Citation Nr: 1760786 Decision Date: 12/28/17 Archive Date: 01/02/18 DOCKET NO. 16-00 156A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for insomnia disorder with urinary frequency (insomnia). 2. Entitlement to an increased disability rating in excess of 20 percent for prostate cancer. 3. Entitlement to a compensable, initial disability rating for erectile dysfunction. 4. Entitlement to an increased disability rating in excess of 30 percent for bronchial asthma, previously rated as chronic bronchitis. 5. Entitlement to an increased disability rating in excess of 20 percent for the residuals of a rupture of the medical collateral, anterior cruciate ligaments, and medical meniscus of the left knee status post-operative (left knee disability). 6. Entitlement to an increased disability rating in excess of 10 percent for the residual of a perforated ulcer status post-operative (ulcer). 7. Entitlement to a separate, increased disability rating for the scar from intestinal surgery for ulcer perforation. 8. Entitlement to service connection for degenerative disc disease and lumbar facet arthropathy of the lumbar spine (lumbar spine disabilities). 9. Entitlement to service connection for a right knee disability. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION The Veteran represented by: J. Michael Woods, Esq. ATTORNEY FOR THE BOARD Grace J. Suh, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1971 to August 1974, during the Vietnam Era. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. Although the RO included the issue of entitlement to special month compensation (SMC) based on the loss of use of a creative organ among the issues on appeal in its January 2016 Statement of the Case, the Board notes the RO granted SMC on that basis in its June 2014 rating decision. This grant constitutes a full grant of the benefits sought. Moreover, the Veteran never initiated an appeal with respect to this claim. See November 2014 Notice of Disagreement. Therefore, this claim is not in controversy. Cf. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claim remains in controversy where less than the maximum available benefit has been awarded). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of a compensable, initial disability rating for erectile dysfunction and an increased disability rating in excess of 20 percent for the left knee disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's insomnia was manifested by chronic sleep impairment and mild memory loss. 2. The evidence of record shows the Veteran's prostate cancer was manifested by urine leakage, which the changing of absorbent materials less than two times per day; and increased urinary frequency causing daytime voiding in intervals between one and two hours and awakening at nighttime to void between three and four times per night. 3. The evidence of record shows the Veteran's did not require at least monthly visits to a physician due to exacerbations of his bronchial asthma nor any courses of systemic corticosteroids; and that his post-bronchodilator results following a pulmonary function test (PFT) demonstrate FEV-1 (forced expiratory volume in one second) of 84 percent predicted and FEV-1/FVC (forced vital capacity) of 59 percent predicted. 4. The evidence of record shows the Veteran's ulcer was well managed with medications and diet, without any evidence of recurrent episodes of severe symptom or continuous moderate manifestations. 5. The evidence of record does not establish a nexus between the Veteran's currently diagnosed lumbar disabilities and his in service complaint of back pain. 6. The evidence of record does not establish a current right knee disability. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for insomnia have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.27, 4.130, Diagnostic Code (DC) 9410 (2017). 2. The criteria for an increased disability rating in excess of 20 percent for prostate cancer have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.27, 4.115(a), (b), DC 7528 (2017). 3. The criteria for an increased disability rating in excess of 30 percent for bronchial asthma have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.27, 4.96(d)(5), 4.97, DC 6602 (2017). 4. The criteria for an increased disability rating in excess of 10 percent for the ulcer have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.27, 4.114, DC 7305 (2017). 5. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 1132, 1133, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307(a)(3), 3.309(a) (2017). 6. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 1132, 1133, 1137; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. A Higher Initial Disability Rating for Insomnia The Veteran contends that he is entitled to an initial disability rating in excess of 30 for insomnia. See June 2013 Letter from the Veteran; January 2016 VA Form 9. Preliminarily, the Board notes the applicable DC is DC 9410, which is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. §§ 4.27, 4.130. Under the General Rating Formula for Mental Disorders, a 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; or, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to symptoms such as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgement; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges the psychiatric symptoms listed in the rating criteria are not exhaustive, but are examples of typical symptoms for the listed disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Generally, in assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his insomnia. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007), abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013), (holding that while a lay person is not competent to opine as to medical etiology or render medical opinions, they are competent to establish the presence of observable symptomatology). However, as his statements relate to a clinical assessment of occupational and social impairment, the Board is unable to accord them any probative weight because he is not competent to render a medical diagnosis or opinion on such a complex medical question. See Barr, supra; see also Jones v. West, 12 Vet. App. 460, 465 (1999) (holding that only those with specialized medical knowledge, training, or experience are competent to render a medical diagnosis). In that regard, the Board relies on the medical evidence of record. As in this instance, when an initial disability rating is at issue, the evidence to be considered includes the entire appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). A review of the claims reveals only two items of evidence relevant to this claim; a May 2014 Mental Disorders VA Examination Report and a July 2015 Mental Disorders Disability Benefits Questionnaire (DBQ) from a private psychiatrist. The May 2014 VA Mental Disorders VA Examination Report and the July 2015 Mental Disorders DBQ present a stark contrast between the symptoms reported by the Veteran and the opinions rendered with respect to the resulting occupational and social impairment. During the May 2014 VA examination, the Veteran relayed that he has been married twice. He has been married to his second wife for 21 years. Prior to that he was married to his first wife for 25 years until her passing. He reported increasing difficulty at home due to his wife's cognitive decline. He relayed that he has had occasional difficulty with irritability at home. Even so, he described continuing to engage in social activities with his neighbors and friends, such as horseback riding. The Veteran's primary complaint was awakening throughout the night due to the increased urinary frequency following his treatment for prostate cancer. As a result, he was not able to get restorative sleep, which he explained caused him to feel tired and have some difficulty with concentration throughout the day. However, he expressly denied experiencing any depressive symptoms or suicidal ideation. In terms of employment, the Veteran stated he was employed by the Army National Guard as a mechanic in a civil service position for over 22 years following separation form service, but retired 16 years ago. Following examination, the VA examiner identified chronic sleep impairment and mild memory loss, such as forgetting names, directions, or recent events as the Veteran's pertinent symptoms. In doing so, the VA examiner excluded the presence of all other symptoms. The VA examiner opined these symptoms were mild or transient in terms of occupational and social impairment leading to a decrease in work efficiency and ability to perform occupational tasks only during periods of significant stress. In contrast, a July 2015 Mental Disorders DBQ from Dr. G.H.G. concluded the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. During his interview with Dr. G.H.G., the Veteran confirmed he was still married to his second wife. Even though he complained of increased trouble with his short-term memory and that he struggled to remember even basic information, he also admitted that he handled all their daily living activities because of his wife's Alzheimer's. He managed their finances, did the food shopping and meal preparation, but they shared in their household chores. Generally, the Veteran reported the disturbances of motivation and mood, difficulty establishing and maintaining relationships and difficulty adapting to stressful circumstances including work. More specifically, while he lived with his wife, he relayed that he kept his struggles to himself. He kept himself isolated and withdrawn from others. He was unable to enjoy even the simplest of activities. He relayed that keeping up with the demands and stresses of his job caused him to be hospitalized on a couple of occasions. He stated he suffered from chronic sleep impairment, getting up between three and five times per night. His lack of sleep caused him to become irritable and tire easily. He had difficulty concentrating and claimed that he could never get a project done. He also reported experiencing auditory hallucinations, which consisted of hearing voices. Notwithstanding Dr. G.H.G.'s comment the Veteran detailed great ongoing difficulty with his mental health symptoms, he continued to deny ever receiving any treatment or taking medication for his psychiatric symptoms. At the time of his interview, Dr. G.H.G. observed the Veteran's attention was intact, although his concentration was variable; mood was anxious and nervous, and his affect was restricted; speech flow was normal, but the information he offered was brief and responses were vague; thought processes was organized and goal directed with appropriate content; judgement was average; he appeared suspicious and rather paranoid; and overt hallucinations were reported. Ultimately, Dr. G.H.G. determined the Veteran's relevant symptoms were depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; suicidal ideation; and persistent delusions or hallucinations. Significantly, Dr. G.H.G. found his symptoms related back as far as his original claim date of June 25, 2013. After careful consideration of the May 2014 Mental Disorders VA Examination Report and July 2015 Mental Disorders DBQ, the Board finds the May 2014 Mental Disorders VA Examination Report is more probative for the reasons below. See Madden v. Gober, 125 F.3d 1477, 1481 (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"). Dr. G.H.G. cited having received and reviewed the May 2014 Mental Disorders VA Examination Report. In fact, Dr. G.H.G. included the same among her "Supportive Medical Documentation," and referred to the VA examiner's conclusion the Veteran's sleep disturbance was significant enough to cause him difficulty with concentration, focus, and energy throughout the day. While Dr. G.H.G. acknowledged the VA examiner's opinion that his overall occupational and social impairment were caused by mild or transient symptoms, which decreased work efficiency and ability to perform occupation tasks, she did not reconcile this opinion with her own disparate opinion that he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. This is significant in view of Dr. G.H.G.'s finding that his symptoms related as far back as his original date of claim prior to the May 2014 VA examination. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (holding that an opinion is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the disability is a fully informed one) citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). For instance, the Veteran's statement that he kept himself isolated and withdrawn from others and that he was unable to enjoy even the simplest of activities during the July 2015 interview with Dr. G.H.G. is contradictory to his report that he continued to engage in social activities with his neighbors and friends during the May 2015 VA examination. With respect to the Veteran's claim that he was hospitalized due to the demands and stresses of his job, the Board notes he retired well before the May 2014 VA examination and has not been employed since. Thus, his statements during the May 2014 VA examination and July 2015 interview pertain to the same periods of employment. On this account, this statement is inconsistent with his report during the May 2014 VA examination that he did well in his position as an Army National Guard mechanic for over 22 years with the exception of occasional flashes of irritability with his subordinates. While Dr. G.H.G. documented the Veteran's report of experiencing auditory hallucinations, which consisted of hearing voices, Dr. G.H.G. did not indicate the frequency with which he experienced them. Nonetheless, Dr. G.H.G. concluded they were persistent. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008) (holding that to have probative value, a medical report must contain not only a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two). As another matter, although Dr. G.H.G.'s opinion also extends the presence of this symptom as far back as the original date of claim, she did not discuss the discrepancy between the May 2014 VA examiner's exclusion of persistent delusions or hallucinations with her own. The same is true for Dr. G.H.G.'s finding that suicidal ideation was also an active symptom of his insomnia. Finally, Dr. G.H.G.'s comment the Veteran "seem[ed] cautious of the important interaction" on the day of the interview draws into the credibility of his lay statements. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996) (holding that credibility may be appraised by evaluating a witness' statements for interest, bias, demeanor, internal consistency, facial plausibility, or consistency with the other evidence of record). In support, Dr. G.H.G. submitted a study titled The Long-term Effect of Insomnia on Work Disability The Hunt-2 Historical Cohort Study, which claimed to document an independent association between insomnia and subsequent permanent work disability in a prospective study. See Borge Sivertsen, et al., The Long-term Effect of Insomnia on Work Disability The Hunt-2 Historical Cohort Study, American Journal of Epidemiology, Vol. 163, No. 11 (April 12, 2006). Given the VA has already recognized there is an association between the Veteran's insomnia and occupational impairment by granting service connection for the same, the study has no probative value because it does not assess the severity of symptoms specific to him. Since there is no other evidence of record, lay or medical, discussing the Veteran's insomnia, the May 2014 Mental Disorders VA Examination Report is necessarily the most probative evidence of record. For this reason, the Board finds the preponderance of the evidence establishes his insomnia more nearly approximates the 30 percent disability rating assigned during the entire appeal period because his only manifestations were chronic sleep impairment and mild memory loss. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (2009); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007) (holding that the Board must examine the relevant evidence to determine whether it is possible to grant a higher percentage evaluation for a distinct period; this concept is known as the "staging" of ratings; Vazquez-Claudio, supra; Mauerhan, supra. II. An Increased Disability Rating for Prostate Cancer The Veteran contends that he is entitled to an increased disability rating in excess of 20 percent for prostate cancer. See June 2013 Letter from the Veteran; January 2016 VA Form 9. In this instance, the applicable DC is DC 7528. 38 C.F.R. § 4.115b. According to the Note associated with DC 7528, following the cessation of surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure; if there has been no local reoccurrence or metastasis, the disability is to be rated on the residuals of voiding dysfunction or renal dysfunction, whichever is predominant. In this instance, at issue is an increase in the disability rating assigned. As a result, the primary concern is the Veteran's present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994); cf. Fenderson, supra. In such cases, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110 (2012). Therefore, the relevant timeframe for consideration is from June 2012 to the present. See June 2013 Letter from the Veteran (the Veteran initiated an informal claim for an increased disability rating for his prostate cancer; the letter was received by the VA on June 25, 2013). The only pertinent evidence of record discussing the symptoms and diagnostic criteria of the Veteran's prostate cancer is the October 2013 Prostate Cancer VA Examination Report. Upon examination, the VA examiner concluded the Veteran's prostate cancer was in remission. He was last treated for prostate cancer in 2006, during which time he underwent brachytherapy (seed implants). Id.; see also September 2006 S.E.M. Medical Center Operative Report. The VA examiner also found that he had voiding dysfunction as a result of his brachytherapy. The voiding dysfunction caused urine leakage, which the VA examiner determined required the changing of absorbent material less than twice per day. Additionally, it caused increased urinary frequency. He had daytime voiding in intervals between one and two hours as well as nighttime awakening to void between three and four times per night. However, he did not have any signs or symptoms of obstructed voiding. Aside from the above and erectile dysfunction, the VA examiner indicated there were no other pertinent physical findings, complications, conditions, signs, and/or symptoms associated with the Veteran's prostate cancer. Given the evidence of record establishes the Veteran's prostate cancer is in remission and there is no diagnosis of renal dysfunction; the Board finds his prostate cancer must be rated on the residuals of voiding dysfunction. A rating based on the diagnostic criteria for voiding dysfunction can be accomplished in one of three ways; for urine leakage, urinary frequency, or voiding obstruction. 38 C.F.R. § 4.115a. As the VA examiner expressly found there were no signs or symptoms of obstructed voiding, a disability rating under this alternative is foreclosed. For urine leakage, a 20 percent disability rating is warranted if the disability requires the changing of absorbent materials less than twice per day; a 40 percent disability rating is warranted if it requires the changing of absorbent materials between two and four times per day; and a 60 percent disability rating is warranted if it requires the changing of absorbent materials more than four times per day. Under urinary frequency, a 20 percent disability rating is warranted if the daytime voiding interval is between one and two hours, or the awakening to void is between three and four times per night; and a 40 percent disability rating is warranted if the daytime voiding interval is less than one hour, or the awakening to void is five or more times per night. The Board notes the current disability rating is based on the diagnostic criteria prescribed under urinary frequency. See June 2014 Rating Decision; January 2016 Statement of the Case. In this respect, while the July 2015 Mental Disorders DBQ documented the Veteran's report of waking up three to five times per night, he did not clarify whether it was due to increased urinary frequency. Thus, this symptom is more appropriately addressed by the disability rating assigned for his insomnia. See 38 C.F.R. § 4.14 (2017); see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994). There is no other evidence of record suggesting the Veteran experienced daytime voiding in intervals less than one hour, or that he awakened to void five or more times per night at any time during the pendency of this appeal. Consequently, the Board finds the preponderance of the evidence does not substantiate a disability in excess of 20 percent due to urinary frequency at any time during the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304; see also Fagan, 573 F.3d at 1287 (holding that the benefit of the doubt doctrine is not applicable based on "pure speculation or remote possibility"); Hart, supra. Neither can a disability rating in excess of 20 percent be assigned under the diagnostic criteria for urine leakage because the there is no evidence of record demonstrating the Veteran had to change his absorbent materials between two and four times per day or more at any time during the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.1; see also Fagan, supra; Hart, supra. Ordinarily, the Board must also consider increased evaluations under other potentially applicable DCs. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, because the evidence of record does not disclose any other symptoms associated with the Veteran's prostate cancer, the Board finds such consideration is unnecessary. While the Veteran's symptomatology may include distinct manifestations of urine leakage, urinary frequency, and obstructed voiding, they do not warrant separate consideration as they stem from the same residual disability; voiding dysfunction. Necessarily, the disability rating assigned under one of these subcategories contemplates the other manifestations in determining the most advantageous and appropriate disability rating for a veteran. Thus, awarding a separate disability rating for urine leakage, urinary frequency, and obstructed voiding would constitute pyramiding. 38 C.F.R. § 4.14. III. An Increased Disability Rating for Bronchial Asthma The Veteran contends that he is entitled to an increased disability rating in excess of 30 percent for bronchial asthma. See June 2013 Letter from the Veteran; January 2016 VA Form 9. The applicable DC for bronchial asthma is DC 6602. 38 C.F.R. § 4.97. Under DC 6602, a 30 percent disability rating is warranted if the FEV-1 is of 56-70 percent predicted; FEV-1/FVC is of 56-70 percent predicted; daily inhalational or oral bronchodilator therapy; or, daily inhalational anti-inflammatory medication is required. A 60 percent disability rating is warranted if the FEV-1 is of 40-55 percent predicted; FEV-1/FVC is of 40-55 percent predicted; at least monthly visits to a physician is required for care of exacerbations; or, intermittent (at least three times per year) courses of systemic (oral or parenteral) corticosteroids are required. Since this claim is one for an increase in the disability rating assigned, the primary concern is the Veteran's present level of disability. See Francisco, supra; cf. Fenderson, supra. Accordingly, the relevant timeframe for consideration is from June 2012 to the present. See 38 U.S.C. § 5110; June 2013 Letter from the Veteran. The