Citation Nr: 1753490 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 12-02 641 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable evaluation for hypertensive vascular disease characterized as hypertension. 2. Entitlement to a compensable evaluation for left knee instability prior to April 20, 2016. 3. Entitlement to a rating in excess of 10 percent for left knee instability from April 20, 2016. 4. Entitlement to service connection for allergic or vasomotor rhinitis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD E. Miller, Associate Counsel INTRODUCTION The Veteran served on active duty in the US Navy from January 1990 to June 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Jurisdiction presently resides with the St. Petersburg, Florida RO. In the Veteran's original April 2010 claim, he filed for service connection for several disabilities, to include, as two separately identified disabilities, a) left knee instability, and b) left knee degenerative joint disease. The RO considered these two left knee claims as individual service connection claims, granting service connection for left knee degenerative joint disease in an October 2010 rating decision, while in the same decision denying service connection for left knee instability based on lack of a diagnosis for left knee instability. The Veteran submitted a Notice of Disagreement (NOD) in December 2010, and a Substantive Appeal (e.g., VA Form 9 or equivalent statement) in November 2011, specifically disagreeing with the denial of service connection for left knee instability. See 38 U.S.C. § 7105(a) (West 2014); 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.300, 20.302 (2017). In August 2015, the Veteran filed an increased rating claim for his service-connected left knee degenerative joint disease (DJD), at that time rated at 10 percent. In response to a letter from the RO which did not include the increased rating claim for his left knee DJD because it noted that issue was on appeal, the Veteran submitted a statement in December 2015 that the issue he was currently appealing was the denial of service connection for his left knee instability, and he requested that the RO continue to process the claim for increased rating for left knee DJD. In a June 9, 2016 rating decision, the RO continued the 10 percent rating for the left knee DJD. The Veteran was notified of this decision and how to appeal, and he did not do so. In July 2016 this case came before the Board which characterized the denial of service connection for left knee instability on appeal as, "entitlement to a compensable rating for left knee instability." Rather than separately grant the Veteran service connection for left knee instability, the Board considered the left knee instability claim as a separate compensable evaluation of a general left knee disability claim, for which the Veteran was already service-connected under Diagnostic Code (DC) 5260-5003 for left knee DJD. After evaluating the medical evidence of record, the Board granted the Veteran a 10 percent rating for his left knee instability and also remanded the left knee instability claim with the other claims on appeal to the RO for further development. Accordingly, in a July 2016 decision, the Appeals Management Center (AMC) implemented the Board's decision by rating the Veteran's left knee instability as a service-connected disability with a 10 percent rating effective April 20, 2016. In December 2016, the Veteran underwent a VA examination for his left knee, which was included in the evaluation by the RO in the January 2017 supplemental statement of the case, in which the Veteran's claim was characterized as "entitlement to a rating in excess of 10 percent for left knee instability." The RO denied a rating for left knee instability beyond 10 percent. The RO has completed the additional requested development and the case has now been returned to the Board for appellate review. The Veteran also appealed a June 22, 2016 rating decision, which denied entitlement to service connection for sleep apnea; and a December 2015 rating decision which denied entitlement to service connection for erectile dysfunction. The RO, however, has not yet certified these issues to the Board, indicating that additional development may be ongoing. Therefore, the Board will not take jurisdiction of these issues at this time. FINDINGS OF FACT 1. Throughout the claim period, the Veteran's hypertensive disability more closely approximates that of an individual with a history of diastolic blood pressure predominantly 100 or more that requires continuous medication for control; however, his systolic and diastolic readings throughout the appeal period are not shown to be predominantly 200 or more, or 110 or more, respectively. 2. Prior to April 20, 2016, the Veteran was not diagnosed with left knee instability. 3. After April 20, 2016, the Veteran's left knee was not productive of moderate instability. 4. The competent medical evidence does not support a finding that the Veteran has allergic or vasomotor rhinitis. CONCLUSIONS OF LAW 1. The criteria for award of an initial 10 percent evaluation, but no higher, throughout the appeal period for hypertension have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2017). 2. The criteria for a compensable rating for instability of the left knee under DC 5257 have not been met prior to April 20, 2016. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1 -4.14, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2017). 3. The criteria for a rating in excess of 10 percent rating for instability of the left knee under DC 5257 for the period from April 20, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1 -4.14, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2017). 4. Service connection for allergic rhinitis is not warranted. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2016), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). VA's duty to notify was satisfied by notice dated in April 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service treatment records (STRs), VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran has been medically evaluated. The Board finds, at a minimum, that the December 2016 VA examinations were thorough and adequate, and the AMC issued a supplemental statement of the case for the issues on appeal. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that there was substantial compliance with the July 2016 Board remand. Stegall v. West, 11 Vet. App. 268 (1998). In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. II. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different DCs, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings are sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2016). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37; Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board acknowledges that a claimant may experience multiple degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart, 21 Vet. App. 505. The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. a. Hypertension Upon review of the medical evidence of record, the Board finds that a rating for hypertension of 10 percent is warranted for the period of appeal. The Veteran is currently assigned a noncompensable evaluation for hypertension from July 1, 2010, under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a rating of 10 percent requires diastolic blood pressure predominantly 100 or more, or systolic blood pressure predominantly 160 or more, or minimum evaluation for an individual with a history of diastolic blood pressure predominantly 100 or more who requires continuous medication for control. A rating of 20 percent requires diastolic blood pressure predominantly 110 or more, or systolic blood pressure predominantly 200 or more. A rating of 40 percent requires diastolic pressure predominantly 120 or more. A rating of 60 percent requires diastolic blood pressure predominantly 130 or more. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2016). On appeal, the Veteran asserts that his hypertension warrants a compensable evaluation. In particular, he has argued-in his January 2011 notice of disagreement -that he requires continuous medication for control of his hypertension throughout the appeal period, thus his condition is worse than it appears. The Board agrees that a compensable evaluation for the Veteran's hypertension is warranted for the reasons explained below. The Veteran served for over 20 years in the Navy, separating in June 2010. During that time he underwent numerous medical evaluations and treatments. The STRs show several readings of diastolic pressure over 100. At an August 2005 dental appointment, the Veteran's blood pressure was measured as 150/101. Records show a diagnosis of hypertension in August 2005 and prescription of Nisodipine. At a July 2006 dental appointment, the Veteran's blood pressure was measured at 137/101 and 135/99 and noted as "being monitored by medical." There is a record during the Veteran's active service for prescription of Lisonopril, a blood pressure control medication, but the date of prescribing is unclear. At a February 2007 medical appointment, the Veteran's blood pressure was measured as 174/135, 153/100, and 154/110; the examiner requested to have the Veteran evaluated for high blood pressure. The Veteran was discharged from service in June 2010; the Board has reviewed the Veteran's available VA treatment records since his date of discharge. The Board notes that he had the following blood pressure readings in those records: 103/63 (10/4/2013), 126/78 (4/29/2015), 126/82 (8/5/2015), 124/86 (3/2016). At the December 2016 VA examination, the Veteran was shown to still be treated with blood pressure medication; records throughout indicate the Veteran has been on blood pressure medication continuously since the mid-2000s. Thus, the Board notes that the Veteran is shown to have been taking medication for his hypertension continuously since discharge from service. Based on the foregoing evidence, the Board finds that a 10 percent evaluation throughout the appeal period is warranted for the Veteran's hypertension. Since naval service, the Veteran has been shown to be taking continuous medication for treatment and control of his hypertension. While the RO noted in its various decisions that the Veteran did not have a history of diastolic blood pressure readings which were predominantly 100 or more, the Veteran has clearly had continuous medication use throughout the appeal period. Moreover, at least some of the Veteran's diastolic readings were 100 or more. However, an evaluation greater than 10 percent for the Veteran's hypertension is not warranted as the evidence of record does not demonstrate that his diastolic blood pressure is predominantly 110 or more or that his systolic blood pressure is predominantly 200 or more. Such a conclusion is borne out by the above noted evidence. In short, the Board finds that the Veteran's disability picture more closely approximates the criteria for a 10 percent disability rating, but no higher. 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7101. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). b. Left knee instability Upon review of the medical evidence of record, the Board finds that a compensable rating for left knee instability prior to April 20, 2016, and a rating in excess of 10 percent from that date, are not warranted. In general, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that 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. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the Veteran undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). However, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply to DC 5257 as those criteria are not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Descriptive words, such as "slight," "moderate" and "severe," are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). According to DC 5257, a 10 percent rating will be assigned with evidence of slight recurrent subluxation or lateral instability of a knee; a 20 percent rating will be assigned with evidence of moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned with evidence of severe recurrent subluxation or lateral instability. At a June 2010 pre-discharge medical examination, the Veteran asserted that he had symptoms of left knee disability such as giving way and instability. The examiner stated that the Veteran's left knee showed no signs of instability or subluxation. The medial/lateral collateral ligaments test, the anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all reported by the examiner as being within normal limits for the left knee. The examiner noted that the Veteran's X-rays showed degenerative changes, which are already contemplated by the separate rating for left knee DJD under DC 5260-5003 at a 10 percent. The diagnosis was degenerative arthritis of the bilateral knee joints. In the April 2016 VA examination, the examiner noted a history of left knee instability. However, the objective testing showed all normal limits for the left knee with respect to instability. The examiner diagnosed "degenerative joint disease left knee; not currently apparent (S/P ACL and quad repair). Minimal functional limitation." The examiner did not diagnose left knee instability. At the December 2016 VA examination, the examiner diagnosed no left knee instability. The examiner also noted that the Veteran's current disability rating for left knee instability had been based on incorrect assessment of the April 2016 VA examination which showed no objective signs of left knee instability. The Board finds that the preponderance of the evidence is against granting the Veteran's claim for a compensable disability rating prior to April 20, 2016, or a rating greater than 10 percent after April 20, 2016 for left knee instability. The medical evidence of record does not support an assessment for slight left knee instability prior to April 20, 2016 required for a 10 percent rating, or an assessment of moderate left knee instability after April 20, 2016 required for a 20 percent evaluation. The Board acknowledges the Veteran's contentions that he feels his left knee is unstable; however, the VA examinations do not show the Veteran suffers from left knee instability. Disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran's assessment of the severity of his disability. In this regard, the December 2016 VA examiner specifically noted that the Veteran had complained his knee pops and locks, and that he sometimes uses a knee brace. However, the VA examiner noted there was no objective clinical evidence of ligament instability in the left knee. Similarly, the April 2016 VA examiner noted the Veteran's complaints of the left knee "giving" sometimes, but concluded that testing of the left knee did not show instability. It is therefore clear that the VA examiners considered the evidence of the Veteran's statements. The Board therefore concludes that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran's assertions as to the severity of his disability. Caluza; Jandreau; see also Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). Accordingly, the Board finds that the criteria for a compensable disability rating prior to April 20, 2016 or for a rating greater than 10 percent from that date for left knee instability have not been met. II. Service connection for allergic rhinitis The Veteran contends that during service he developed seasonal allergies and that he continues to suffer from this disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C.A. § 1113(b) (West 2014); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disability, there must be: (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury incurred, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). Lay evidence can be competent and sufficient to establish the elements of service connection when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau, 492 F.3d at 1377. In short, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). For instance, a layperson is competent to identify such disorders as varicose veins, tinnitus, and flat feet. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). In contrast, a layperson is not competent to identify medical conditions that require scientific, technical, or other specialized knowledge, such as in identifying bronchial asthma. 38 C.F.R. § 3.159(a)(1); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board must assess the competence and credibility of lay statements. Barr, 21 Vet. App. at 308. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran, as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). The Veteran's STRs show treatment for rhinorrhea due to seasonal allergies in 2006 and a prior diagnosis of allergic rhinitis in September 2005. The Veteran states he took over-the-counter (OTC) medication to deal with the symptoms and that he still takes OTC medications to deal with the symptoms of seasonal allergies. Post-service, the Veteran's records do not show regular treatment for allergies, rhinitis, sinusitis, or related disorders. At the June 2010 VA examination, the examiner recorded the Veteran's description of his history with allergic rhinitis as beginning about 10 years prior to the appointment date. The Veteran described the symptoms as sinus problems which occur 6 times per year for about one week in duration during which he is not incapacitated. The Veteran reported no headaches associated with this condition, or requirement to take antibiotics during episodes. The Veteran reported interference with breathing through his nose, hoarse voice, and sneezing with drainage. The Veteran stated he does not receive treatment for this condition nor does he experience any overall functional impairment. Upon examination there was no nasal obstruction, no deviated septum, no partial loss of the nose, and no nasal polyps. There was no rhinitis, bacterial rhinitis, or sinusitis detected. The examiner made no opinion on service connection for this condition because there was no diagnosis due to lack of demonstrated pathology. At the December 2016 VA examination, the Veteran reported that he takes OTC medications when he has allergic symptoms, but he does not seek treatment. The Veteran also reported getting treated in the Navy and getting skin testing done, which is not shown in the STRs. The Veteran reported he gets symptoms especially in the summer when cutting grass but can treat it with OTC medications. The Veteran reported he was not currently suffering from seasonal allergic rhinitis. The examiner noted that the Veteran has rhinitis. There was not 50 percent obstruction of both sides of his nasal passage or complete obstruction of right or left side. There were no nasal polyps, granulomatous conditions, or permanent hypertrophy of the nasal turbinates. The examiner concluded there was insufficient evidence to confirm a diagnosis of acute or chronic allergic rhinitis or residuals (claimed as allergies). The examiner concluded that the episode of in-service allergic rhinitis concluded without residuals. The Board notes that the Veteran contacted VA via telephone on December 22, 2016. The call was logged as the Veteran stating he wanted a new VA examination because he had "problems with the examiner." The December 2016 VA examination was consistent with the prior VA examination and with prior treatment records and STRs. As the Veteran gave no specific indication of the problems with the examiner, and the findings were consistent with prior examination and treatment records, the Board finds no basis to schedule a new VA examination. While the Veteran may believe that his occasional seasonal allergic symptoms are related to his active service, as a lay person, he has not been shown to have specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the Veteran is competent to report symptoms such as watery eyes and runny nose, but the diagnosis and etiology of sinus conditions requires medical testing and expertise to determine. Thus, his lay opinion regarding the etiology of his seasonal allergic symptoms is not competent medical evidence. The Board finds the opinion of the VA examiner in December 2016 to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran has a chronic allergic rhinitis condition due to service. The findings of the VA examiner were based on a review of the evidence, and cited to the medical evidence. The examiner considered the complete record and the Veteran's contentions, and provided an explanation as to why the evidence does not support a confirmed diagnosis of chronic allergic rhinitis. The opinion contains an internal logic consistent with the known facts, as well as with other evidence of record. The Board finds this opinion highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The most probative and persuasive evidence is against finding that the Veteran has a chronic allergic rhinitis condition related to service. Accordingly, service connection for allergic rhinitis is denied. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial disability evaluation of 10 percent, but no higher, for hypertensive vascular disease characterized as hypertension, is granted. Entitlement to a compensable evaluation for left knee instability prior to April 20, 2016 is denied. Entitlement to a rating in excess of 10 percent for left knee instability from April 20, 2016 is denied. Entitlement to service connection for allergic or vasomotor rhinitis is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs