Citation Nr: 18147168 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 15-00 052 DATE: November 5, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for left ear hearing loss is denied. Entitlement to service connection for a gastrointestinal (GI) disorder to include a functional GI disorder or other qualifying chronic disorder associated with Persian Gulf service, is denied. Entitlement to service connection for a disorder manifested by fatigue, to include chronic fatigue syndrome or other qualifying chronic disorder associated with Persian Gulf service, is denied. Entitlement to service connection for a disorder manifested by multi-joint and muscle pain, to include fibromyalgia or other qualifying chronic disorder associated with Persian Gulf service, is denied. Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a neurological disorder of the bilateral lower extremities, to include a qualifying chronic disorder associated with Persian Gulf service, is denied. Entitlement to service connection for a bilateral knee disorder, to include a qualifying chronic disorder associated with Persian Gulf service, is denied. A disability rating in excess of 0 percent for right ear hearing loss is denied. A disability rating in excess of 10 percent for a right bunionectomy residuals is denied. A disability rating of 30 percent, but not higher, for headaches is granted. Eligibility for hospital and medical treatment for a psychiatric/mental disorder under 38 U.S.C. § 1702 is denied. FINDINGS OF FACT 1. An acquired psychiatric disorder is not related to service. 2. Sleep apnea is not related to service. 3. The Veteran does not have disabling left ear hearing loss for VA purposes. 4. A GI disorder is not related to service. 5. A disorder manifested by fatigue is not related to service. 6. A disorder manifested by multi-joint and muscle pain is not related to service. 7. A low back disorder is not related to service. 8. A neurological disorder of the bilateral lower extremities is not related to service. 9. A bilateral knee disorder is not related to service. 10. The service-connected right ear hearing loss has been manifested by hearing acuity of level I. 11. The service-connected right bunionectomy residuals have been manifested by moderate hallux valgus with pain and burning. 12. The service-connected headaches have been manifested by characteristic prostrating attacks occurring on an average once a month over last several months. 13. The Veteran does not have a psychiatric/mental pertinent to the claim on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.317, 4.125 (2017). 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017). 4. The criteria for service connection for a GI disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.317, 4.125 (2017). 5. The criteria for service connection for a disorder manifested by fatigue have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 6. The criteria for service connection for a disorder manifested by multi-joint and muscle pain have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317, 4.125 (2017). 7. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 8. The criteria for service connection for a neurological disorder of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 9. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.317, 4.125 (2017). 10. The criteria for a disability rating higher than 0 for right ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.85, Diagnostic Code 6100 (2017). 11. The criteria for a disability rating higher than 0 for right bunionectomy residuals have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2017). 12. The criteria for a disability rating of 30 percent for headaches have been met; the criteria for a rating higher than 30 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2017). 13. The criteria for eligibility for treatment pursuant to the provisions of 38 U.S.C. § 1702 have not been met. 38U.S.C. §§ 1702, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 17.109 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had qualifying (honorable) periods of active duty service from September 1986 to February 1990; from January 31, 1991, to February 21, 1991; and from June 1993 to September 1998. He also has a non-qualifying period of service from February 1999 to December 2000. This appeal comes before the Board of Veterans’ Appeals (Board) from May 2012 and August 2012 rating decisions of the RO in St. Petersburg, Florida. In October 2010, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge, and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e) (2017). At the Board hearing, the Veteran was informed of the basis for the RO’s denial of his claims, and he was informed of the information and evidence necessary to substantiate each claim. The Veteran testified at the Board hearing that his service-connected disabilities had worsened. The record was held open for an additional 30 days following the hearing so that the Veteran could submit additional evidence regarding the worsening of his service-connected disabilities, and in support of his service connection claims. 