only evidence of record during this time period bearing on the symptoms and diagnostic criteria of the Veteran's bronchial asthma is the October 2013 Respiratory Conditions VA Examination Report. The claims file lacks any other medical record or lay statements pertinent to this claim. In assessing the evidence below, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his bronchial asthma. See Barr, supra. In that regard, the Board finds his lay statements competent and credible as well. During the examination, the Veteran stated he believed his breathing had worsened since his last examination. October 2013 Respiratory Conditions VA Examination Report. He suspected the weather had something to do with his shortness of breath. He reported using inhalers daily, but denied any recent infections. The VA examiner confirmed the Veteran used a daily inhalational bronchodilator therapy as well as a daily inhalational anti-inflammatory medication. However, the VA examiner determined his condition did not require the use or oral or parenteral corticosteroids. A PFT conducted yielded the following pre-bronchodilator results; FVC of 102 percent predicted, FEV-1 of 61 percent predicted, FEV-1/FVC of 51 percent predicted, and DLCO (diffusion capacity of carbon monoxide) of 172 percent predicted. The post-bronchodilator, the results were: FVC of 121 percent predicted; FEV-1 of 84 percent predicted; FEV-1/FVC of 59 percent predicted; and no result was logged for DLCO. According to the VA examiner, the FVC results most accurately reflected his level of disability due to bronchial asthma. With the exception of the above, the VA examiner determined there were no other pertinent physical findings, complications, conditions, signs, or symptoms related to his bronchial asthma. In contemplating the above, the Board finds the preponderance of the evidence is against a disability rating in excess of 30 percent for the Veteran's bronchial asthma at any time during the pendency of this appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; see also Fagan, supra; Hart, supra. Even though the VA examiner indicated the FVC results most accurately reflected his level of disability due to bronchial asthma, neither the diagnostic criteria at the 30 percent nor 60 percent disability rating consider the FVC individually. Rather, in terms of PFT results, in order to warrant the next higher 60 percent disability rating the FEV-1 must be between 40 and 55 percent predicted, or the FEV-1/FVC must be between 40 and 55 percent predicted. In this regard, the Board acknowledges the Veteran's pre-bronchodilator FEV-1/FVC of 51 percent predicted meets the 60 percent disability rating criteria. However, 38 C.F.R. § 4.96(d)(5) mandates the use of post-bronchodilator results for rating purposes. The only exception recognized by 38 C.F.R. § 4.96(d)(5) is in the instance where the post-bronchodilator results are worse than the pre-bronchodilator results, in which case the pre-bronchodilator results are to be considered for ratings purposes. Since his post-bronchodilator results are not poorer than his pre-bronchodilator results, the Board must rate his disability based on his post-bronchodilator results. His post-bronchodilator results demonstrate FEV-1 of 84 percent predicted and FEV-1/FVC of 59 percent predicted, which are both well above the range prescribed for a 60 percent disability rating. Furthermore, there is no evidence of record showing the Veteran required at least monthly visits to a physician due to exacerbations of his bronchial asthma, or that his condition required any courses of systemic corticosteroids. The Board is mindful that during the VA examination, the Veteran's statement suggested the possibility of flare-ups due to changes in weather. However, he did not provide any further detail regarding the shortness of breath he experienced with a change in weather. Significantly, he did not discuss what type of weather affected his breathing, the frequency with which he experienced shortness of breath, nor the severity of his breathing issue during such an episode. There is no other medical or lay evidence of record to consider in this respect. For this reason, the Board finds the VA examiner's conclusion does not require further investigation. Cf. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (holding that when the record is unclear as to whether a VA examiner has considered all procurable and assembled data that might reasonably illuminate the medical analysis, the Board must remand for clarification or additional development). Again, because the evidence of record does not disclose any other symptoms associated with the Veteran's bronchial asthma, the Board finds consideration of increased evaluations under other potentially applicable DCs is not necessary. Cf. Schafrath, supra. IV. An Increased Disability Rating for an Ulcer The Veteran contends that he is entitled to an increased disability rating in excess of 10 percent for his ulcer. See June 2013 Letter from the Veteran; January 2016 VA Form 9. The applicable DC for duodenal ulcers is DC 7305. 38 C.F.R. § 4.114. Under DC 7305, a 10 percent disability rating is warranted if the symptoms are mild, recurring once or twice yearly; a 20 percent disability rating is warranted if the symptoms are moderate, with recurrent episodes of severe symptoms two or three times per year averaging 10 days in duration or continuous moderate manifestations. The words "mild," "moderate," and "severe" are not defined in by the VA's Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. Part 4, § 4.114, DC 7305. As such, rather than applying a mechanical formula, the Board must evaluate all of the evidence for an "equitable and just decision." 38 C.F.R. § 4.6. Once more, as this is a claim for an increase in the rating assigned, the primary concern is the Veteran's present level of disability. See Francisco, supra; cf. Fenderson, supra. For this reason, the relevant timeframe for consideration is from June 2012 to the present. See 38 U.S.C. § 5110; June 2013 Letter from the Veteran. The only relevant medical or lay evidence of record in this regard is the October 2013 Stomach and Duodenal Conditions VA Examination Report and October 2013 Intestinal Surgery VA Examination Report. At the time of his VA examination for stomach and duodenal conditions, the Veteran relayed that he was doing okay as long as he takes his medications and watches the food he eats. October 2013 Stomach and Duodenal Conditions VA Examination Report. However, he did report the onset of gastroesophageal reflux disease (GERD) in 2008. The VA examiner confirmed the Veteran was taking two medications for his ulcer. The VA examiner documented that he had a scar not greater than 39 square centimeters (sq. cm.) in size, which was stable and not painful following intestinal surgery in 1975 for ulcer perforation. Id.; see also October 2013 Intestinal Surgery VA Examination Report. Aside from the foregoing, the VA examiner expressly found there were no other pertinent physical findings, complications, conditions, signs or symptoms associated with his ulcer. October 2013 Stomach and Duodenal Conditions VA Examination Report. Similarly, in the October 2013 Intestinal Surgery VA Examination Report, the VA examiner recorded there were no other pertinent physical findings, complications, conditions, signs or symptoms associated with his exploratory surgery for gastric/duodenal ulcer perforation other than the scar described above. In assessing the evidence above, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his ulcer. See Barr, supra. In that regard, the Board finds his lay statements competent and credible as well. Notably, the Veteran's lay statements are consistent with the VA examiner's findings. He did not report any significant residuals other than taking medications. While he described his ulcer was well managed as long as he took his medications and maintained a proper diet, he did not describe what, if any, symptoms he experienced without medication and/or a proper diet. Although the Board acknowledges that a higher disability rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria, as noted above, there is no evidence of record bearing on the Veteran's symptoms without medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). On that account, the Board must base its decision on the available evidence. As there is no evidence demonstrating continuous moderate manifestations much less any recurrent episodes of severe symptoms at any time during the entire appeal period, the Board finds the preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran's ulcer. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304; see also Fagan, supra; Hart, supra. Given the Veteran's report of developing an issue with GERD in 2008 and the VA examiner's notation of a scar following intestinal surgery for ulcer perforation, the Board's inquiry does not end here. See Schafrath, supra. In terms of the Veteran's GERD, considering the VA examiner found there were no other pertinent physical findings, complications, conditions, signs or symptoms associated with his ulcer other than his medications and a scar, despite acknowledging his complaint of GERD, the Board infers there is no etiological relationship between his GERD and ulcer. Therefore, the Board finds the preponderance of the evidence is against a separate disability rating for GERD. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304; see also Fagan, supra; Hart, supra. With respect to the Veteran's scar, the Board notes the potentially applicable DCs are DC 7801 for burns or scars due to other causes not of the head, face, or neck, that are deep and non-linear; DC 7802 for burns or scars due to other causes not of the head, face, or neck, that are superficial and non-linear; and DC 7804 for unstable or painful scars. 38 C.F.R. § 4.118 (2017). In light of the fact the scar is not greater than 39 sq. cm., an increased disability rating under DC 7802 cannot be granted because it requires the scar cover an area of at least 929 sq. cm.. for the minimum compensable disability rating at 10 percent. Since the evidence of record demonstrates the Veteran's scar is neither unstable or painful, an increased disability rating under DC 7804 cannot be granted because there must be at least one unstable or painful scar for the minimum compensable disability rating at 10 percent. The issue of entitlement to an increased disability rating under DC 7801 is addressed in the remand portion of this decision. V. Service Connection for a Lumbar Spine Disability The Veteran contends that his diagnoses of degenerative disc disease and lumbar facet arthropathy of the lumbar spine stem from his service. See June 2013 Letter from the Veteran; January 2016 VA Form 9; see also October 2013 Back Conditions VA Examination Report (the VA examiner alternatively refers to lumbar facet arthropathy as degenerative joint disease); DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 158 (32nd ed.) (2012) (defining "arthropathy" as any joint disease); Greyzck v. West, 12 Vet. App. 288, 291 (1999) (noting that the terms "osteoarthritis," "degenerative arthritis," and "degenerative joint disease are synonymous with each other). Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R § 3.303(d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be granted on a presumptive basis for arthritis as a chronic disease in accordance with 38 C.F.R. §§ 3.303(b), 3.307(a) and 3.309(a). A chronic disease may be presumptively service connected if it is shown as such in service or within the one year presumptive period under 38 C.F.R. § 3.307(a)(3) and it manifested again thereafter; if it is shown to have manifested to a compensable degree within one year of separation from service; or, if the evidence establishes chronicity and continuity of symptomatology post-service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In weighing the evidence below, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his lumbar spine disabilities. See Barr, supra. However, he is not competent to render a medical diagnosis or opinion on such a complex medical question the etiology of his lumbar spine disabilities. See Barr, supra; Jones, supra. In that regard, the Board must rely on the medical evidence of record. At the outset, the Board notes the evidence of record establishes current disabilities of degenerative disc disease and lumbar facet arthropathy of the lumbar spine. October 2013 Back Conditions VA Examination Report. Thus, the current disability element has been met. See Shedden, supra. Furthermore, a review of the Veteran's service treatment records confirms he complained of back pain in service. According to a September 1972 Sick Call Treatment Record, he reported suffering from back pain since May after driving 6,000 miles while on vacation. Upon physical examination, the treatment provider found evidence of a very slight muscle spasm, but no joint or other abnormalities. September 1972 Sick Call Treatment Record. Therefore, while the element of an in service incurrence element has been met, there is no evidence his lumbar facet arthropathy manifested in service. See Shedden, supra; cf. 38 C.F.R. § 3.303(b). Accordingly, the Board must determine whether the Veteran's lumbar facet arthropathy manifested to a compensable degree within one year of separation from service; whether the evidence establishes chronicity and continuity of symptomatology of his lumbar facet arthropathy; or, whether there is a nexus between either of his lumbar spine disabilities and the September 1972 report of back pain in service. See 38 C.F.R. §§ 3.303(b), 3.307(a)(3); Shedden, supra. A review of the claims file shows the only relevant lay statements from the Veteran in this regard are contained in the October 2013 Back Conditions VA Examination Report. At that time, he asserted that he experienced some back pain in service, and over the years, his low back pain has come and gone. See October 2013 Back Conditions VA Examination Report. Given his statement covers a span of 39 years and the dearth of information provided by him describing the type of pain and the frequency with which it has occurred, the Board is unable to find there is sufficient evidence of chronicity and continuity of symptomatology of his lumbar facet arthropathy. 38 C.F.R. § 3.303(b); Walker, supra; see also Fagan, 573 F.3d at 1287 (holding that the benefit of the doubt doctrine is not applicable based on "pure speculation or remote possibility"). The October 2013 Back Conditions VA Examination Report is the only piece of pertinent medical evidence of record as well. Since the October 2013 VA examination occurred 38 years after the one year presumptive period, and the Veteran has provided no information specifically bearing on the manifestation of his back pain during the one year presumptive period, the Board finds there is insufficient evidence to determine whether the Veteran's lumbar facet arthropathy manifested to a compensable degree within one year of separation from service. 38 C.F.R. § 3.307(a)(3); see also Fagan, supra. In light of the above, the Board finds the preponderance of the evidence does not permit service connection on a presumptive basis as a chronic disease. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307(a)(3), 3.309(a). The only remaining avenue for direct service connection is by showing a positive nexus between either of his lumbar spine disabilities and the September 1972 report of back pain in service. In this regard, despite diagnosing the Veteran with degenerative disc disease and lumbar facet arthropathy of the lumbar spine, the VA examiner opined it was less likely than not either diagnosis was caused by or otherwise related to his service. October 2013 Back Conditions VA Examination Report. Rather, the VA examiner concluded his lumbar spine disabilities were consistent with the natural progression associated with age. The VA examiner acknowledged the Veteran's report of back pain after driving 6,000 miles while on vacation documented by the September 1972 Sick Call Treatment Record. However, the VA examiner explained that non-traumatic back pain would not cause degenerative disc disease or degenerative joint disease, and there is no record of a traumatic injury in service. In support, the VA examiner noted the treatment recommended by the September 1972 treatment provider was conservative and by the time of his separation examination, no abnormalities pertaining to the lumbar spine were found upon clinical evaluation. Id.; September 1972 Sick Call Treatment Record (the treatment provider prescribed a pain reliever and Valium, heat, and low back exercises); July 1974 Report of Medical Examination. Based on the foregoing, the Board finds the preponderance of the evidence is against direct service connection for a lumbar disability. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304; see also Fagan, supra. VI. Service Connection for a Right Knee Disability The Veteran contends that his claimed right knee disability stems from his service. See June 2013 Letter from the Veteran; January 2016 VA Form 9. Once more, in assessing the evidence, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his right knee disability. See Barr, supra. However, in this instance, the record is devoid of any statements discussing the lay observable symptoms specific to his claimed right knee disability. The only medical evidence of record pertinent to this claim is the October 2013 Knee and Lower Leg VA Examination Report. A review of the same is silent as to any statements by the Veteran bearing on his claimed right knee disability. Nonetheless, the VA examiner conducted a thorough physical examination of the right knee. In the end, the VA examiner found it was normal in all respects. While the Board acknowledges the VA examiner did not obtain an imaging study of the right knee; given the findings of the physical examination, the Board is unable to infer such testing was necessary. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Fagan, supra. Pivotal to any service connection claim is evidence establishing a current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that in the absence of proof of a current disability, there is no valid claim); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of a "current disability" is satisfied when a veteran has a disability at the time a claim for VA compensation is filed or during the pendency of that claim, even though the disability resolves prior to the adjudication of the claim). In view of the fact there is no evidence establishing a current disability, the Board finds the preponderance of the evidence does not support service connection for a right knee disability. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Fagan, supra. ORDER An initial disability rating in excess of 30 percent for insomnia is denied. An increased disability rating in excess of 20 percent for prostate cancer is denied. An increased disability rating in excess of 30 percent for bronchial asthma is denied. An increased disability rating in excess of 10 percent for an ulcer is denied. Service connection for a lumbar disability is denied. Service connection for a right knee disability is denied. REMAND I. Increased Rating for the Left Knee Disability The Veteran contends that he is entitled to an increased disability rating in excess of 20 percent for his left knee disability. See June 2013 Letter from the Veteran; January 2016 VA Form 9. In furtherance of this claim, the Veteran was afforded a VA examination in October 2013. See October 2013 Knee and Lower Leg VA Examination Report. Upon initial range of motion testing, while the VA examiner documented that he could achieve flexion of 125 degrees with evidence of painful motion beginning at the same, the VA examiner failed to record a measurement for extension despite noting there was no objective evidence of painful motion. Consequently, the October 2013 Knee and Lower Leg VA Examination Report is inadequate to adjudicate this claim, and a remand is necessary for another VA examination. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (holding that an opinion is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the disability is a fully informed one) citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). II. Compensable, Initial Disability Rating for Erectile Dysfunction The Veteran contends that he is entitled to a compensable, initial disability rating for his erectile dysfunction in addition to the SMC for loss of use of a creative organ. See November 2013 Notice of Disagreement. In this instance, the relevant DC is DC 7522. 38 C.F.R. § 4.115b. Pursuant to 7522, there is only one compensable disability rating available; a 20 percent disability rating if there is loss of erectile power with penis deformity. Since the Veteran's loss of erectile power is recognized by the grant of service connection and the loss of erectile power is not assessed in terms of degrees, the crux of the issue is whether there is a penile deformity. Unfortunately, it appears the October 2013 prostate cancer examination did not include a penile examination. See October 2013 Prostate Cancer VA Examination Report. Therefore, a remand is necessary to obtain a VA examination. III. Separate, Increased Disability Rating for Scar As noted above, the October 2013 Stomach and Duodenal Conditions VA Examination Report and October 2013 Intestinal Surgery VA Examination Report documented the Veteran had a scar not greater than 39 sq. cm. in size following intestinal surgery for ulcer perforation. For an increased disability rating under DC 7801, the scar must cover an area of at least 39 sq. cm. for the minimum compensable disability rating at 10 percent. As such, neither the October 2013 Stomach and Duodenal Conditions VA Examination Report nor October 2013 Intestinal Surgery VA Examination Report is adequate to adjudicate this issue. Thus, a remand is necessary to obtain a VA examination. III. Entitlement to TDIU The Board finds a claim for TDIU has been reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 454-55 (2009) (holding that a claim for TDIU due to service-connected disability(ies) is part and parcel of every initial rating claim). As such, a remand is necessary to give the RO an opportunity to provide the requisite notice under the Veteran's Claims Assistance Act of 2000 (VCAA) and to undertake all evidentiary development necessary to substantiate a claim for TDIU. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the current nature and severity of his left knee disability. 2. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the current nature and severity of his erectile dysfunction. 3. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the current nature and severity of his scar from intestinal surgery for ulcer perforation. 4. Develop the Veteran's claim for TDIU, to include providing him with appropriate notice in accordance with the VCAA; requesting that he submit a completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability; and, if necessary, obtaining a VA examination with an appropriate medical professional to determine the occupational impairment resulting from the combination of his service-connected disabilities in terms of his ability to engage in both physical and sedentary employment. 5. Once each of the above requests has been completed to the extent possible, readjudicate the appeal. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ L.M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs