Citation Nr: 0005493 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 95-20 725A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for chronic obstructive pulmonary disease (COPD). 2. Entitlement to an initial rating in excess of 10 percent for low back disability, including degenerative disc disease at L4-5. 3. Entitlement to an initial, compensable rating for pronator muscle syndrome of the right arm. 4. Entitlement to an initial, compensable rating for left ear hearing loss. 5. Entitlement to service connection for chronic disability resulting from asbestos exposure. 6. Entitlement to service connection for chronic sinusitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Artur F. Korniluk, Associate Counsel INTRODUCTION The veteran had active service from July 1969 to October 1993. This matter comes to the Board of Veterans' Appeals (Board) from Department of Veterans Affairs (VA) Los Angeles Regional Office (RO) rating decisions which in September 1994 granted service connection for COPD, assigning it a noncompensable rating, degenerative disc disease at L4-5, assigning it a 10 percent rating, degenerative changes involving the left and right knee, assigning each knee a noncompensable rating, pronator muscle syndrome of the right arm, assigning it a noncompensable rating, denied service connection for residuals of asbestos exposure, bilateral hearing loss, and chronic sinusitis; in December 1998, the RO granted service connection for left ear hearing loss, assigning it a noncompensable rating. By decision in December 1998, the RO increased the evaluation of the veteran's service-connected right and left knee disabilities and COPD from 0 to 10 percent each. In view of AB v. Brown, 6 Vet. App. 35, 38 (1993), the claims remain in controversy where less than the maximum available benefit is awarded, but by March 1999 letter to the RO, the veteran expressed satisfaction with the 10 percent ratings assigned his left and right knee disabilities. Accordingly, his claims of increased ratings for the service-connected left and right knee disabilities are considered to have been withdrawn, 38 C.F.R. § 20.204 (1999), but the claim of a rating in excess of 10 percent for COPD remains in appellate status. By March 1999 letter to the RO, the veteran also withdrew from appellate consideration the claim of service connection for right ear hearing loss. 38 C.F.R. § 20.204. Appellate consideration of entitlement to a rating in excess of 10 percent for COPD is held in abeyance pending completion of the development requested in the remand below. FINDINGS OF FACT 1. The veteran's low back disability is associated with degenerative disc disease and neurologic impairment producing radiating pain and discomfort, weakness, and lack of endurance; range of motion is reduced and associated with pain on extreme motion; flare-ups of symptoms, productive of excruciating and incapacitating pain, occurring about once every two months. 2. His service-connected right arm pronator muscle syndrome is manifested by pain, numbness, and decreased sensation, but is not associated with arthritis, reduced range of motion, instability, deformity, effusion, weakness, or muscle atrophy. 3. The veteran has Level I hearing in the left ear. 4. There is no current medical diagnosis of asbestosis or any other chronic disability shown to have developed as a result of asbestos exposure in service. 5. There is no current medical diagnosis of chronic sinusitis, and competent medical evidence does not show that any such claimed disability is linked to active service, any incident occurring therein, or episodes of sinusitis symptoms evident and treated in service. CONCLUSIONS OF LAW 1. The schedular criteria for a 20 percent rating for the service-connected low back disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5293 (1999). 2. Resolving the benefit of the doubt in the veteran's favor, the schedular criteria for a 10 percent rating for right arm pronator muscle syndrome have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.73, Code 5307 (1999). 3. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.85, 4.86, Code 6100 (1999). 4. The veteran has not presented a well-grounded claim of service connection for chronic disability resulting from asbestos exposure. 38 U.S.C.A. § 5107(a) (West 1991). 5. The veteran has not presented a well-grounded claim of service connection for chronic sinusitis. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased rating claims: The veteran's claims of ratings in excess of the currently assigned 10 percent for his service-connected low back disability, and for compensable evaluations of his left ear hearing loss and right arm pronator muscle syndrome are well grounded, Murphy v. Derwinski, 1 Vet. App. 78 (1990), as they stem from the ratings initially assigned at the time of the September 1994 grant of service connection for low back disability and right arm pronator muscle syndrome, and the December 1998 grant of service connection for left ear hearing loss. Shipwash v. Brown, 8 Vet. App. 218 (1995). Once determined that a claim is well grounded, VA has a duty to assist in the development of evidence pertinent to the claim. 