Citation Nr: 0004620 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 95-30 152 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease and joint disease of the lumbosacral spine. 2. Entitlement to an initial evaluation in excess of 10 percent for organic brain syndrome with post traumatic headaches due to skull fracture. 3. Entitlement to an initial evaluation in excess of 10 percent for degenerative disc disease of the cervical spine. 4. Entitlement to an initial evaluation in excess of 10 percent for benign prostatic hypertrophy. 5. Entitlement to an initial evaluation in excess of 10 percent for atrial fibrillation with sinus bradycardia. 6. Entitlement to an initial evaluation in excess of 10 percent for hiatal hernia. 7. Entitlement to an initial compensable evaluation for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. L. Smith, Counsel INTRODUCTION The appellant served on active duty from August 1972 to July 1992. This matter came before the Board of Veterans' Appeals (the Board) on appeal from the initial March 1994 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) located in New York, New York. Jurisdiction of this case was subsequently transferred several times during the pendency of this appeal due to the physical relocation of the veteran. Current jurisdiction is with the VARO in St. Petersburg, Florida as the veteran now resides within that state. The Board notes that the veteran, in written correspondence dated October 1998, has raised the issue of a total rating based on individual unemployability, and in March 1999, the issue of reopening his previously denied claim for service connection for periodontal disease. As these additional issues have not been adjudicated and developed, and as neither is intertwined with the issues on appeal, they are referred to the RO for appropriate action. See Kellar v. Brown, 6 Vet. App. 157 (1994); Godfrey v. Brown, 7 Vet. App. 398 (1995). The issue of the veteran's entitlement to a disability rating in excess of 10 percent for atrial fibrillation with sinus bradycardia, as well as the issue of entitlement to a disability rating in excess of 10 percent for organic brain syndrome with post traumatic headaches due to a skull fracture, will be addressed in the remand portion of this decision. FINDINGS OF FACT 1. The veteran's lumbosacral disc and joint disease is moderately disabling and is manifested by a moderate degree of limitation of motion, complaints of pain on movement, tenderness in the low back and sacroiliac areas, and subjective complaint of numbness. 2. The veteran's cervical disc disease is manifested by subjective complaints of pain and stiffness; objectively, there is x-ray evidence of low-grade multi-level degenerative disc disease with no evidence of radiculopathy, and normal physical findings except for demonstrated pain with normal range of motion. 3. The service-connected benign prostatic hypertrophy is manifested by subjective complaints of weakness in the stream and waking to void three to four times per night; and objective findings of a moderately enlarged prostate. 4. Objective findings of the veteran's hiatal hernia include nontender abdomen with no organomegaly or masses noted; subjective complaints include discomfort, regurgiation, and difficulty swallowing, which do not result in considerable impairment of health, do not interfere with the appellant's work and are mostly controlled by medication and diet. 5. The veteran's service-connected hearing loss is manifest by an average puretone decibel loss of 43 and 88 percent speech discrimination in the right ear and by an average puretone decibel loss of 43 and 92 percent speech discrimination in the left ear. CONCLUSIONS OF LAW 1. An evaluation in excess of 20 percent for lumbosacral disc and joint disease is not warranted. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Code 5293 (1999). 2. An evaluation in excess of 10 percent is not warranted for degenerative disc disease of the cervical spine. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5293 (1999). 3. The criteria for a 20 percent evaluation, but no higher, for benign prostatic hypertrophy have been met. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. §§4.1, 4.2, 4.3, 4.7, 4.31, 4.115a, 4.115b, Diagnostic Codes 7527 (1999); and 4.115a, Diagnostic Codes 7527-7512 (1993). 4. The criteria for an evaluation in excess of 10 percent for hiatal hernia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.113, 4.114, Diagnostic Code 7346 (1999). 5. The criteria for a compensable disability evaluation for bilateral hearing loss have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.85 TABLES VI and VII and Diagnostic Code 6100 (1999); see 38 C.F.R. § 4.85 TABLES VI and VII and Diagnostic Code 6100 (1999); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented claims which are plausible. It is also found that all relevant facts have been properly developed. The record is devoid of any indication that there are other records available which should be obtained. Therefore, no further development is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Because the veteran has perfected an appeal as to the assignment of the initial ratings following the initial awards of service connection, the Board is required to evaluate all the evidence of record reflecting the period of time between the effective date of the initial grant of service connection until the present. See Fenderson v. West, 12 Vet. App. 119 (1999). Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). When a question arises as to which of two evaluations shall be assigned, the higher evaluation will be assigned of 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 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, that requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2 which requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.10 states that, in cases of functional impairment, evaluations are to based upon lack of usefulness, and medical examiners must furnish, in addition to etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon a person's ordinary activity. This evaluation includes functional disability due to pain under the provisions of 38 C.F.R. § 4.40. These requirements for the evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decision based upon a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the disability level and any changes in the condition. Lumbosacral disc and joint disease According to the applicable criteria, a 20 percent evaluation is warranted for moderate recurring attacks of intervertebral disc syndrome. A 40 percent evaluation requires severe recurring attacks with intermittent relief. 38 C.F.R. Part 4, Code 5293 (1999). In evaluating a service-connected disability involving a joint rated on limitation of motion, the Board must also consider functional loss due to weakness, fatigability, incoordination or pain on movement of joint under the provisions of 38 C.F.R. § 4.45 (1999). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (1999). Historically the veteran complained in service of back pain and was diagnosed to have degenerative disc disease and degenerative joint disease. On VA examination of the spine conducted in December 1993, objective findings included mild kyphosis in the thoracic lumbar spine, mild spasm in the lumbar spine area, and slight limitation of motion. Pain on motion was also noted. There were no motor or sensory deficits; although subjective numbness in the feet was present. Mild incoordination in the lower extremity was also noted. X-ray was reported to show disc space narrowing at L5-S1. The diagnoses was chronic low back syndrome and mild degenerative joint disease. On VA examination in January 1996, the veteran gave a history of lower back pain. He took Tylenol occasionally. Range of motion was normal but there was some objective evidence of pain on lateral flexion. X-rays of the lumbosacral spine showed the intervertebral disc spaces, pedicles and processes to be intact. There were minimal degenerative changes. The impression was minimal early degenerative osteoarthritis. VA outpatient treatment records dated in 1997 show reports of low back pain. X-rays of the lumbosacral spine in May 1997 were interpreted to show osteoporotic bones, as well as mild spondylitic changes. On VA examination in June 1998, reported complaints and findings related only to the cervical spine. Private medical reports, dated August 1998, from Dr. Robert D. Gruber, D.O., noted subjective complaints of low back pain with intermittent weakness in the legs, and numbness and tingling in the feet. An MRI study revealed two level stenosis, 4-5 in the lateral recess and 5-1 lateral recess and neural foraminal. EMG and nerve conduction studies demonstrated paraspinal positive sharp waves but no frank gross acute radiculopathy. The final diagnostic impression was lumbar degenerative disc disease with secondary spinal stenosis with predominant mechanical back pain and intermittent neurogenic claudication. After a careful review of the evidence of record, it is found that an evaluation in excess of 20 percent for the service- connected lumbosacral disc and joint disease is not warranted. The evidence of record does not indicate that the veteran during the period of time at issue has experienced severe recurring attacks of intervertebral disc syndrome with intermittent relief. The objective evidence of record does not show the existence of any actual myelopathic or radiculopathies findings related to his degenerative disc disease of the low back. Nor does the objective evidence show the presence of incoordination, weakness or fatigue. Therefore, it is found that an increased evaluation is not justified at this time. In conclusion, it is found that the preponderance of the evidence is against the veteran's claim for an evaluation in excess of 20 percent for the service-connected degenerative disc and joint disease of the lumbosacral spine. Cervical disc disease In the original March 1994 rating decision, the RO evaluated this disability with the lumbar spine disorder and assigned one disability rating (10%). However, by rating decision dated February 1997, this was corrected and a separate 10 percent rating, also effective from August 1, 1992, was assigned for the cervical spine disability. The appellant's degenerative disc disease of the cervical spine was assigned a 10 percent evaluation under Diagnostic Codes 5293-5290. As noted above in the Board's discussion relevant to the veteran's lumbosacral spine disorder, the VA must also consider functional impairment and effects of painful motion. 38 C.F.R. §§ 4.40, 4.59 (1999). 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 absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology. Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (1999); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). 38 C.F.R. § 4.59 provides that the intention of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Id. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvement of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. 38 C.F.R. § 4.45 (1999). Under the applicable criteria for degenerative disc disease, a 10 percent evaluation is warranted for mild symptoms of intervertebral disc syndrome; a 20 percent evaluation is warranted for moderate recurring attacks of intervertebral disc syndrome. A 40 percent evaluation requires severe recurring attacks with intermittent relief. 38 C.F.R. Part 4, Code 5293 (1999). The diagnostic code for limitation of motion of the cervical spine is Diagnostic Code 5290 which provides a 10 percent evaluation for slight limitation of motion, a 20 percent rating for moderate limitation of motion, and a 30 percent rating for severe limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5290 (1999). Historically, the veteran was noted to complain of back and neck pain in service and was diagnosed to have degenerative disc disease and degenerative joint disease. The retirement physical examination report, dated July 1992, contained no reference to any cervical spine disorder or disability. Outpatient treatment record from a Navy facility, dated January 1993, noted complaint of low back and neck pain; however, there were no findings made relative to the cervical spine. On VA examination in December 1993, the veteran complained of low back and neck pain; objectively, there was very mild limitation of motion with range of motion measured at 35 degrees forward flexion; 24 degrees extension; left lateral flexion of 30 degrees and right of 34 degrees; and bilateral rotation of 35 degrees. Pain was felt in the neck area during all movement. There were no motor or sensory deficits. X-ray of cervical spine showed disc space narrowing at C6-7. The diagnosis was mild degenerative joint disease of the cervical spine. In a written statement received from the veteran in October 1994, he indicated that his neck pain was such that it was "killing me even to get out of bed." He complained of constant pain and "stooped posture". In statement dated August 1995, he complained primarily of low back and shoulder pain and "numb" fingers. Navy outpatient treatment note, dated October 1995, indicated the veteran complained of neck pain due to a motor vehicle accident three weeks earlier. VA outpatient treatment note, dated in May 1997, noted complaint of left shoulder pain of recent origin. Physical therapy note dated August 1997, noted that the veteran complained of pain in the left shoulder and neck. He had full range of motion in both upper extremities. He was instructed in strengthening exercises for the left shoulder and neck. An MRI of the cervical spine performed in October 1997 revealed spondylitic changes. Specifically, there was slightly decreased disc space at C5-6 level; mild end plate spur formation at C5-6 and C6-7 levels. There was mild encroachment on the right side of C5-6. There was no evidence of fracture, subluxation or perivertebral soft tissue swelling demonstrated. VA records show that the left shoulder continued to be symptomatic and was treated with steroid injection in January 1998. Report of VA examination of the cervical spine, conducted in June 1998, indicated current complaint of pain and stiffness. Objectively, he had normal range of motion, although he had subjective complaint of pain on all motions. Otherwise, the examination was negative. Following x-rays, the diagnosis was spondylosis of the cervical spine. Private medical reports, dated August 1998, from Dr. Robert D. Gruber, D.O., focus primarily on complaints and findings relative to the veteran's lumbosacral spine. However, complaint of neck pain as well as low back pain was noted. There was also subjective complaint of numbness and tingling in his hands. Radiographic films were read to show low grade multilevel degenerative disc disease in the cervical spine. In written statement dated October 1998, the veteran indicated that pain in his neck, left shoulder and left arm continued. Based on the evidence of record and the applicable law and regulations, the Board finds that the preponderance of the evidence is consistent with no more than a 10 percent evaluation under Diagnostic Code 5290. The medical evidence of record, including the 1998 VA and private examination reports, does not show significant complaints or treatment of the cervical spine. A cervical spine disorder was not noted at the veteran's retirement physical examination in service. The post-service medical evidence shows that the appellant has sought medical treatment for the cervical spine only occasionally. In fact, his recent complaints and statements for a higher evaluation appear partially, if not mostly, to be based on his complaints of shoulder pain and his belief that this is somehow related to his service-connected cervical spine disability. However, there is no medical evidence of such a relationship between any current shoulder symptoms and his service- connected cervical spine disability. The Board also notes that while the veteran did complain of pain during range of motion testing in 1998; he was noted to have normal range of motion. Furthermore, physical examination was essentially negative with no recorded evidence of any neurological deficits, spasms, or tenderness to palpation in the paracervical muscles. The Board also finds that an increased rating is not warranted as a result of functional loss due to pain. 38 C.F.R. § 4.40 (1999); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case a higher rating is not supported by adequate pathology and is not evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (1998). The Board further finds that the appellant's symptoms through the period of time at issue are consistent with no more than a mild evaluation under Diagnostic Code 5293 based on the medical evidence of record, as well as the appellant's own statements. The Board has also assessed whether additional Diagnostic Codes are for application in this case. As there is no evidence in the record of ankylosis or residuals of fractured vertebra in the cervical spine, the Board deems that other Diagnostic Codes specifically referable to the cervical spine are not for application in this case. 38 C.F.R. § 4.71a, Diagnostic Codes 5285-87 (1999). Thus, based on the objective evidence of only mild cervical complaints and mild to essentially normal findings on examination, the low level of pain reported and demonstrated on examination, as well as the infrequent documented episodes of treatment for cervical spine complaints in the medical records, the Board finds that the 10 percent disability evaluation for the appellant's cervical spine disability is appropriate. Accordingly, the preponderance of the evidence of record is against the claim for a rating in excess of 10 percent for degenerative joint disease of the cervical spine. Benign prostatic hypertrophy Initially, the Board notes that the regulatory requirements for this disability were changed, effective February 17, 1994, during the pendency of the appellant's appeal. In the February 1997 rating action, the RO apparently determined that the rating criteria in effect on and after February 17, 1994, were more favorable to the appellant and accordingly assigned a 10 percent rating, under the criteria of 38 C.F.R. § 4.115b, Diagnostic Code 7527 (1999). Under the rating criteria in effect prior to February 17, 1994, prostate gland injuries, infections, hypertrophy, and post-operative residuals were rated as for chronic cystitis, depending upon functional disturbance of bladder. 38 C.F.R. § 4.115a, Code 7527 (1993). The rating criteria for chronic cystitis were found under Diagnostic Code 7512 which provided for a 60 percent rating where incontinence existed, requiring constant wearing of an appliance; a 40 percent rating for severe cystitis where there was urination at intervals of 1 hour or less and contracted bladder; a 20 percent rating for moderately severe cystitis with diurnal and nocturnal frequency with pain, tenesmus; and a 10 percent rating for moderate cystitis with diurnal and nocturnal frequency; and a 0 percent rating for mild chronic cystitis. 38 C.F.R. § 4.115a, Code 7512 (1993). Under current regulations, in effect since February 17, 1994, under 38 C.F.R. § 4.115b, Diagnostic Code 7527 (1999), prostate gland injuries, infections, hypertrophy, and post- operative residuals are to be rated as voiding dysfunction or urinary tract infection, whichever is predominant. Voiding dysfunction may be rated based on urine leakage, frequency, or obstructed voiding. Where there is continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day, a 60 percent rating is warranted. A 40 percent rating is warranted where the disorder requires the wearing of absorbent materials which must be changed 2 to 4 times per day. A 20 percent rating is warranted where the disorder requires the wearing of absorbent materials which must be changed less than 2 times per day. For a rating based on urinary frequency, a 40 percent rating is warranted when there is a daytime voiding interval less than one hour, or awakening to void five or more times per night. A 20 percent rating is warranted when there is a daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 10 percent rating is warranted when there is a daytime voiding interval between two and three hours, or awakening to void two times per night. For a rating based on obstructed voiding, a 30 percent rating is warranted when there is urinary retention requiring intermittent or continuous catheterization. A 10 percent rating is warranted if there is marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1. Post void residuals greater than 150 cc. 2. Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec). 3. Recurrent urinary tract infections secondary to obstruction. 4. Stricture disease requiring periodic dilatation every 2 to 3 months. A noncompensable rating is warranted for obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year. See 38 C.F.R. § 4.115a (1999). On service examination in June 1992, prior to the veteran's retirement, he was noted to have 2+ prostatic enlargement with no nodules, and nocturia of 2 times a night. On VA general medical examination conducted in December 1993, he was noted to have no urinary problems; the prostate on rectal examination showed mild hypertrophy. Review of outpatient treatment records from a navy medical facility, dated from 1993 to 1995, indicate that in October 1993, the veteran complained of nocturia once every two hours per night. In July 1994, the veteran presented for a "prostate gland check". He complained of a weak stream, frequency and nocturia; physical examination revealed an enlarged prostate with no nodules. In October 1995, it was noted that he experienced nocturia of 2 to 4 times a night. On special VA genitourinary examination conducted in January 1996, the veteran was noted to complain of nocturia of 3 to 4 times a night, with some decrease in the caliber and force of the urinary stream. Physical examination revealed a moderate prostatic enlargement of a benign consistency. The final diagnostic impression was benign prostatic hypertrophy with prostatic enlargement and moderate obstructive symptoms. Based on the above rating criteria and after consideration of all the evidence, the Board finds that the veteran would not be entitled to an increased evaluation under rating criteria formerly in effect. Specifically, a 20 percent rating would not be warranted under the criteria in effect prior to February 1994, in that there is no evidence of tenesmus or pain with urination, nor does the subjective complaints of frequency and dribbling equate or more closely approximate moderately severe symptoms rather than the moderate symptoms contemplated by a 10 percent rating. See 38 C.F.R. § 4.115a, Code 7512 (1993). However, under the rating criteria currently in effect since February 1994, the veteran's reported symptoms of nocturia of three to four times a night would warrant a 20 percent evaluation. See 38 C.F.R. § 4.115a (1999). However, the evidence does not support a rating in excess of 20 percent. The evidentiary record does not demonstrate that the appellant requires the wearing of absorbent material at all. In addition, the medical evidence does not establish that he has been treated for urinary tract infection in recent years, that he has marked obstructive symptomatology with any of the required manifestation - let alone that has required dilation to alleviate obstruction, or that he has frequency requiring voiding intervals of less than one hour, or that he must void five or more times per night. Thus, giving the veteran the benefit of all reasonable doubt, the Board concludes that the veteran should be granted an increased evaluation of 20 percent, but no higher. Hiatal hernia Under the provisions of DC 7346 (hiatal hernia), a 10 percent evaluation is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Code 7346 (1999). Review of the evidence of record indicates that the veteran was diagnosed with hiatal hernia and gastroesophageal reflux disease in service in 1988 and begun on Tagamet therapy. On VA examination in December 1993, he complained of occasional epigastric discomfort relieved with Tums, with increased symptomatology 5 to 6 times a year. Navy outpatient treatment record, dated July 1994, indicated a history of hiatal hernia and taking Tagamet. The assessment was hiatal hernia and gastroesophageal reflux and Zantac was prescribed. In a written statement received from the veteran in October 1994, he indicated that he frequently experienced regurgitation of food and difficulty in swallowing. Review of the Navy outpatient treatment records dated in 1995 revealed no evidence of treatment for gastrointestinal complaints. Likewise, there is no reference to any gastrointestinal complaint in the recent VA or private examination reports of record, or the written statements submitted by veteran. After reviewing the evidence on file, it is the conclusion of the Board that a rating in excess of 10 percent is not in order. The 10 percent rating contemplates persistently recurrent epigastric distress with two or more of the following symptoms: dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. See 38 C.F.R. § 4.114, Code 7346 (1999). The Board finds that the evidence does not support a finding of symptoms more approximate to the criteria of the next higher available rating, 30 percent. A 30 percent rating requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Furthermore, the veteran's primary complaints have been recurrent discomfort and regurgitation which the appellant has indicated can be mostly controlled by medication. Finally, there is no evidence of symptomatology productive of considerable impairment of health. Specifically, there is no evidence of malnutrition or anemia due to his gastrointestinal symptoms. Accordingly, there is no basis under DC 7346 for an increased rating. While the evidence is uncontroverted that the veteran has gastrointestinal symptomatology, there is no competent evidence of symptomatology of such severity to produce considerable impairment of health. It is the conclusion of the Board, therefore, that the evidence on file does not support an increased rating for hiatal hernia. The objective findings for the period of time at issue clearly more nearly approximate those for the 10 percent rating, and accordingly the lower rating is for application. 38 C.F.R. § 4.7 (1999). Hearing loss Historically, the veteran was originally awarded service connection for bilateral hearing loss by rating decision dated March 1994, and assigned a noncompensable rating which has remained in effect to the present time. He has appealed the assignment of the noncompensable rating and contends that a higher rating is warranted. After review of the record, the Board finds that the evidence does not support the veteran's claim. Disability evaluations are based upon the average impairment of earning capacity as contemplated by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by a pure tone audiometry test in the frequencies of 1,000, 2,000, 3,000 and 4,000 cycles per second. To evaluate the degree of disability from bilateral service-connected defective hearing, the rating schedule establishes 11 auditory acuity levels designated from level I for essentially normal auditory acuity through level XI for profound deafness. 38 C.F.R. § 4.85, Part 4, Codes 6100-6110 (1999). In the instant case, an audiogram conducted as part of the veteran's June 1992 retirement examination noted pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15dB. 25dB 30dB. 35dB. 45dB. LEFT 20dB. 25dB. 25dB. 35dB. 55dB. On VA audiological evaluation in December 1993, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25dB. 35dB 35dB. 45dB. 45dB. LEFT 25dB. 30dB. 45dB. 45dB. 55dB. Speech audiometry revealed speech recognition ability of 94 percent correct in the right ear and 96 percent correct in the left ear. The pure tone threshold average was 40 in the right ear, and 44 in the left ear. On VA audiological evaluation in January 1996, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 05dB. 15dB 25dB. 25dB. 40dB. LEFT 05dB. 20dB. 30dB. 30dB. 50dB. Speech audiometry revealed speech recognition ability of 100 percent correct in the right ear and 96 percent correct in the left ear. The pure tone threshold average was 26 in the right ear, and 32 in the left ear. On the most recent VA audiological evaluation in June 1998, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15dB. 25dB 45dB. 45dB. 55dB. LEFT 10dB. 25dB. 45dB. 45dB. 55dB. Speech audiometry revealed speech recognition ability of 88 percent correct in the right ear and 92 percent correct in the left ear. The pure tone threshold average was 43 in the right ear, and 43 in the left ear. According to the schedule for rating disabilities, the findings from the 1992, 1993, and 1996 audiological evaluations equate to Level I hearing loss in both the right and left ears. The findings from the most recent evaluation in 1998, equate to Level II hearing loss in the right ear and level I hearing loss in the left. A reference to the tables in 38 C.F.R. § 4.87 indicates that such hearing loss is to be evaluated at zero percent under Diagnostic Code 6100. When hearing loss in one ear is at Level II, hearing loss in the other ear must be at least Level V before a compensable rating is assigned. When hearing loss in one ear is at Level I, hearing loss in the other ear must be at least Level X before a compensable rating is assigned. See 38 C.F.R. § 4.87, Table VII (1999). In Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992), the Court noted that the assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Consequently, the Board concludes that the preponderance of the evidence is against the veteran's claim for a compensable rating for the service-connected bilateral hearing loss disability. ORDER The claim for an evaluation in excess of 20 percent for lumbosacral disc and joint disease, is denied. The claim for an evaluation in excess of 10 percent for cervical disc disease, is denied. The claim for a 20 percent evaluation, but no higher, for benign prostatic hypertrophy is granted. The claim for an evaluation in excess of 10 percent for hiatal hernia, is denied. The claim for a compensable evaluation for bilateral hearing loss disability, is denied. REMAND Evaluation in excess of 10 percent for atrial fibrillation New regulations promulgated by VA for rating service- connected cardiovascular disorders became effective on January 12, 1998. 62 Fed. Reg. 65207-65224 (December 11, 1997). Where law or regulations change after a claim has been filed but before the administrative or judicial appeal process has been concluded, the version most favorable to appellant should apply unless otherwise specified. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991); see also Dudnick v. Brown, 10 Vet. App. 79 (1997) (with respect to the amended regulations in question, VA is required to apply the amendments to the extent that they are more favorable to the claimant than the earlier provisions). In this case, which version of the pertinent regulations is more favorable to the veteran's claim, if indeed either one is more favorable than the other, cannot be determined because the medical evidence does not directly address the questions involved in this case so that a proper rating may be assigned. The veteran underwent VA examinations in 1994, 1996, 1997, and 1998, but the examiners did not determine metabolic equivalent (METS) scores, as required under the new rating criteria. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, NOTE (2) (1999). In short, the Board cannot derive findings of medical fact from the medical evidence in this case. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that Board must rely on independent medical evidence to support its findings and must not refute medical evidence in the record with its own unsubstantiated medical conclusions). Therefore, on remand the veteran should be afforded a comprehensive VA examination. Evaluation in excess of 10 percent for organic brain syndrome with post traumatic headaches due to skull fracture Initially, the Board notes that the RO has failed to individually rate the veteran's organic brain syndrome and post-traumatic headaches as separate disabilities. Thus, on remand the RO should re-adjudicate the appropriate rating for each disability with due consideration of Fenderson v. West, 12 Vet. App. 199 (1999). The Board notes that just prior to his discharge from service, the veteran underwent a neuropsychological evaluation at a private medical facility in July 1992. It was noted that since the bicycle accident in 1990 he had suffered from headaches in the left frontal temporal region as well as a decrease in cognitive functioning. Following a personal interview as well as a battery of psychological tests, the final diagnoses on Axis I were: Organic brain syndrome, not otherwise specified (NOS), mild; and organic mood disorder, depressed. Service medical records also show that on several prior occasions the veteran was prescribed anti-depressant drugs for brief periods of time. Review of post-service treatment records indicate the veteran has been prescribed medication for "depression". It is not clear if this is related to the residuals of brain injury and skull fracture incurred in service. The Board finds that the veteran has not been afforded a comprehensive VA psychiatric evaluation to adequately determine the severity of his organic brain syndrome. In addition, the veteran has continued to complain of progressively worsening headaches as well as cognitive deficits which he attributes to his service-connected disability. On VA examination dated June 1998, further neurological consultation was recommended. However, it does not appear from the record that the veteran has been afforded a VA neurological examination for rating purposes. Furthermore, the Board notes that effective November 7, 1996, during the pendency of the veteran's appeal, VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4, was amended with regard to rating mental disabilities. Schedule for Rating Disabilities; Mental Disorders, 61 Fed. Reg. 52695 (1996) (codified at 38 C.F.R. Part 4). Because the veteran's claim was filed before the regulatory change occurred, the veteran has not been provided the revised regulations in a supplemental statement of the case, he has not been provided a VA examination based on the revised rating criteria, nor has the RO re-adjudicated his claim based on the revised criteria. See Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). As noted above, the Board finds it cannot derive findings of medical fact from the medical evidence in this case with regard to this issue. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that Board must rely on independent medical evidence to support its findings and must not refute medical evidence in the record with its own unsubstantiated medical conclusions). Therefore, on remand the veteran should be afforded a comprehensive VA examination. Accordingly, this case is remanded for the following: 1. The RO should request that the veteran provide a list of those who have treated him for his service-connected atrial fibrillation, organic brain syndrome and headaches, since his retirement from service. After the list is submitted by the veteran, the RO should make arrangement in order to obtain copies of all records of any treatment reported by the veteran that are not already in the claims file. The Board is particularly interested in treatment received at any VA facilities. With respect to VA records, all records maintained are to be requested, to include those maintained in paper form and those maintained electronically (e.g., in computer files) or on microfiche. All records obtained should be associated with the claims file. If the RO is unable to obtain any private treatment records, the veteran and his representative should be informed and given an opportunity to obtain and submit the records. 38 C.F.R. § 3.159(c). 2. The veteran should be afforded VA psychiatric examination to determine the nature and severity of the psychiatric symptomatology of his service-connected organic brain syndrome. The claims file and a separate copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The psychiatrist should conduct a thorough psychiatric examination and provide a complete description of the history of the psychiatric disorder and the current symptomatology that affects the veteran's social and occupational functioning. If the psychiatrist finds that psychological testing would assist in the assessment of his psychiatric disability, that testing should be completed. The examiner should provide a Global Assessment of Functioning (GAF) score in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and an explanation of the meaning of the score assigned. The examiner should also provide an opinion on the extent to which the veteran's psychiatric symptomatology affects his ability to adapt and function in a work environment, in terms of how any occupational and social impairment found impacts his work efficiency, ability to perform occupational tasks, and ability to establish or maintain effective work and social relationships. The examiner should provide the complete rationale for all opinions given. 3. The veteran should be provided a VA neurological examination in order to determine any neurological residuals of the in-service brain trauma, to include post-traumatic headaches. The claims file and a copy of this remand should be made available to and be reviewed by the examiner in conjunction with the examination. The examination should include any diagnostic tests or studies, that are deemed necessary for an accurate assessment. The examiner should conduct a thorough neurological examination and provide a diagnosis for any pathology found. The examiner should also provide an opinion on whether that pathology is a residual of the in-service brain trauma or a non- serviceconnected disorder. 4. The RO should subsequently afford the veteran a comprehensive VA medical examination limited to determine the current severity of his service-connected atrial fibrillation. The claims folder and a copy of this remand are to be made available to the examiner prior to the examination. All tests deemed necessary by the examiner are to be performed. The examiner should comment on all manifestations of the veteran's service- connected atrial fibrillation. A series of blood pressure readings should be taken. The examiner should be provided copies of the recently revised rating criteria for cardiovascular disorders (Codes 7000- 7020), together with the criteria that were in effect prior to January 12, 1998. Appropriate exercise testing must be conducted in order to determine metabolic equivalent scores (METS). If a determination of METS by exercise testing cannot be done for medical reasons, the examiner must indicate so, and should then provide an estimation of the level of activity (expressed in METS and supported by specific examples, such as slow stair climbing or shoveling snow). The physician should specifically indicate at what level the are symptoms of dyspnea, fatigue, angina, dizziness, or syncope. The examiner should include in the report an assessment of functions which precisely correspond to the functions which are listed in the rating criteria to include workload restrictions, and should answer the following questions: a. Is there any evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or x- ray? b. Does the veteran suffer with chronic congestive heart failure? If so, how many episodes of acute congestive heart failure has he suffered in the past year? c. At what level of METS score does the veteran experience dyspnea, fatigue, angina, dizziness, or syncope? d. Are there any attacks of arrhythmia, and if so, describe the frequency and severity of such attacks. e. To what extent does the veteran's service-connected atrial fibrillation limit his social and industrial adaptability? Is ordinary manual labor feasible? Does this disability prohibit him from doing light manual labor and/or is more than sedentary work precluded? Any indications that the veteran's complaints or other symptomatology are not in accord with physical findings on examination should be directly addressed and discussed in the examination report. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the examiner's conclusion. If further testing or examination by other specialists is determined to be warranted in order to evaluate the condition(s) at issue, such testing or examination is to be accomplished. 5. The RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. Specific attention is directed to the examination report. If the requested examination does not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the report must be returned for corrective action. 38 C.F.R. § 4.2 (1999); see also Stegall v. West, 11 Vet. App. 268 (1998). 6. The RO should then readjudicate the veteran's claims, with application of all appropriate laws and regulations, and any additional information obtained as a result of this remand. In so doing, review the evidence of record at the time of the March 1994, and subsequent rating decisions, that was considered in assigning the original disability rating for these conditions, then consider all the evidence of record to determine whether the facts showed that the veteran was entitled to a higher disability rating for either condition at any period of time since his original claim. See Fenderson v. West, 12 Vet. App. 119 (1999). The RO should also consider carefully and with heighten mindfulness the benefit of the doubt rule. 38 U.S.C.A. § 5107(b). If the evidence is not in equipoise the RO should explain why. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991). 7. The veteran is hereby informed that he has a right to present any additional evidence or argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995); and Kutscherousky v. West, 12 Vet. App. 369 (1999). The veteran is further advised that he should assist the RO in the development of his claim. Wood v. Derwinski, 1 Vet. App. 191, 193 (1991). If the benefits sought on appeal are not granted to the complete satisfaction of the veteran, he and his representative should be provided with a supplemental statement of the case, which includes consideration of all medical evidence received since the supplemental statement of the case issued in March 1999 and all applicable criteria as described above. They should be afforded an appropriate period of time for response. Then, the claims folder should be returned to the Board for further appellate consideration, if in order. The veteran need take no action until he is so informed. The purpose of this REMAND is to obtain additional information and to comply with all due process considerations. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, (CONTINUED ON NEXT PAGE) directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21- 1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. C. P. RUSSELL Member, Board of Veterans' Appeals