38 C.F.R. § 3.103 (2017). A transcript of the hearing is associated with the claims file. The Board has considered whether a claim of entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is a component of the rating claims on appeal in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the claims on appeal were specifically addressed at the Board hearing. The Veteran did not assert that his service-connected disabilities rendered him unemployable, and he indicated that he was employed. The Veteran submitted additional medical evidence after the most recent Statement of the Case. A recent amendment to governing law (38 U.S.C. § 7105) stipulates that, with respect to claims for which a substantive appeal is filed on or after the date that is 180 days after the Aug. 6, 2012, date of the enactment of the amendment, i.e., February 2, 2013, such evidence shall be subject to initial review by the Board unless the claimant or the claimant’s representative, as the case may be, requests in writing that the agency of original jurisdiction initially review such evidence. As the current appeal was perfected by a substantive appeal received in November 2014, the Board will consider this evidence in the first instance. Service Connection VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). For specific enumerated diseases designated as “chronic” there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The presumptive chronic diseases include arthritis, other organic diseases of the nervous system (hearing loss), psychoses, and peptic ulcers, but do not includes non-psychotic mental diseases or GERD. The Veteran in this case served in the Persian Gulf during the Gulf War. Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a “qualifying chronic disability” that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. To constitute a “qualifying” chronic disability, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term “objective indications of chronic disability” includes both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(3). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, menstrual disorders. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(b). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): undiagnosed illness; the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: chronic fatigue syndrome; fibromyalgia; functional gastrointestinal disorders (excluding structural gastrointestinal diseases). See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2)(i). The term medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability shall be considered service connected for purposes of all laws of the United States. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(4). The presumptive period ends December 31, 2021. Compensation shall not be paid if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(c). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Entitlement to service connection for an acquired psychiatric/mental disorder. Entitlement to service connection for sleep apnea. Entitlement to service connection for left ear hearing loss. Entitlement to service connection for a GI disorder. Entitlement to service connection for a disorder manifested by fatigue. Entitlement to service connection for a disorder manifested by multi-joint and muscle pain. Entitlement to service connection for a low back disorder. Entitlement to service connection for a neurological disorder of the bilateral lower extremities. Entitlement to service connection for a bilateral knee disorder. Service treatment records reveal that, with the exception of an episode of shin splints in May 1987 (Record 10/03/2014 at 24), and a bunion of the right great toe in February 1989 (Record 10/03/2014 at 16), there are no complaints, treatments, or diagnoses pertinent to the claimed musculoskeletal or neurological disorders during service. There is certainly no record of specific injuries to the knees or low back. While the Veteran was treated for various other complaints, there was no finding of GERD, sleep apnea, psychiatric illness, chronic fatigue syndrome, or fibromyalgia. A report of medical examination performed on November 17, 1998, which is effectively the service separation examination, given that the service period from February 17, 1999, to December 14, 2000, is not qualifying for VA purposes, reveals normal clinical findings for the GI system, psychiatric, and lower extremities (Record 10/03/2014 at 42). A report of medical history completed by the Veteran on the same date reveals the Veteran’s account that he had no history of, or current, depression or excessive worry; nervous trouble of any sort; frequent trouble sleeping; neuritis; trick or locked knee; bone or joint deformity; arthritis; stomach, liver, or intestinal trouble; frequent indigestion; shortness of breath; or swollen or painful joints. He reported a history of throat trouble, but specified tonsils as a child, and made no mention of sleep apnea (Record 10/03/2014 at 44). The Veteran was separated from qualifying service on September 14, 1998. After service, a PTSD screen on May 30, 2011, was negative. The examiner noted that the Veteran had not reported a traumatic experience (Record 05/09/2012). Correspondence dated November 21, 2011, from A. Saifi, MD, states that the Veteran had been under his care since 2008 for evaluation and follow-up on injuries sustained while in the service from 1986-1999. He stated that the Veteran had low back pain radiating to his lower extremities. Dr. Saifi noted gastrointestinal symptoms, namely GERD; an anxious mood; depression; frequent flashbacks of his war events and experiences; sleep impairment with snoring; fatigue; and headaches, which “can be” due-to his sleep pathology (Record 12/02/2011). The Veteran’s spouse submitted a statement in February 2012 attesting to having witnessed loud snoring when he is sleeping, as well as flashbacks of the war (Record 02/09/2012). The report of a February 2012 VA Esophageal Examination reveals a diagnosis of GERD with associated symptoms of pyrosis (heartburn) and sleep disturbance. (Record 02/16/2012 at 6). The examiner opined that it is less likely than not that the Veteran’s current acid reflux is related to his military service. The rationale was that symptoms in service do not show chronicity. He also has other risk factors for these conditions, and his current complaints of lactose intolerance probably developed later in life after leaving service (Record 02/16/2012 at 60). The report of a February 2012 VA Muscles Examination reveals complaint of back pain with radiation into the lower extremities. However, the examination was normal (Record 02/16/2012 at 12). The report of a February 2012 VA Chronic Fatigue Syndrome Examination reveals a finding that the criteria for chronic fatigue syndrome were not met (Record 02/16/2012 at 15). The examiner also opined that the Veteran does not meet the criteria for fibromyalgia, and that his symptoms of fatigue and joint pain are possibly related to his anxiety/depression (Record 02/16/2012 at 59). The report of a February 2012 VA Knee and Lower Extremity Examination reveals a diagnosis of chondromalacia of the bilateral lower extremities (Record 02/16/2012 at 18). The report of a February 2012 VA Spine Examination reveals a diagnosis of arthritis. The Veteran reported that he started having gradual back pain onset in the last tour of duty (Record 02/16/2012 at 39). The examiner opined that the Veteran’s back disability was not related to service or to his service-connected right foot. The examiner reasoned that service records fail to show back complaints. He has a service-connected a right foot condition, but his gait is normal. He has been a surgical tech with the VA for approximately 10 years. This job requires long hours of standing and repetitive heavy lifting. This is likely the cause of his back condition. The examiner also opined that the Veteran’s right leg neurological complaints were less likely as not related to his right foot disability. The examiner reasoned that the service records show one entry for shin splints, and there is no other mention. The examiner opined that the Veteran’s symptoms down the lateral thigh seem most likely to be sciatic pain from his lumbar spine arthritis. There is also no obvious connection with this complaint and his service-connected status post right bunionectomy. His gait is normal. His shoe wear pattern is also normal. His bilateral knees clinically have chondromalacia. The service records have no knee complaints (Record 02/16/2012 at 58). The report of a February 2012 VA Gulf War Examination reveals that, other than the DBQs specifically completed, the Veteran had no signs or symptoms affecting his ability to work or that may represent an undiagnosed illness or diagnosed medically unexplained chronic multi-symptom illness. The examiner opined that sleep disturbance was related to sleep apnea and acid reflux and possibly anxiety. Fatigue was related to anxiety and depression. The examiner also found that there was no undiagnosed illness. All medical conditions were common conditions with known or studied causes and were less likely than not to have been caused by exposure to environmental hazards in Southwest Asia (Record 02/16/2012 at 51). The report of a February 2012 VA Audiology Examination reveals pure tone thresholds as follows: HERTZ 500 1000 2000 3000 4000 LEFT 15 20 20 15 35 (Record 02/29/2012). The report of a July 2012 VA Mental Disorders Examination reveals the Veteran’s account of a stressor as witnessing the aftermath of the war in Kuwait and cleaning up mines. He denied sustaining any injury. The examiner found this stressor inadequate to support a PTSD diagnosis. The examiner found that the stressor was not related to the Veteran’s fear of hostile military or terrorist activity. The examiner reasoned that the Veteran was not deployed at the time of ground action in Kuwait, but was deployed 4-6 months after the cessation of hostilities. A second stressor was related to physical and emotional abuse by the Veteran’s father was found not related to service as it occurred prior to service. The examiner opined that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD. The examiner opined that the Veteran’s depression