38 U.S.C.A. § 5107(a). The Board is satisfied that all relevant facts have been properly developed, and that VA has satisfied its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991). Under applicable criteria, disability ratings are determined by application of a schedule of ratings 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. VA has a duty to consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (1998); Peyton v. Derwinski, 1 Vet. App. 282 (1991). A claim placed in appellate status by disagreement with the initial rating award and not yet ultimately resolved is an original claim, as opposed to a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). On the other hand, where entitlement to compensation has already been established, disagreement with an assigned rating is a new claim for increase, based on facts different from a prior final claim. Suttmann v. Brown, 5 Vet. App. 127, 136 (1993); Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992) (in a claim for increased rating, appellant claims the disability has increased in severity since a prior final decision). In such claims, the present level of disability is of primary concern; although a review of the recorded history of a disability is required to make a more accurate evaluation, past medical reports do not have precedence over current findings. 38 C.F.R. § 4.2 (1999); Francisco v. Brown, 7 Vet. App. 55 (1994). Service connection for degenerative disc disease at L4-5 and right arm pronator muscle syndrome was granted by RO rating decision in September 1994, and service connection for left ear hearing loss was granted by RO rating decision in December 1998. Those decisions were based on service medical records (documenting treatment for low back impairment including degenerative disc disease, herniated nucleus pulposus, and radiating pain, and intermittent treatment for right arm pain and numbness) and post-service clinical evidence demonstrating that the pertinent chronic disabilities had their onset during active service. On VA orthopedic examination in June 1994, the veteran reported persistent low back pain and impairment since service, but denied having undergone any surgery. On examination, there was no postural abnormality, fixed defect, or neurologic impairment but some paralumbar muscular tightness was noted, bilaterally; range of motion was to 70 degrees flexion, to 20 degrees extension, to 35 degrees left lateral flexion, to 30 degrees right lateral flexion and left rotation, and to 50 degrees right rotation. The examiner's review of old magnetic resonance imaging (MRI) showed disc herniation at L5-S1. X-ray study of the lumbar spine showed disc degeneration at L4-5 and central disc spur at L5-S1. Herniated disc at L5-S1 was diagnosed. On VA orthopedic examination in June 1994, the veteran indicated that he performed "constant" typing in 1990; reportedly, he experienced right arm pain and numbness since that time. On examination, there was no right arm deformity or range of motion impairment, but grip-strength in the right hand was diminished as compared to the left. Right pronator muscle syndrome was diagnosed. On VA audiological examination in June 1994, left ear auditory thresholds at 1,000, 2,000, 3,000, and 4,000 Hertz were 5, 10, 20, and 45 decibels, respectively; speech recognition ability using the Maryland CNC test was 96 percent correct in the left ear. Moderate high frequency hearing loss with normal speech discrimination, left ear, was diagnosed. On VA orthopedic examination in February 1997, the veteran reported daily low back pain, noting that the pain at times radiated to his lower extremities. He stated that he had excruciating and incapacitating back pain episodes about once every two months, and that he wore a back brace during flare- ups of pain. On examination, there was no postural abnormality or fixed deformity, but paraspinal lumbar tenderness was noted; thoracolumbar spine range of motion was to "mid tibia" flexion, to 40 degrees extension, to 30 degrees each left and right lateral flexion, and to 90 degrees each left and right rotation; there was no evidence of motor function impairment or sensation deficit. X-ray study of the thoracolumbar spine showed mild degenerative changes; MRI study showed multi-level spondylosis, predominantly at L4-5 and L5-S1 with a 3-centimeter right L4- 5 paracentral disc protrusion. Chronic mechanical low back pain with intermittent moderate to severe flares secondary to multi-level degenerative disc disease with occasional radiating leg pain (worse on the left) was diagnosed. On VA fee-basis medical examination in January 1999, the veteran reported constant and uninterrupted low back pain, weakness, fatigue, and stiffness with lack of endurance, noting that the pain at times radiated to the legs; reportedly, the pain increased with physical activity. On examination, he did not require assistive devices for ambulation or a brace; lumbar spine range of motion was to 90 degrees flexion, to 20 degrees extension, and to 20 degrees each left and right lateral flexion; he had trouble getting up after back flexion, and there was evidence of pain on extreme motion; the mid-lumbar area was tender to palpation and slight muscle spasm was noted; straight leg raising was to 60 degrees on the right and 40 degrees on the left; X-ray study of the lumbar spine showed spondylosis. Lumbar strain was diagnosed. On VA fee-basis examination in January 1999, the veteran indicated that he experienced right arm pain, difficulty picking up objects with the right hand, numbness, fatigue, and impaired motion, noting that the pain was at times excruciating. On examination, right elbow range of motion was full and there was no erythema, warmth, synovitis, effusion, instability, weakness, or muscle atrophy, but the arm suddenly became numb to palpation and right forearm sensation was decreased, compared to the left; X-ray study of the right elbow showed no abnormality. Pronator muscle syndrome involving the right arm was diagnosed. VA medical records from February 1996 to February 1999 document intermittent treatment of various symptoms and illnesses and include reports of low back pain. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain, supported by adequate pathology, evidenced by visible behavior of a veteran undertaking motion; weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Factors considered in rating residual disability include less movement than normal, more movement than normal, weakened movement, excess fatigability, pain on movement, swelling, deformity or atrophy from disuse or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). With regard to the rating of disabilities involving the substantiated presence of degenerative or traumatic arthritis, Diagnostic Code 5003 provides that arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Codes 5200 et seq.), and that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. §§ 4.50, 4.51, 4.53, 4.54, 4.56 and 4.72 (1999), pertinent to the effects of missile and muscle injuries and setting out principle factors and symptoms such as weakness, undue fatigue-pain, incoordination, muscular fusing or scarring and joint involvement, are applicable to the veteran's increased rating claim (to the extent they apply to disability rating under Diagnostic Code 5307). Currently, the veteran's service-connected low back disability, including degenerative disc disease at L4-5, is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5293, intervertebral disc syndrome, and a 10 percent evaluation is assigned based on evidence of mild impairment. Under Code 5293, a 20 percent evaluation will be assigned where there is evidence of moderate intervertebral disc syndrome with recurring attacks. A 40 percent is warranted under the same code if there is evidence of severe intervertebral disc syndrome, recurring attacks with intermittent relief. A 60 percent rating may be assigned if there is evidence of pronounced intervertebral disc disease with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, little intermittent relief. Based on the foregoing, the Board finds that the evidence supports a 20 percent rating for the veteran's service- connected low back disability. In particular, the evidence clearly shows that the disability is associated with degenerative changes and neurological impairment and is productive of pain, discomfort, fatigue, lack of endurance, impaired motion, and prompts him to seek intermittent outpatient treatment. On recent VA medical examinations, he indicated that he was essentially never symptom-free and he reported occasional flare-ups of symptoms manifested by excruciating and incapacitating pain. Overall, considering both objective clinical evidence of record and the veteran's subjective complaints of pain and functional impairment, including during flare-ups of pain, the Board is of the opinion that the severity of his low back disability more nearly approximates the rating criteria of moderate intervertebral disc syndrome with recurring attacks under Code 5293. The Board finds that a rating of the veteran's service- connected low back disability in excess of 20 percent is unwarranted. In particular, although the presence of degenerative disc disease and neurologic impairment has been confirmed by objective clinical evidence, the disability does not appear to necessitate regular or extensive medical treatment or surgery. Moreover, while the veteran has indicated that he experiences low back pain on a daily basis and his symptoms flare-up about once every two months, the objective evidence does not suggest that the severity of his symptoms may be characterized as severe with recurring attacks and intermittent relief; although he appears to feel, subjectively, that the severity of low back impairment is relieved only intermittently, such subjective perception is not supported by objective evidence of record as he does not require, apparently, regular or extensive inpatient and/or outpatient medical treatment; as noted on VA fee-basis medical examination in January 1999, there was no evidence of muscle atrophy. Thus, a rating of his disability in excess of 20 percent under Code 5293 is unwarranted based on both objective evidence of disability and subjective complaints of impairment. Although the service-connected low back disability is shown to be associated with degenerative changes, a separate disability rating may not be assigned for low back arthritis under Code 5003, as the currently assigned 20 percent evaluation under Code 5293 includes impairment of the range of motion and provides for disability rating based on the presence of arthritis. See 38 C.F.R. § 4.14 (1999). The evidence before the Board does not reveal that the veteran's service-connected low back disability is associated with a fractured vertebra, complete spine bony fixation (ankylosis), lumbar spine ankylosis, severely limited lumbar spine motion, or severe lumbosacral strain; thus, a rating of his disability, in excess of 20 percent, under Codes 5285, 5286, 5289, 5292, or 5295, respectively, is unwarranted. With regard to the veteran's claim for a compensable rating for his service-connected right arm pronator muscle syndrome, during pendency of this appeal, the rating criteria under which muscle injuries are evaluated were amended, effective July 3, 1997. 62 Fed. Reg. 30,235-240 (June 3, 1997) (codified at 38 C.F.R. §§ 4.55-4.73 Diagnostic Codes 5301- 5329; 38 C.F.R. §§ 4.47-4.54 and 4.72 were removed and reserved). Consistent with the decision in Marcoux v. Brown, 10 Vet. App. 3, (1996), holding that a liberalizing regulatory change during pendency of a claim must be applied if it is more favorable to the claimant, and if the Secretary has not enjoined retroactive application, Id. at 6, citing Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), the version most favorable to the veteran must be applied. In this case, the defined purpose of the regulatory changes was to incorporate updates in medical terminology, advances in medical science, and to clarify ambiguous criteria. The comments clarify that the changes were not intended to be substantive. See 62 Fed. Reg. 30,235-237 (June 3, 1997). Nevertheless, the veteran was provided notice of the change in the regulations pertaining to the rating of muscle injuries (see Sept. 1999 supplemental statement of the case). Currently, the veteran's service-connected right arm pronator muscle syndrome is rated under 38 C.F.R. § 4.73, Diagnostic Code 5307, muscle group VII injuries. Muscle group VII involves the muscles arising from internal condyle of humerus. Flexors of the carpus and long flexors of fingers and thumb; pronator. The stated function of muscle group VII consists of flexion of wrist and fingers. If the injury is slight, a noncompensable rating will be assigned under Code 5307; if it is moderate, a 10 percent rating is of application (whether the disability involves the major or minor extremity); if there is moderately severe injury to the major extremity, a 30 percent rating will be assigned; moderately severe injury involving the minor extremity will be evaluated 20 percent disabling. 38 C.F.R. § 4.56, evaluation of muscle disabilities, in effect since July 3, 1997, provides: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal; (b) A through- and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged; (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement; (d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles. (i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles. (i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound due to high- velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. As indicated above, no substantive changes were made to 38 C.F.R. § 3.56. Based on all of the pertinent evidence of record, as discussed above, the Board believes that a 10 percent rating for the veteran's service-connected right arm pronator muscle syndrome is warranted. The evidence reveals subjective symptoms of right arm numbness, decreased sensation, pain, and impairment in the ability to pick up objects with the right hand. Objective medical evidence, however, does not show evidence of arthritis, impaired motion, instability, weakness, effusion, or muscle atrophy, and there is no indication that he receives regular medical treatment for right arm impairment. Thus, considering both subjective complaints of pain and functional impairment and objective manifestations of the disability recorded on recent medical examination, the Board believes that the severity of the service-connected right arm disability is consistent with evidence of moderate injury of muscle group VII. The benefit of the doubt is resolved in his favor. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.73, Diagnostic Code 5307. Although the veteran suggested on VA fee-basis medical examination in January 1999 that the right arm impairment is significant and that he had episodes of excruciating pain, the subjectively perceived severity of such impairment is unsupported by objective evidence of record. Thus, there is no basis on which an evaluation greater than 10 percent may be assigned the service-connected right arm pronator muscle syndrome in this case. With regard to the claim for a compensable rating for left ear hearing loss, that disability is currently rated under 38 C.F.R. § 4.85, Diagnostic Code 6100, and a noncompensable rating is assigned. During the pendency of this appeal, the rating criteria under which diseases of the ear and other sense organs are rated were amended, effective June 10, 1999. 38 C.F.R. § 4.85 et seq. (see 64 Fed. Reg. 25,202-10). Consistent with Marcoux, 10 Vet. App. 3 (a liberalizing regulatory change during pendency of a claim must be applied if it is more favorable to the claimant, if the Secretary has not enjoined retroactive application), Id. at 6, citing Karnas, 1 Vet. App. at 313, the version of the criteria for diseases of the ear most favorable to the veteran must be applied. In this case, the defined purpose of the regulatory changes was a part of the overall revision of the rating schedule based on medical advances, etc., rather than representing liberalizing interpretations of regulations; the purpose of the change was an attempt to assure more equitable ratings in a small number of veterans with unusual patterns of hearing impairment. The comments clarify that the changes were not intended to be substantive. See 62 Fed. Reg. 25,204 (May 11, 1999). Impairment of auditory acuity is evaluated using the criteria in 38 C.F.R. § 4.85. 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. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of hearing loss 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 pure tone audiometry tests in frequencies 1,000, 2,000, 3,000, and 4,000 Hertz. To evaluate the degree of disability from bilateral service- connected defective hearing, the rating schedule establishes eleven auditory acuity levels designated from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85 and Part 4, Diagnostic Code 6100. To evaluate the degree of disability if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, the nonservice-connected ear will be assigned a Roman numeral designation for hearing impairment of I, subject to the provisions of 38 C.F.R. § 3.383 (which provides, in pertinent part, that compensation is payable for the combination of service-connected and nonservice-connected disabilities as if both disabilities were service-connected, if there is total deafness due to disability in the service- connected and nonservice-connected ear). 38 C.F.R. § 4.85(f). Under VA schedular standards, the test results reported from the June 1994 VA audiological evaluation reveal that the veteran's left ear hearing acuity is at level I. Hearing impairment in the right ear is not service-connected and is therefore assigned Level I for the purpose of rating disability from the service-connected left ear hearing loss (and there is no evidence of deafness in either the right or left ear). Level I hearing in both ears warrants a noncompensable evaluation. 38 C.F.R. § 4.85, Diagnostic Code 6100. Consequently, entitlement to a rating greater than the currently assigned 0 percent for his left ear hearing loss is not established under the rating criteria. To be assigned a higher evaluation under VA schedular standards, the average pure tone thresholds and/or speech recognition scores would have to reflect more significantly impaired hearing than is evident in the most recent audiometric examination. Thus, the preponderance of the evidence is against his claim for a compensable rating under the rating criteria. The Board stresses that the preponderance of the evidence is against the veteran's claim for a compensable rating for left ear hearing loss, and it presents no question as to which of two evaluations should be applied. Thus, 38 C.F.R. § 4.7 (1999) is inapplicable. Service connection claims: Service connection may be allowed for a chronic disability, resulting from an injury or disease, incurred in or aggravated by the veteran's period of active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Service connection may also be allowed on a presumptive basis for bronchiectasis, if the disability becomes manifest to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). 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 when 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 of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). The U.S. Court of Appeals for Veterans Claims (the Court) has held that lay observations of symptomatology are pertinent to the development of a claim of service connection, if corroborated by medical evidence. See Rhodes v. Brown, 4 Vet. App. 124, 126-127 (1993). The Court established the following rules with regard to claims addressing the issue of chronicity. Chronicity under the provisions 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 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 (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). A lay person is competent to testify only as to observable symptoms. A lay person is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability. Falzone v. Brown, 8 Vet. App. 398, 403 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1994). However, service connection may be granted for a post-service initial diagnosis of a disease that is established as having been incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (1999). The threshold question which must be resolved is whether the veteran has presented evidence that his claim is well grounded. See 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim. Murphy, 1 Vet. App. at 81. A mere allegation that a disability is service connected is not sufficient; the veteran must submit evidence in support of his claim which would justify a belief by a fair and impartial individual that the claim is plausible. In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in- service injury or disease and a current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995); see also, Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Where the determinative issue involves a question of medical diagnosis or causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Libertine v. Brown, 9 Vet. App. 521 (1996); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. See Grivois v. Brown, 6 Vet. App. 136, 140 (1994), citing Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Therefore, lay statements regarding a medical diagnosis or causation do not constitute evidence sufficient to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). See Grottveit, 5 Vet. App. at 93. The veteran's service medical records reveal intermittent treatment for symptoms including itching/watering eyes, allergic rhinitis, sinus headaches, allergies, congestion, and upper respiratory infections. A June 1976 X-ray study of the skull and sinuses showed soft tissue density in the right maxillary sinus. In June 1977, he reported sustaining a nasal fracture when he was 5 years old and having symptoms including frontal headaches for many years. In August 1977, he had rhinoplasty due to difficulty breathing and right- sided deviation of the tip of the nose, which reportedly existed since nose trauma in childhood; on examination, the septum was deviated, the left airway was occluded, and the right turbinate was markedly hypertrophied. In November 1989, he complained of sinus pressure and indicated that he had sinus problems "most of his life." In March 1992, it was noted that he had a history of sinus "problems." In May 1992, bilateral, maxillary sinusitis was diagnosed. In August 1992, he appeared to have seasonal rhinitis versus sinusitis. On service separation medical examination in September 1993, he reported a history of sinusitis, hay fever, and nose trouble, but no pertinent clinical findings were noted on examination. The service medical records document intermittent treatment for various pulmonary/respiratory symptoms including bronchitis, upper respiratory infections, and pneumonia. In May 1988 and December 1990, it was indicated that the veteran had mild "chronic" bronchitis. In November 1990 and September 1992, he completed an Asbestos Medical Surveillance Program questionnaire in which he indicated that he had no exposure to asbestos prior to service, but was exposed to the dust from that substance for 3-4 years in service (in 1969, 1972, 1976, and 1980). In November 1990, he indicated that he had persistent cough and shortness of breath. In September 1992, he denied recent medical treatment for pneumonia, bronchitis, asthma, or eye, ear, nose, throat infections. X-ray studies of the chest in November 1990 and March 1991 showed no active infiltrates. No report or clinical findings referable to any asbestos exposure residuals were noted on service separation medical examination in September 1993. On VA medical examination in June 1994, the veteran reported recurrent sinusitis "for years." On examination, the sinuses were non-tender, but nasal congestion and deviation was noted. In pertinent part, history of sinusitis was diagnosed. On VA pulmonary examination in June 1994, the veteran reported shortness of breath and dyspnea on exertion, noting that he was exposed to asbestos during service. X-ray study of the chest showed no active infiltrates. (Mild obstructive lung disease was diagnosed on special diagnostic examination in June 1994, and, as indicated above, service connection for COPD was granted by RO rating decision in September 1994; symptoms and impairment associated with the service-connected COPD are the subject of separate appellate consideration). On general medical examination in June 1994, a history of asbestosis was noted. On VA pulmonary examination in February 1997, the veteran reported having handled large amounts of asbestos and having been exposed to asbestos dust during service in the 1960s and 1970s. He indicated that, despite his history of asbestos exposure, he was never informed that he had any asbestos- related lung disease. X-ray study of the chest was negative for infiltrates. History of significant asbestos exposure with mild apical thickening of the pleura was diagnosed. On VA fee-basis medical examination in January 1999, the veteran reported asbestos exposure in service from 1969-72 and 1975-76; X-ray study of the chest showed no abnormality. VA medical records from February 1996 to February 1999 include a June 1998 X-ray study of the chest, showing no infiltrates or other acute pathologic processes. On several occasions during treatment for symptoms and illnesses unrelated to the claimed asbestos exposure residuals, the veteran reported a history of asbestosis. Based on the foregoing, the Board finds that the claims of service connection for chronic sinusitis and residuals of asbestos exposure are not well grounded. With regard to the claimed residuals of in-service asbestos exposure, the Board notes that the service medical records and post-service clinical records document the presence of various pulmonary/respiratory symptoms and impairment. However, the veteran was awarded service connection for COPD by RO rating decision in September 1994, precisely because his pulmonary/respiratory symptoms were shown to have developed during active service. Nevertheless, the medical evidence does not show that a chronic pulmonary disability, other than the service-connected COPD, developed because of in-service exposure to asbestos. Although both service medical records and post-service clinical evidence indicate that he may have been exposed to asbestos in service, there is no indication that any such exposure resulted in chronic asbestos-related disability. It is noted that history of asbestosis was indicated on VA medical examination in June 1994, but there were no contemporaneous clinical findings suggestive of that disability; numerous X-ray studies, performed both during service and thereafter, fail to show the presence of any chronic asbestos-related disability. Although mild apical thickening of the pleura was shown on VA pulmonary examination in February 1997, there is no indication that such pleural thickening was caused by a chronic disability due to asbestos exposure. Absent evidence of current disability resulting from asbestos exposure, the claim must be denied as not well grounded. See Brammer v. Derwinski, 3 Vet. App. 223 (1992) (in the absence of proof of a present disability there can be no valid claim). With regard to the claimed chronic sinusitis, while the veteran's service medical records reveal intermittent treatment associated with recurrent sinusitis and symptoms such as nasal congestion and headaches, chronic sinusitis was not diagnosed on service separation medical examination in September 1993 (but it is noted that he did report history of recurrent sinusitis in conjunction with service separation medical examination) or indeed at any time thereafter. Thus, as a current confirmed diagnosis of chronic sinusitis is not supported by objective medical evidence, the veteran's claim must be denied as not well grounded. See Rabideau, 2 Vet. App. 14; see also Brammer, 3 Vet. App. 223 (in the absence of proof of a present disability there can be no valid claim). The Board is mindful of the veteran's assertion that he now has chronic disability resulting from asbestos exposure and chronic sinusitis, and that such disability is related to service. While the credibility of his contention is not challenged and his competence to testify with regard to observable respiratory symptoms such as headaches and congestion is noted, consistent with Cartright v. Derwinski, 2 Vet. App. 24 (1991), he is simply not competent, as a lay person, to render a medical diagnosis of chronic disability resulting from asbestos exposure or chronic sinusitis, or to provide a nexus or etiological link between in-service symptoms and/or asbestos exposure and any current symptomatology. See Grivois, 6 Vet. App. at 140, citing Espiritu, 2 Vet. App. at 494. Finally, the evidence does not show, nor is it contended that the claimed sinusitis and/or disability from asbestos exposure are related to combat service; thus, the provisions of 38 U.S.C.A. § 1154(b) (West 1991) are not applicable in these claims. If a claim is not well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14 (1993). A not well-grounded claim must be denied. Edenfield v. Brown, 8 Vet. App. 384 (1995). If the initial burden of presenting evidence of a well-grounded claim is not met, VA has a duty to assist the veteran in the development of the claim. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81-82. The RO has advised the veteran of the evidence necessary to establish a well-grounded claim, and he has not indicated the existence or availability of any medical evidence (not already of record) that would well ground his claims. Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). ORDER A rating of 20 percent for the service-connected low back disability, including degenerative disc disease, is granted, subject to the law and regulations governing the payment of monetary awards. A rating of 10 percent for the service-connected right arm pronator muscle syndrome is granted, subject to the law and regulations governing the payment of monetary awards. A compensable rating for the service-connected left ear hearing loss is denied. Service connection for chronic disability resulting from asbestos exposure is denied. Service connection for chronic sinusitis is denied. REMAND The veteran's claim for a rating in excess of the current 10 percent for the service-connected COPD is well grounded, Murphy, 1 Vet. App. 78, as it stems from the rating initially assigned at the time of the September 1994 grant of service connection for that disability. Shipwash, 8 Vet. App. 218. If a claim is well grounded, VA has a duty to assist in the development of facts pertinent to the claim (38 U.S.C.A. § 5107(b)) which includes a thorough VA examination. Hyder v. Derwinski, 1 Vet. App. 221 (1991). The available record reveals that the most recent VA pulmonary examination (and pulmonary function study) was performed in February 1997 (it is noted that a pulmonary function study was not performed on VA fee-basis medical examination in January 1999 because the veteran was unable to undergo the study due to a persistent cough). Although the examination and pulmonary function study reports provide detailed information regarding the nature and severity of the veteran's disability, the pulmonary function study does not reveal specific findings referable to Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) or the levels of oxygen consumption in compliance with the rating criteria listed in 38 C.F.R. § 4.97 (1999). Where the available evidence is inadequate to evaluate the current state of the condition, VA must provide a new examination. Olsen v. Principi, 3 Vet. App. 480 (1992). The Board is of the opinion that another thorough VA pulmonary examination and pulmonary function study should be performed to fully address the rating criteria referable to evaluation of disabilities of the respiratory system. In particular, the VA examiner indicated, in February 1997, that obtaining DLCO values would help evaluate the veteran's restrictive defect. Accordingly, the claim of a rating in excess of 10 percent for COPD is REMANDED for the following action: 1. The veteran should be afforded another VA pulmonary examination to determine the extent and severity of his service-connected COPD. The claims folder and the information necessary for the examiner to make findings concerning the rating of the service-connected lung fibrosis in accordance with the new criteria effective October 7, 1996 (38 C.F.R. § 4.97) must be provided the examiner for review in conjunction with the examination. All indicated studies should be conducted, including pulmonary function tests and X-ray studies. Symptomatology associated with the service-connected COPD should be delineated, if possible, from any nonservice-connected symptomatology. If it is impossible to so distinguish the symptoms, the examiner should so state for the record. 2. The RO should carefully review the examination report to ensure compliance with this remand. If any development requested above is not accomplished, remedial action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). If the remaining benefit sought on appeal is not granted, the veteran and his representative should be provided a supplemental statement of the case and afforded an opportunity to respond. The case should then be returned to the Board for review. The veteran has the right to submit additional evidence and argument on the matter remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). J. F. Gough Member, Board of Veterans' Appeals