Citation Nr: 0005181 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 98-14 106 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to an initial evaluation in excess of 10 percent for duodenal ulcer with hiatal hernia and gastroesophageal reflux disease (GERD) with Barrett's esophagus. 3. Entitlement to an initial compensable evaluation for pulmonary nodules. 4. Entitlement to an initial compensable evaluation for defective hearing, left ear. 5. Entitlement to an initial compensable evaluation for left heel spurs. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from March 1976 to October 1997. This appeal to the Board of Veterans' Appeals (the Board) is from rating action taken by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, in April 1998. In addition to the disabilities with which the appeal is herein concerned, service connection is also in effect for history of fracture of the right humerus, major, rated as 10 percent disabling; bilateral pes cavus with calluses and history of metatarsalgia, rated as 10 percent disabling; and plantar warts, rated as noncompensably disabling. FINDINGS OF FACT 1. The claim of entitlement to service connection for a low back disorder is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The veteran's gastrointestinal disability is productive of not more than mild impairment. 3. A history of pulmonary nodules, shown on X-ray, of undetermined origin, are entirely asymptomatic at present and cause no respiratory impairment. 4. Hearing acuity in the left ear translates to a literal I, and the nonservice-connected right ear is not totally deaf. 5. The veteran's left heel spurs are asymptomatic except when he jogs or runs. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a low back disorder is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. The criteria for an initial evaluation in excess of 10 percent for duodenal ulcer, hiatal hernia, GERD and Barrett's esophagus are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.14, 4.20, 4.25, 4.113, 4.114, Diagnostic Code 7305 (1999). 3. The criteria for an initial compensable evaluation for pulmonary nodules are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.31, 4.97, Diagnostic Code 6820 (1999). 4. The criteria for an initial compensable evaluation for defective hearing, left ear, are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.2, 4.85, 4.86, 4.87, Diagnostic Code 6100 (effective prior to June 10, 1999); 38 C.F.R. §§ 4.85, 4.86, 4.87; Diagnostic Code 6100; 64 25202-25210 (May 11, 1999) (effective June 10, 1999). 5. The criteria for an initial compensable evaluation for left heel spurs are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.2, 4.7, 4.14, 4.20, 4.31, Diagnostic Code 5284 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to service connection for a low back disorder. Criteria The threshold question to be answered in any case is whether the appellant has presented evidence of a well grounded claim; that is, a claim which is plausible and meritorious on its own or capable of substantiation. If he has not, his appeal must fail. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Case law provides that although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant may submit some supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be (1) competent evidence of a current disability (a medical diagnosis), (2) an incurrence or aggravation of a disease or injury in service (lay or medical evidence), (3) a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Where the determinative issue involves the question of a medical diagnosis or causation, only individuals possessing specialized training and knowledge are competent to render a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 192 (1992). The United States Court of Appeals for Veterans Claims (the Court) has held that if an appellant fails to submit a well- grounded claim, VA is under no duty to assist him/her in any further development of the claim. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); 38 C.F.R. § 3.159(a) (1999). In fact, a recent decision has reiterated that such evidentiary assistance absent a well-grounded claim is precluded. See Morton v. West, 12 Vet. App. 477 (1999). Service connection may be established for disability incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). The Court has held that the chronicity provision of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumptive period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if the condition is observed during service or any applicable presumptive period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Voerth v. West, No. 95-904 (Oct. 15, 1999); Clyburn v. West, 12 Vet. App. 296 (1999); Savage v. Gober, 10 Vet. App. 488 (1997). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). The Court has also held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). A determination with regard to entitlement to service connection must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). In this, and in other cases, only independent medical evidence may be considered to support Board findings. If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, it remains the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established through competent lay evidence, not medical records alone. Horowitz, op. cit. But a lay witness is not capable of offering evidence requiring medical knowledge. Espiritu, op. cit. The Board is not bound to accept medical opinions that are based on history supplied by the veteran where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); and Guimond v. Brown, 6 Vet. App. 69 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, op. cit. When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Factual Background Service medical records show a single instance of low back complaints. On May 5, 1993, the veteran reported for emergency care at the U.S. Air Force medical facility at Hill Air Force Base (AFB) with complaints of having developed a sore, tight low back the prior evening while working around the house. The morning of the hospital visit, his back was said to be very stiff and sore. He was having no radicular symptoms or bowel or bladder problems. On examination, there was full range of motion. There was some muscle spasm at the area of the sacroiliac joint, right side greater than left. Otherwise, neurological evaluation was entirely negative. He was told to use ice and rest. There was felt to be some possible relief with adjustment. Motrin and Flexeril were prescribed. He was returned to full duty at 1135 hours, some 33 minutes after his arrival at the facility, in a condition described as "improved". The assessment was low back strain. Subsequent service records show no complaints or findings of any low back disorder. Negative clinical findings include on an orthopedic evaluation just prior to separation relating to other disabilities; there was no mention of back complaints or positive findings at that time. On his initial claim for compensation benefits, filed at the time of separation from service, the veteran reported that 2 years before, when lifting boxes, he had hurt his back. He stated that the condition limited the amount he could do before the back would start to hurt. On VA examination in November 1997, the veteran reported that while at Hill AFB in 1995, while lifting heavy boxes at home, he had developed sudden onset of low back pain. The diagnosis of strain had been made, and treatment consisted of muscle relaxants. He reported currently having intermittent low back pain aggravated by twisting movements and heavy lifting, but without radiculopathy or changes in sensory perception. Prolonged walking produced no pain, except that on long walks, he reported having some tightness over his lower back. This would involve his walking well over one mile. The examination concluded in a pertinent diagnosis of lumbosacral strain with intermittent low back pain and normal range of motion without pain or spasm, without radiculopathy and with intact sensory perception. Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that a claim is well grounded; that is, that a claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit, 5 Vet. App. at 92. Because the veteran has failed to meet this burden, the Board finds that his claim for service connection for a low back disorder is not well grounded and should be denied. Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy, 1 Vet. App. at 81. The claimant does not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority. Espiritu, 2 Vet. App. 492. Consequently, lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, Tirpak, 2 Vet. App. at 611, the absence of cognizable evidence renders the veteran's claim not well grounded. While the veteran had a single episode of low back pain in service, this was without noted residuals thereafter in service. Post-service VA examination disclosed the veteran was found to have a lumbosacral strain which was not linked to anything of service origin, and he was not found to have a chronic disorder and/or symptomatology linked to service. Based upon the evidence of record, the Board finds that competent medical evidence has not been submitted which demonstrates that the veteran currently has a chronic acquired low back disorder or chronic low back symptomatology which has been linked to active service or any incident therein. In the absence of medical evidence of a present disability and/or low back symptomatology linked to service on the basis of competent medical authority, there is no valid claim. The Board further finds that the RO advised the appellant of the evidence necessary to establish a well grounded claim, and the appellant has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claim. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the appellant has not submitted a well grounded claim of entitlement to service connection for a low back disorder, the doctrine of reasonable doubt has no application to his case. II. Initial increased evaluations General Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, 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. The Board has also considered all regulatory provisions which are potentially applicable through the assertions and issues raised in the evidence of record as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board notes that this case involves an appeal as to the initial rating of all of the herein concerned disabilities, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. In the case at hand, the Board finds that staged ratings are inappropriate in each of the instances below. Conclusions reached on any given medical issue to include a determination with regard to such things as degree or extent of functional impairment of a disability, etc., the Court has repeatedly admonished that VA cannot substitute its own judgment or opinion for that of a medical expert. See, i.e., Colvin v. Derwinski, 1 Vet. App. 761 (1991). The Court has also held that a determination with regard to both entitlement to the assignment of specific ratings must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies are to be avoided, as are the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor are ratings assigned to organic diseases and injuries to be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (1999). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (1999). The Court has held that a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). In every instance where the schedule does not include a noncompensable evaluation for a diagnostic code, a noncompensable rating is assignable when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert, op. cit. When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Duodenal Ulcer, Hiatal Hernia, GERD with Barrett's Esophagitis Special Criteria Under 38 C.F.R. § 4.113, there are diseases of the digestive system, particularly within the abdomen which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress, pain, anemia, disturbances in nutrition. Consequently, certain coexisting diseases in this area, do not lend themselves to distinct and separate disability evaluations without violating fundamental principles relating to pyramiding (38 C.F.R. § 4.14). One Diagnostic Code under which the rating may be made is 7305 for duodenal ulcer, which provides for a 10 percent rating when mild with recurring symptoms once or twice yearly. A 20 percent rating is assignable when moderate with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. A 40 percent rating is assignable when moderately severe with less than severe symptoms but impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 60 percent rating is assignable when severe, with delineated symptoms producing definite impairment of health. 38 C.F.R. § 4.114; Diagnostic Code 7305. A 30 percent evaluation may be assigned for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation may be assigned with two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114; Diagnostic Code 7346. Factual Background On VA examination in 1997 the veteran's inservice history of various testing procedures and confirmation of the diagnosed now service-connected disabilities was recorded. It was also noted that he had taken Zantac and antacids with some improvement over the more recent time frame. In fact, it was noted that as long as he took Prilosec, he was fairly well symptom free with only occasional eructation of sour stomach contents. On examination it was noted that the veteran had worked for a defense contractor in an engineering position since service. He had had no loss of weight or gain over the past year. He was 5' 10 " tall and weighed 220 pounds. Abdominal examination was negative. The pertinent diagnosis was duodenal ulcer, remote with hiatal hernia, GERD, with Barrett's esophagus by history. Analysis Initially the Board finds that the veteran's claim for an initial evaluation in excess of 10 percent for his variously diagnosed gastrointestinal disability is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of his service-connected variously diagnosed disability (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an increased evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). The veteran has a history of having experienced a variety of gastrointestinal symptomatology while in service, as the designation of service-connected disabilities clearly reflects. However, the assignment of compensation benefits after service is based upon the degree of severity of current symptomatology. In this regard, whether the veteran is rated by comparison to the criteria for hiatal hernia, ulcer, or GERD, the fact remains that he is relatively symptom-free. However, primarily because he is required to continue medication, specifically Prilosec, and yet on occasion he has been known to experience eructation of sour stomach contents, the RO has assigned a 10 percent rating under Code 7805, reflecting the no more than mild nature of his symptoms. He has not had any change in his weight, or any other symptoms which would warrant the assignment of a rating in excess of 10 percent regardless of the Code used. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial evaluation in excess of a 10 percent for mild, currently virtually asymptomatic gastrointestinal impairment. Gilbert, op. cit. Pulmonary Nodules Special Criteria In rating non-tuberculous disease under 38 C.F.R. § 4.97, neoplasms of any specified part of the respiratory system, when benign, are rated using an appropriate respiratory analogy under Code 6820. In general, these ratings are provided when there is respiratory impairment or other symptoms. A minimum rating of 10 percent may be assigned for restrictive lung disease manifested by a FEV-1 (forced expiratory volume) of 71 to 80-percent predicted, or; FEV- 1/FVC (forced vital capacity) of 71 to 80 percent, or; DLCO (SB) (diffusion capacity of carbon monoxide) (single breath) 66- to 80 percent predicted. 38 C.F.R. § 4.97; Diagnostic Code 6845 (1999). A noncompensable evaluation may be assigned for sarcoidosis with chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment; or rate active disease or residuals as chronic bronchitis (DC 6600) and extra-pulmonary involvement under specific body system involved. A 30 percent evaluation may be assigned for sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. 38 C.F.R. § 4.97; Diagnostic Code 6846 (1999). A noncompensable evaluation may be assigned for sleep apnea syndrome (Obstructive, Central, Mixed): Asymptomatic but with documented sleep disorder breathing. A 30 percent evaluation may be assigned for persistent day-time hypersomnolence. 38 C.F.R. § 4.97; Diagnostic Code 6847 (1999). Factual Background In service, the veteran was found to have chest X-rays reflective of pulmonary nodules indicative of a prior infectious process. These lesions did not appear to progress or at any time become active. On VA examination in 1997 the veteran reported the history of prior apparently nonprogressive pulmonary nodules. Clinical inspection of the chest disclosed it was equal with no audible rales, rhonchi, or wheezing. The pertinent diagnosis was pulmonary nodules by history (sarcoidosis questionable). Analysis Initially, the Board finds that the veteran's claim for entitlement to an initial compensable rating for pulmonary nodules is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The Board also notes that, in general, an allegation of increased disability is sufficient to establish as well- grounded a claim seeking an increased rating. See Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of pulmonary nodules (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed with respect to the disability at issue and that no further assistance to the veteran is required in order to comply with VA's duty to assist mandated by 38 U.S.C.A. § 5107(a); Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). As noted above, the only sign of any respiratory-related disability at all, in service or since, has been X-ray evidence of nonprogressive pulmonary nodules. While it is unclear what these connote in the overall scheme of things, it is clear that the veteran exhibits no concomitant respiratory related symptoms and thus must be rated at a noncompensable rating regardless of the Code. Under Code 6820, absent any discernible respiratory symptoms or any ascertainable disablement, a noncompensable rating is warranted. 