jet fuel on his clothes and skin on a regular basis and also inhaled fumes although he had been provided an ill-fitting and malfunctioning respirator. The question for the Board is whether the Veteran's has a current disability manifested by vertigo and dizziness that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's service treatment records are absent any complaints, findings, or diagnoses of vertigo or dizziness during active service from November 1988 to May 1992. The Veteran's DD Form 214, Certificate of Release or Discharge from Active Duty, indicates that during his period of active duty service, the Veteran was a Structural Maintenance Specialist for three years and five months; and that his key duties, tasks and responsibilities included, Repairs, modifies, fabricates and installs metal, fiberglass and honeycomb structures on A-10 aircraft, flight simulator, and associated in support equipment. Using drawings to fabricate stainless steel and aluminum tubing assemblies. Fabricates and tests for reliability flight control cables and cable assemblies. Repairs and replaces hardware on TF34 engines and associated support equipment. It was also noted that the Veteran had repaired an A-10 engine inlet assembly for a scheduled sortie aircraft. An Occupational Health Examination in October 1989 noted in the workplace narrative that the structural repair workers cut fiberglass, sheer and sand sheet metal, mix and apply resin and adhesives, wipe MEK (methyl ethyl ketone) onto surfaces, operate power tools, apply zinc chromate putty to surfaces using putty knives. The narrative also noted that as of November 1989, workers would be combining AFSC with corrosion control; that they wore respirators with organic vapor and HEPA filters and were exposed to hazardous noise. A Master Workplace Data Summary completed in May 1991 indicated exposure to noise, paint, lead, and chromates. In January 2001, the Veteran completed an OSHA Respiratory Medical Evaluation Questionnaire in which he reported having been exposed to jet fuel and jet exhaust and that he had a second job or side business as an aircraft mechanic. The Veteran's Reserve service records indicate that the Veteran was seen on November 13, 2008, with complaints of vomiting, earache, ringing, and extreme dizziness. The Veteran also noted that he could not hear out of his right ear. The Veteran reported that he had never had those symptoms before. The Veteran was seen on November 20, 2008, for consultation with a private otolaryngologist at which time he presented with hearing loss and vertigo. Audiological evaluation and physical examination were performed after which the Veteran was diagnosed as having right sensorineural hearing loss, unilateral (profound and sudden) and dizziness. Additional tests were ordered including MRI which showed subtle enhancement along the posterior and inferior aspects of the right internal auditory canal consistent with neuritis and mild cerebral atrophy and mild cerebral white matter disease. The Veteran returned in December 2008 at which time he was diagnosed as having right vestibular neuronitis and right auditory nerve neuritis. Additional tests were ordered. The Veteran underwent VA examination in February 2015 at which time the examiner determined that the Veteran had never been diagnosed with an ear or peripheral vestibular condition. The examiner stated, In my opinion, the most likely diagnosis for the veteran's complaint of dizziness would be residuals from the acute vestibular neuronitis (viral labyrinthitis) that occurred November 2008. Although the veteran said that his family doctor told him he had Meniere's, in my opinion that is NOT the appropriate diagnosis. The veteran is scheduled for an ENG (VNG) study at the VA on 2/26/15. I will provide an addendum to this encounter with additional information after the ENG study completed and read. At this point it is apparent that the veteran's episode was not incurred while on active duty between 11/88 and 5/92. In a February 2015 Addendum, the examiner noted that ENG (VNG) study completed was normal and stated, "I am unable to find objective evidence of the presence of a specific vestibular disorder to account for the veteran's complaint of recurrent dizziness." The Veteran underwent VA examination in July 2015 at which time he was diagnosed as having benign positional vertigo. After review of the record and physical examination of the Veteran, the examiner opined that the Veteran's vertigo was less than 50 percent probability due to inservice event or illness. The examiner noted that noise exposure was usually not considered a cause of vertigo or vertigo-related conditions. In support of his claim, the Veteran has submitted two favorable medical opinions. The first opinion in June 2016 was rendered by Dr. J.W. Ellis, and the second opinion in April 2020 was rendered by Dr. S.R. Baber. In his June 2016 opinion, Dr. Ellis found that it was more likely than not that the Veteran's BPPV and Meniere's syndrome was caused by his exposure to jet fuel while working as an aircraft structural repair specialist in the military. Dr. Ellis stated, The Veteran's service records show that his job involved exposure to jet fuel, paint, chromate, and other chemicals on a daily basis during his active duty. I note that the Veteran also had significant noise exposure in the service and that hearing loss and tinnitus are often associated with BPPV and Meniere's Syndrome. It is difficult to say if hearing loss and tinnitus are separate conditions caused by noise exposure, or if they are symptoms of BPPV/Meniere's Syndrome. The other medical opinions on the subject are split regarding the etiology of the Veteran's BPPV/Meniere's Syndrome. On the one hand, the Air Force Physical Evaluation Board from May 2010 attributed the Veteran's right auditory nerve neuritis/right vestibular ne[u]ronitis and equilibrium imbalance was due to his total hearing loss in the left ear. Dr. Kenneth Katzen, D.O. also felt the Veteran's hearing loss and vertigo were related. On the other hand, in August 2016, Dr. John Gilmore opined that the Veteran's vertigo and vertigo related conditions were not caused by noise exposure in service. I recognize that the Veteran is currently service connected for hearing loss and tinnitus due to noise exposure but none of the physicians discuss his exposure to jet fuel. I will consider the conditions separate from BPPV/Meniere's Syndrome although it is very likely that the conditions are related. Published medical literature from the National Library of Medicine confirms that exposure to jet fuel, such as JP-4 and JP-8, can cause permanent hearing loss, dizziness, and other neurological impairment. During the Veteran's active duty service, he experienced daily exposure to JP-8 jet fuel while working inside of fuel tanks and on mechanical parts that were covered with fuel, oil, lubricants, and other chemicals. He inhaled the fumes from the jet fuel on days when he was working without a respirator and on days when his respiratory was malfunctioning. He also experienced daily skin exposure through his hands, arms, and legs when he would work on parts and kneel or sit inside the fuel tanks. He also inhaled the fumes when traveling home after work because his clothes would often have jet fuel on them. For these reasons, it is my medical opinion that it is more likely than not that the Veteran's current BPPV/Meniere's Syndrome is directly related to his frequent and prolonged exposure to jet fuel during his active duty service in the Air Force. In his April 2020 opinion, Dr. Baber found that the Veteran's Meniere disease (MD) was as likely as not secondary to jet fuel exposure while enlisted in the military. Initially, Dr. Baber notes that the constellation of symptoms of hearing loss, tinnitus, and vertigo were a hallmark of Meniere's disease and that there were numerous findings in the literature which show there is a strong nexus between occupational toxicants and Meniere's disease. Dr. Baber stated, There is significant evidence this Veteran has been exposed to copious amounts of Jet Fuel during his active duty service in the military, most importantly from November 19[8]8 to May 1992. Time exposure to the Jet Fuel and quantity exposed to the Jet Fuel were variable. There are too many unknown variables and no scientific basis to support an opinion that Jet Fuel did not have an impact on the Veteran's MD. However, the medical literature ... shows that Jet Fuel contaminants have the potential to cause MD. Another fact present is, the Veteran did not have any other risk factors present. His exposure to Jet Fuel is the only risk factor and the most likely culprit of his MD. Given this information, it is well supported to opine, [the Veteran]'s MD is as least as likely as not secondary to his Jet Fuel exposure from his active duty service. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current disability manifested by vertigo and dizziness is related exposure to jet fuel during his active duty service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a disability manifested by vertigo and dizziness is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for an acquired psychiatric disability, to include MDD and anxiety The Veteran contends that his psychiatric disorders are related to his military service; and in the alternative, are due to hypertension and GERD. The Veteran underwent VA examination in July 2011 at which time he was diagnosed as having moderate, recurrent, major depression. After interview with the Veteran and mental status examination, the examiner opined that the Veteran major depression was less likely as not secondary to service-connected hypertension. The examiner explained, The veteran was diagnosed with hypertension in service, but experienced no depression in his life until his 2002 divorce and, after that, "everything going to shit." Between his 2002 difficult divorce and the present, the veteran has lost his job in 2004 after many years due to downsizing, experiences back pain constantly and had back surgery in 2008, was diagnosed with Meniere's disease in 2008, had a house in foreclosure early in 2011, is currently homeless, and his wife was diagnosed with a serious medical condition "sarcoidosis" in 2010. The veteran described his mental health symptoms, including depression and anger symptoms, as an aspect of his life only during this last difficult decade. These multiple and severe stressors are the likely cause of his depressive symptoms, not his service connected hypertension. The Veteran underwent VA examination in February 2015 at which time he was diagnosed as having unspecified depressive disorder. After interview with the Veteran and mental status examination, the examiner stated, Based upon direct evaluation of the Veteran and review of records the undersigned examiner concurs with the previous C&P examiner that the Veteran's mental illness symptoms are not associated with or aggravated by his service connected hypertension and most likely associated with post-military life stressors. The Veteran described to the undersigned that he and several of his siblings were like their father in that they had problems with anger. The Veteran indicates he and his current wife have a good relationship and his anger is reportedly under control in that relationship. He describes issues with road rage and getting out of his vehicle to confront other drivers in traffic. Onset of the Veteran's mental illness complaints did not begin until well after his discharge from service and the medical records clearly associate them with post-military life stressors which were considered time limited as the Veteran at the time estimated he would not continue on medication beyond two to three months. The Veteran denied anxiety on many of his health evaluation forms. Based upon the Veteran's description and review of records Unspecified Depressive Disorder, mild is diagnosed rather than the previously diagnosed Major Depressive Disorder. Unspecified Depressive Disorder is not caused by, associated with or aggravated by the Veteran's service connected hypertension. In his June 2016 opinion, Dr. Ellis found that it was as likely as not that the Veteran's depression was secondary to his physical impairment of lumbar spine DDD, Meniere's Syndrome/BPPV, hearing loss, tinnitus, and hypertension. Dr. Ellis stated, The Veteran currently suffers from moderate depressive disorder as confirmed by his treating psychiatrist and previous GAF score of 55. Upon examination I observed symptoms of irritability, depressed mood, chronic sleep impairment, panic attacks, impaired concentration, and outbursts of anger. The Veteran's medical records note current treatment with Celexa but he states that the medication is not helping. I concur with Dr. Gregory Dayton, Ph.D. that the Veteran's physical impairments and chronic pain are contributing to and aggravating his depression. Namely, the Veteran's chronic back pain caused by his lumbar spine degenerative disc disease, bilateral knee pain, Meniere's Syndrome, hearing loss, and tinnitus all contribute to the Veteran's depression. His depression was non-symptomatic and not in need of medication but as his physical impairments worsened, the chronic pain and debilitating limitations he experiences aggravated his depression symptoms to the point where he now requires medication and continues to experience moderate symptoms, sleep impairment, panic attacks, and even passive suicidal ideation. Service connection had been established for lumbar spine DDD, bilateral lower extremity radiculopathy, bilateral knee chondromalacia patellae, hearing loss, tinnitus, hypertension, and lumbar surgical scar; and herein, service connection is established for a disability manifested by vertigo and dizziness. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current acquired psychiatric disability is aggravated by his service-connected disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102." 3. Entitlement to service connection for GERD The Veteran contends that his GERD is related to his military service; and in the alternative, is due to service-connected disability. At the Veteran's August 2014 Board hearing, he testified that he believed that he was diagnosed with GERD in the Spring 2006. The question for the Board is whether the Veteran's GERD began during service; is at least as likely as not related to an in-service injury, event, or disease; or is proximately due to, the result of, or aggravated beyond its natural progress by service-connected disability. The Veteran's service treatment records are absent complaints, findings or diagnoses of GERD during any period of active duty or ACDUTRA. On the clinical examinations in August 1995 and in February 2001, the Veteran's abdomen and viscera were evaluated as normal; and on the Reports of Medical History completed by the Veteran in connection with those examinations, he denied ever having frequent indigestion or stomach trouble. In a Health History & Respiratory Questionnaire completed by the Veteran in August 2005, he denied having heartburn or indigestion not related to eating. On the Veteran's post-deployment health assessment completed in May 2007, he denied having frequent indigestion or having it at any time during his deployment. A December 2008 private medical record notes that the Veteran denied abdominal bloating and pain. In an October 2008 private medical record, the Veteran reported having dysphagia but denied heartburn. A February 2010 Operative Report noted that the Veteran underwent gastroscopy with postoperative diagnosis of reflux esophagitis. A March 2010 letter from one physician to another regarding the Veteran's several year history of progressive episodes of difficulty swallowing noted that the Veteran had a swallow study that showed him to have some areas of spasm but there was no fixed stenosis; that a barium tablet passed easily into the stomach; that an Esophagogastroduodenoscopy (EGD) examination done in February 2010 showed some changes of reflux in the distal esophagus; and that biopsies from the middle and lower third of the esophagus excluded eosinophilic esophagitis from consideration. It was noted that since the EGD, he had been taking pantoprazole on a routine regular daily basis and had experienced no further dysphasia and that dyspepsia had resolved. An April 2010 private medical record noted that the Veteran had other dysphagia and a gastroenterologist referral was made. The Veteran underwent VA examination in February 2015 at which time the examiner diagnosed him with GERD. The examiner noted that the Veteran reported initial symptoms of choking with all food intake for a few weeks before seeking treatment and being diagnosed with GERD in approximately 2006. The examiner stated that there were no indications or documentation found for treatment of GERD in the available medical records and opined that the GERD less likely originated in service or is otherwise attributable thereto or any incident thereof. As noted above, active military, naval, and other air service includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty. There is no evidence in the record that the Veteran was on ACDUTRA during the Spring 2006. The Veteran was on active duty in May 2007; however, as noted above, he denied having frequent indigestion during his deployment. As such, there is no indication that his GERD increased in severity due to his deployment. No medical professional has ever related the Veteran's GER to either his military service or to service-connected disability. The Board concludes that although the Veteran has a current diagnosis of GERD, the evidence of record persuasively weighs against finding that the Veteran's GERD began during service or is otherwise related to an in-service injury, event, or disease or that it is proximately due to, the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Although the Veteran believes that his GERD is related to his active service or service-connected disability, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the unfavorable medical evidence of record. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection is warranted for GERD. 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). Effective Dates In general, the effective date of compensation based on an original claim or a claim for increase will 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. The exception to the rule allows for the earliest date as of which it was factually ascertainable that an increase in disability had occurred if the claim was received within one year from such date; otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400 (o)(2). Beginning March 24, 2015, a specific form prescribed by the Secretary of VA must be submitted for benefits to be paid to any individual under the laws administered by the VA. 38 U.S.C. § 5101 (a). Prior to March 24, 2015, VA recognized formal and informal claims. A claim is defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1 (p). An informal claim is any communication or action indicating intent to apply for one or more benefits and must identify the benefit sought. 38 C.F.R. § 3.155 (a). VA must look to all communications from a claimant that may be interpreted as applications or claims both formal and informal for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196 (1992). 4. Entitlement to an effective date prior to August 31, 2015, for the assignment of a 20 percent rating for lumbar spine DDD 5. Entitlement to an effective date prior to August 31, 2015, for the grant of service connection and assignment of an initial 10 percent rating for left lower extremity radiculopathy The Veteran seeks an effective date earlier than August 31, 2015, for the assignment of a 20 percent rating for lumbar spine DDD and the grant of service connection and assignment of an initial 10 percent rating for left lower extremity radiculopathy. As noted above, on February 22, 2017, the Board granted service connection for lumbar spine DDD and right lower extremity radiculopathy; a June 2017 rating decision effectuated the February 22, 2017, Board decision and assigned a 20 percent rating for right lower extremity radiculopathy and a 10 percent rating for lumbar spine DDD. The Veteran did not appeal the effective dates assigned or the ratings assigned for either the lumbar spine DDD or the right lower extremity radiculopathy. New and material evidence was also not received within a year of the June 2017 rating decision notice. Also as noted above, in April 2018, the Veteran submitted his RAMP Opt-In Election for all eligible issues on appeal. In July 2018, the Veteran was informed that his appeal had been withdrawn with respect to the issues of service connection for hemochromatosis, Meniere's syndrome, sinusitis, GERD, and MDD as well as entitlement to a TDIU. As service connection for lumbar spine DDD and right lower extremity radiculopathy had been granted prior to submission of his RAMP Opt-In Election, the issues were not part of the Supplemental Claim. On January 18, 2019, the Veteran underwent VA examination for his lumbar spine disability at which time he was diagnosed as having lumbar spine DDD, right lower