38 C.F.R. § 4.31. It is readily apparent that the post service VA examination did not find any of the requisite clinical findings to meet the diagnostic criteria for assignment of a compensable evaluation under any of the diagnostic codes reported above. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for a compensable evaluation. Gilbert, op. cit. Defective Hearing, Left Ear Special Criteria The Court has found that the schedular disability ratings assigned for hearing impairment are derived from the mechanical application of the rating schedule to the exact numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). In general, the basis for evaluating defective hearing will be the impairment of auditory acuity within the conversational voice range according to findings reported by audiology clinic examinations as certified. For VA purposes, impairment of auditory acuity contemplates the degrees of organic hearing loss for speech. 38 C.F.R. § 4.87 (1999). In Hensley v. Brown, 5 Vet. App. 155 (1993), the Court found that "normal" hearing exists when the thresholds are between 0 and 20 decibels, and "hearing loss" exists when the threshold is 25 decibels or more. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as noted by the results of controlled speech discrimination tests, together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 cycles per second. To evaluate the degree of disability from unilateral or bilateral service-connected defective hearing, the rating schedule establishes 11 auditory acuity levels, designated from level I for essentially normal acuity through XI for profound deafness. 38 C.F.R. § 4.85, Codes 6100 to 6110 (1999 in effect prior to May 1999; and under Code 6100 using comparable and appropriate Tables as specified under 38 C.F.R. §§ 4.85 and 4.86, as revised in May 1999. However, for evaluations for unilateral defective hearing, wherein the nonservice-connected ear is less than totally deaf, the ratings assignable may range from noncompensable to a maximum of 10 percent, and the latter rating is assignable only when the hearing loss in the service-connected ear is very significant, and translates to a level of X or XI. In situations where service connection has been granted only for defective hearing involving one ear, and the appellant does not have total deafness in both ears, the hearing acuity of the nonservice-connected ear is considered to be normal. VAOPGCPREC 32-97. Impairment of auditory acuity means the organic hearing loss for speech. 38 C.F.R. § 4.87 (1999). Factual Background On VA examination in December 1997, the veteran reported that he had had progressive hearing loss since 1991. He had had exposure to noise in service including artillery, large motors and generators within a launch control area. The veteran's post-service civilian noise exposure included recreational shooting and proximity to farm equipment with ear protection. The report of VA examination in 1997 shows that the authorized audiological evaluation recorded pure tone thresholds in the service-connected left ear, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 LEFT 15 20 35 55 50 This reflects an average of 40 decibels. Speech audiometry revealed a speech recognition ability of 96 percent in the left ear. As to the nonservice-connected right ear there was an average loss of 15 decibels at 1000, 2000, 3000, and 4000 Hertz. Speech audiometry revealed a speech recognition of 100 percent. The examiner noted that the veteran's organic hearing sensitivity was normal hearing on the right by VA standards and category I on the left. Analysis Initially, the Board finds that the veteran's claim for entitlement to an initial compensable rating for defective hearing in the left ear is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The Board also notes that, in general, an allegation of increased disability is sufficient to establish as well- grounded a claim seeking an increased rating. See Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of defective hearing (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed with respect to the disability at issue and that no further assistance to the veteran is required in order to comply with VA's duty to assist mandated by 38 U.S.C.A. § 5107(a); Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). The 1997 VA audiology examination disclosed a puretone average of 40 decibels in the left ear at the conversational voice range frequencies of 1,000, 2,000, 3,000 and 4,000 Hertz, with a speech recognition of 96 percent. There was an average loss of 15 decibels with a speech recognition of 100 percent in the right ear, noted by the examiner to be normal. The results of the aforementioned 1997 tests translate to a literal designation of I in the left ear, as well as the right ear which must be designated as normal. VAOPGCPREC 32- 97. The assignment of ratings for defective hearing are made by comparing test results to the pertinent criteria. And under schedular criteria in effect both before and since June 1999, these findings do not translate to an initial compensable evaluation. The Board has no discretion in this regard and must predicate its determination on the basis of the latest audiology studies on record. Since service connection is in effect for only the left ear, his hearing acuity in that ear would have to deteriorate to a state significantly worse than now shown to even be of such degree as to receive a 10 percent rating, which is the maximum under such circumstances, for unilateral hearing loss. No question has been presented as to which of two evaluations would more properly classify the severity of the appellant's unilateral hearing loss. 38 C.F.R. § 4.7. For the foregoing reasons, the Board concludes that the evidentiary record does not support a grant of entitlement to an initial compensable evaluation for defective hearing in the left ear with application of pertinent governing criteria. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial compensable evaluation for defective hearing in the left ear. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Left Heel Spurs Criteria The Court has held that when a diagnostic code provides for compensation based solely upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45 must be considered. The examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 206 (1995). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, 4.59. Johnson v. Brown, 9 Vet. App. 7 (1997) and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to pain which is supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The Court also held in Hicks v. Brown, 8 Vet. App. 417 (1995) that once degenerative arthritis is established by X-ray evidence, there are three circumstances under which compensation may be available for service-connected degenerative changes. Further, while a separate rating for pain is not required, the impact of pain must be considered in making the rating action. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Pursuant to 38 C.F.R. § 4.71a, rating heel spurs is on the basis of benign new growths of bone under Diagnostic Code 5015. This is on the basis of limitation of the affected parts as degenerative arthritis which in turn refers to comparable sites, such as for other foot injuries, Diagnostic Code 5284, wherein a 10 percent rating is assignable when moderate; 20 percent when moderately severe; or 30 percent when severe. Similar ratings are available for foot injury under Code 5014. Metatarsalgia is also ratable as 10 percent disabling whether unilateral or bilateral under Code 5279. Factual Background On VA examination in 1997 the veteran reported a history of bone spurs at the base of the left os calcis. These were said to be no problem as long as he did not run or jog. Pertinent diagnosis was heel spurs over "right" os calcis by history, asymptomatic at this time. [The Court has indicated that substituting "right" for "left" as in this case is inadvertent error, and may be corrected without prejudice. Gifford v. Brown, 6 Vet. App. 269 (1994)]. Analysis Initially, the Board finds that the veteran's claim for entitlement to an initial compensable rating for left heel spurs is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The Board also notes that, in general, an allegation of increased disability is sufficient to establish as well- grounded a claim seeking an increased rating. See Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of his left heel spurs, (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed with respect to the disability at issue and that no further assistance to the veteran is required in order to comply with VA's duty to assist mandated by 38 U.S.C.A. § 5107(a); Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). In this, it is important to note that during the course of the current appellate period, the RO has also granted separate service connection for bilateral pes cavus with calluses and history of metatarsalgia, rated as 10 percent disabling; and plantar warts, rated as noncompensably disabling. These grants are reflective of the nature of the veteran's current symptomatic foot pathology. Neither issue is part of the current appeal. However, the last VA examination was quite clear in showing that the veteran's left heel spurs was entirely asymptomatic except when he may wish to jog or run; and accordingly, a compensable evaluation is not warranted regardless of which diagnostic criteria may be applied. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial compensable evaluation for left heel spurs. Gilbert, supra. Additional Matter Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996). The Board notes that the RO not only provided the veteran the criteria for assignment of an extraschedular evaluation, it also discussed the provisions in light of his claims, and in so doing determined that none of the disabilities at issue warranted assignment of an extraschedular evaluation. The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the VA Undersecretary for Benefits or the Director of the VA Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The veteran is employed as a defense contract engineer, and has not been shown to have experienced marked interference with employment or to have required frequent inpatient, much less any inpatient care for any of the disabilities at issue as to warrant application of these extraschedular criteria. At this point in the development of the evidentiary record, the Board does not find the veteran's disability picture to be unusual or exceptional in nature as to warrant referral of his case to the Director or Under Secretary for review for consideration of extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). The current schedular criteria adequately compensate the veteran for the current nature and extent of severity of his service-connected disabilities. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER The veteran not having submitted a well grounded claim of entitlement to service connection for a low back disorder, the appeal is denied. Entitlement to an initial evaluation in excess of 10 percent for duodenal ulcer with hiatal hernia and GERD with Barrett's esophagus is denied. Entitlement to an initial compensable evaluation for pulmonary nodules is denied. Entitlement to an initial compensable evaluation for defective hearing in the left ear is denied. Entitlement to an initial compensable evaluation for left heel spurs is denied. RONALD R. BOSCH Member, Board of Veterans' Appeal