extremity radiculopathy, and left lower extremity radiculopathy. In the February 6, 2019, rating decision on appeal, the rating for the Veteran's lumbar spine was increased from 10 percent to 20 percent from August 31, 2015; a higher rating for the right lower extremity radiculopathy was denied; and service connection for left lower extremity radiculopathy was granted and a 10 percent rating was assigned effective from August 31, 2015. In its Introduction of the February 2019 rating decision, the AOJ noted that the Veteran's supplemental claim had been received on April 2, 2018. In its Reasons for Decision of the February 2019 rating decision, the AOJ noted that August 31, 2015, was the effective date of the 20 percent rating for the Veteran's lumbar spine DDD as well as the grant of service connection for left lower extremity radiculopathy and assignment of the 10 percent rating. The AOJ explained that August 31, 2015, was the date that the Veteran's claim (for individual unemployability) was received by VA. First, as noted above, the Veteran did not appeal the June 2017 rating decision which assigned a 20 percent rating for right lower extremity radiculopathy and a 10 percent rating for lumbar spine DDD. New and material evidence was also not received within a year of the June 2017 rating decision notice. A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. See 38 C.F.R. §§ 3.156, 20.302, 20.1103. A such, the June 2017 rating decision became final. When the Veteran chose the RAMP Opt-in Election in April 2018, it was only for the issues that were still on appeal -- service connection for hemochromatosis, Meniere's syndrome, sinusitis, GERD, and MDD as well as a TDIU. As such, the issues of entitlement to higher ratings for the Veteran's lumbar spine DDD and right lower extremity radiculopathy were not on appeal. In addition, the June 2017 rating decision that assigned the 10 percent rating for the Veteran's DDD became final. Second, prior to August 31, 2015, there was no claim for service connection for a left lower extremity radiculopathy pending. On his original claim for compensation received by VA in June 2008, the Veteran only claimed right leg numbness. The Veteran made no statement with regard to any left leg neurological impairment on either his Notice of Disagreement; his VA Form 9, Appeal to the Board of Veterans' Appeals; or at his Board hearing in May 2011. At the June 2012 VA examination, the examiner found no left lower extremity symptoms of radiculopathy. As such, there was no formal or informal claim for service connection for left lower extremity radiculopathy prior to March 24, 2015. In addition, from March 24, 2015, to August 30, 2015, VA did not receive a claim for service connection for left lower extremity radiculopathy on the proper form. As the Veteran did not appeal the June 2017 rating decision with respect to the ratings or effective dates assigned for the Veteran's lumbar spine DDD and right lower extremity radiculopathy, and as a claim for service connection for left lower extremity radiculopathy was not pending prior to August 31, 2015, an effective date earlier than August 31, 2015, is not warranted for the 20 percent rating for lumbar spine DDD or for service connection for left lower extremity radiculopathy and assignment of a 10 percent rating. 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. Although the AOJ adjudicated the issues of entitlement to rating in excess of 10 percent for lumbar spine DDD and entitlement to service connection for left lower extremity radiculopathy in error, the Board will not disturb the 20 percent rating or effective date of August 31, 2015, assigned for Veteran's lumbar spine DDD; nor will it disturb the 10 percent rating or the effective date of August 31, 2015, assigned for the grant of service connection for the Veteran's left lower extremity radiculopathy. Further, the Board will review the record from August 31, 2015, to February 6, 2019 (the date of the rating decision on appeal), and from December 17, 2019 (the date the Veteran submitted his Notice of Disagreement), to April 21, 2020 (the date the evidence window closed), to determine if higher ratings are warranted for the lumbar spine DDD, the right lower extremity radiculopathy, and the left lower extremity radiculopathy. 6. Entitlement to a rating in excess of 20 percent for lumbar spine DDD The Veteran's lumbar spine DDD is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5237. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that degenerative arthritis of the spine (Diagnostic Code 5242) has been rated under the criteria for a lumbosacral strain (Diagnostic Code 5237). See 38 C.F.R. § 4.27. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. [Include any other relevant Note(s).] When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). VA treatment records indicate that the Veteran was seen for a TENs unit trial in June 2017 with complaints of chronic lumbar pain with a level of 7/10. Physical examination demonstrated no tenderness with palpation. The Veteran underwent VA examination in January 2019 at which time he The Veteran denied flare-ups but noted that prolonged standing worsened his pain. Physical examination demonstrated forward flexion to 60 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 15 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 30 degrees. The examiner noted that pain itself did not contribute to a functional loss but that pain noted on examination caused functional loss on all motion except for left lateral rotation. There was objective evidence of mild localized tenderness or pain on palpation to bilateral paraspinal muscles. There was no loss of function or range of motion on repetitive use testing. The examiner noted that pain significantly limited functional ability with repeated use over a period of time; however, the Veteran reported increased pain but no loss of range in motion after repetitive use over time. There was no guarding or muscle spasm, no ankylosis, and no additional associated objective neurological abnormalities. The examiner also determined that the Veteran did not have intervertebral disc syndrome (IVDS). The Board finds that the evidence of record persuasively weighs against a rating in excess of 20 percent for the Veteran's lumbar spine DDD. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain; however, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Based on the foregoing, the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 20 percent for lumbar spine DDD. As the evidence of record persuasively weighs against a rating in excess of 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch, 21 F.4th at 776. 7. Entitlement to a rating in excess of 20 percent for radiculopathy of the right lower extremity 8. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity The Veteran's right and left lower extremity radiculopathy is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8520 for paralysis of the sciatic nerve. Under the criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). At the January 2019 VA examination, muscle strength testing was normal with the exception of slightly diminished 4/5 strength with right hip flexion, reflex examination was normal, and sensory examination was normal. Straight leg raising was positive; and the Veteran was noted to have moderate right lower extremity constant pain, mild left lower extremity constant pain, and mild numbness of both lower extremities. The examiner determined that the sciatic nerve roots were involved and noted the severity of the Veteran's radiculopathy was moderate on the right and mild on the left. Based on the above, the Board finds that the disability is primarily manifest by constant pain and sensory disturbance. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis of the sciatic nerve in the right lower extremity and mild incomplete paralysis of the sciatic nerve in the left lower extremity. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 20 percent for right lower extremity radiculopathy and in excess of 10 percent for left lower extremity radiculopathy. As the evidence of record persuasively weighs against higher ratings for the Veteran's right and left lower extremity radiculopathy, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch, 21 F.4th at 776. REASONS FOR REMAND 9. Entitlement to service connection for hemochromatosis is remanded is remanded. The issue is remanded to correct a duty to assist error that occurred prior to the February 2019 rating decision on appeal. The AOJ obtained a February 2013 medical opinion prior to the rating decision on appeal. The opinion, which indicated that the Veteran's hereditary hemochromatosis preexisted his active duty service; that it began to manifest in 1995 as noted by Dr. Bull in a September 1, 1995, letter which described increased hemoglobin on laboratory tests and increased iron; and that the Veteran was not diagnosed as having hemochromatosis until January 12, 2005, after his father was diagnosed with it and a genetic test confirmed the hereditary nature of it. The opinion further found that the Veteran's hemochromatosis was less likely than not incurred in or caused by claimed in-service injury, event, or illness; clearly and unmistakably existed prior to service and not aggravated beyond its natural progression by an in-service injury, event, or illness or his hypertension; and was less likely than not proximately due to or the result of the Veteran's hypertension. Service connection may be granted for hereditary diseases that either first manifest themselves during service or which preexist service and progress at an abnormally high rate during service. See VAOPGCPREC 67-90 (Jul. 1990). That opinion noted that, ... diseases of hereditary origin can be incurred or aggravated in service, in the sense contemplated by Congress in title 38. They can be considered to be incurred in service if their symptomatology did not manifest itself until after entry on duty. The mere genetic or other familial predisposition to develop the symptoms, even if the individual is almost certain to develop the condition at some time in his or her lifetime, does not constitute having the disease. Only when symptomatology and/or pathology * *In this context we use the term "pathology" in the sense of an active disease process, not just a mere predisposition to develop a disease, which process may or may not precede symptomatology, exist can he or she be said to have developed the disease. At what point the individual starts to manifest the symptoms of, or have pathological changes associated with the disease is a factual, not a legal issue. This must be determined in each case based on all the medical evidence of record. Even where a hereditary disease has manifested some symptoms prior to entry on duty, it may be found to have been aggravated during service if it progresses during service at a greater rate than normally expected according to accepted medical authority. Again, this is a factual, medical determination which must be based upon the evidence of record and sound medical judgement. The Mayo Clinic notes that hereditary hemochromatosis causes one's body to absorb too much iron from food; excess iron is stored in one's organs, especially the liver, heart, and pancreas. Hereditary hemochromatosis can be difficult to diagnose and that early symptoms such as stiff joints and fatigue may be due to conditions other than hemochromatosis. Many people with the disease don't have any signs or symptoms other than elevated levels of iron in their blood. Two key tests to detect iron overload are serum transferrin saturation and serum ferritin. Additional testing could include liver function tests. Signs and symptoms may include joint pain, abdominal pain, fatigue, weakness, diabetes, loss of sex drive, impotence, heart failure, liver failure, bronze or gray skin color, memory fog. https://www.mayoclinic.org/diseases-conditions/hemochromatosis/symptoms-causes/syc-20351443 The Veteran's service treatment records include symptoms of knee pain, leg pain, and foot pain. The service treatment records also indicate that he had elevated findings AST/SGOT level (49 when the normal is between 14 and 48) in July 1991; however, in October 1991, the Veteran's AST/SGOT level was 36. On Report of Medical Examination in August 1995 showed an elevated finding of hemoglobin (17.4 when the normal was between 13.5 and 16.5). The Veteran was advised to see a private physician for hemoglobin. A September 1995 letter from Dr. Bull noted that recent laboratory evaluation revealed the following abnormalities, an increased hemoglobin and hematocrit with an increased serum iron. A July 2007 medical oncology note indicates that the Veteran was initially diagnosed with hemochromatosis by Dr. Edelman; and that he had a ferritin level of 1000 in December 2005. As the record is absent hemoglobin or hematocrit findings prior to 1995, and as there is a finding of high AST/SGOT, elevated liver enzymes, an additional opinion should be obtained to determine if the high AST/SGOT level in July 1991 was at least as likely as not the onset of the Veteran's an active disease process of hemochromatosis. 10. Entitlement to service connection for sinusitis The issue is remanded to correct a duty to assist error that occurred prior to the February 2019 rating decision on appeal. The Veteran underwent VA examination in February 2015 at which time it was noted that the Veteran had never been diagnosed as having a sinus, nose, throat, larynx, or pharynx condition; however, the Veteran was noted to have rhinitis and deviated nasal septum. The examiner stated, The veteran exhibits signs and symptoms of chronic allergic rhinitis, currently untreated. Since he described possible recurrent sinusitis, I ordered a CT of sinuses and will need to provide an addendum to this encounter after the CT of sinuses has been completed and read. From my review of VBMS e-Records, I found no indication that the veteran had been treated for any "sinus condition" between 11/88 and 5/92. My review of STR's failed to show a diagnosis or treatment for a specific chronic sinus condition, including nasal trauma. It would seem appa[r]ent that the veteran's deviated nasal septum was the result of a nasal fracture incurred during childhood, and there was certainly no reference made in any of the records that I reviewed, military or private. As the record is absent an Addendum opinion, one should be obtained. 11. Entitlement to a TDIU The Veteran's claim for a TDIU is inextricably intertwined with the initial ratings and effective dates to be assigned for the disability manifested by vertigo and dizziness and the acquired psychiatric disorder granted herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As such, final appellate review of the Veteran's claim for a TDIU must be deferred until the initial ratings and effective dates for these disabilities are assigned and the matter is either resolved or prepared for appellate review. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, preferably a hematologist, regarding whether the Veteran's hemochromatosis pathology at least as likely as not had its onset during active service including but not limited to whether the elevated findings of AST/SGOT of 49 in July 1991 was a manifestation of hemochromatosis symptomatology. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has a diagnosis of chronic sinusitis or rhinitis that is at least as likely as not related to the Veteran's active duty service including any period of ACDUTRA. 3. After rendering initial ratings and effective dates for the Veteran's disability manifested by vertigo and dizziness and his acquired psychiatric disorder, take all appropriate action to readjudicate the Veteran's claim for entitlement to a TDIU, including any development deemed necessary. 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.