and anxiety were within the realm of normal experience. The only diagnosis rendered was a breathing related sleep disorder. The examiner found that no other psychiatric/mental diagnoses were appropriate (Record 07/28/2012). A November 13, 2012, unidentified nexus statement provides diagnoses of joint/muscle pain; degenerative disc disease of spine; right lower extremity neuropathy; sleep apnea/insomnia; and GERD/tremors. A hand-written statement on the otherwise pre-printed form states: “Patient was involved in very strenuous/physical activities during his service and these activities resulted in muscle/bone/nerve injuries to various degrees” (Record 10/05/2012). In January 15, 2013, correspondence, Dr. Saifi stated the Veteran’s headaches were more frequent (several hours a week), lasting longer and were more severe. According to the Veteran, he is unable to perform work during these episodes. The headaches were also requiring medication for relief (Record 02/05/2013). In correspondence dated November 11, 2014, Dr. Saifi, stated that the Veteran had been evaluated for injuries sustained while in the service. He suffers from low back pain radiating to the legs and feet due to a bulging disc and radiculopathy, this pain has been progressively worsening, causing significant discomfort and debility. The patient’s numbness has been worsening and interfering with his driving and ambulation. The patient has been having more gastrointestinal symptoms and has been on medication maintenance. As far as his mood is concerned, he is apparently depressed, very anxious, and reports frequent flashbacks causing emotional disturbance, and interfering with his daily activities (posttraumatic stress disorder). Sleep issues and disturbance have been documented. The patient currently suffers from obstructive sleep apnea which is causing fatigue and hypersomnolence. His headaches have been more persistent due to his psychological and medical conditions. After reviewing all his medical record, it is my professional opinion that the Veterans conditions named above are more likely than not related to the trauma experienced during his military service (Record 11/20/2014). After a review of all of the evidence, the Board finds that there were no injuries or diseases in service specific to any of the claimed disorders. The Board also finds that a preponderance of the evidence is against any relationship between the claimed disorders and service. Regarding the presumptive chronic diseases, the Veteran does not have a psychosis or a peptic ulcer. While he does have a diagnosis consistent with sensorineural hearing loss, as will be discussed below, such has not become manifest to a degree of 10 percent or more at any time after service. While the Veteran has arthritis of the lumbar spine, such did not become manifest to a degree of 10 percent or more within 1 year of separation from qualifying active duty. Accordingly, those presumptions do not apply. Regarding the Gulf War provisions, the Veteran does not have chronic fatigue syndrome, fibromyalgia, a functional GI disorder, or other qualifying chronic disorder associated with Persian Gulf service. The February 2012 VA examinations provide persuasive evidence that the criteria for chronic fatigue syndrome, fibromyalgia, and functional GI disorders have not been met; and, that the Veteran’s signs and symptoms can be attributed to known clinical diagnoses. Accordingly, the Gulf War provisions are not for application. The Board finds that there is also no left ear hearing loss for VA purposes, and there is no current psychiatric diagnosis, to include PTSD. The Veteran’s hearing acuity does not meet the criteria established for a hearing loss disability under VA law. See 38 C.F.R. § 3.385. The Board also finds the July 2012 VA examiner’s opinion to be persuasive evidence that a current psychiatric diagnosis is not appropriate. While the evidence substantiates current diagnoses of GERD, lower extremity radiculopathy, chondromalacia, and sleep apnea, the Board finds that these disorders are not related to service. The Veteran’s radiculopathy is related to a nonservice-connected low back disability. The Board notes that the November 2011 opinion of Dr. Saifi, can be read as purporting to relate low back pain to “injuries sustained while in the service,” however, this is far from clear from the wording of the opinion. Also significant, a vague reference to injuries in service is unconvincing where those injuries are not identified in the reference, and where such injuries are not reflected in the service record. The Board has reviewed the service treatment records, and finds no complaint of, treatment for, or diagnosis of, a back injury of any description. Moreover, this is not simply an absence of treatment records; the Veteran’s spine was examined and found to be clinically normal at service separation; and, the Veteran specifically denied any history of, or current recurrent back pain. This is probative evidence against an injury or disease of the low back occurring in service. In comparison to these specific contemporaneous findings and statements, Dr. Saifi’s vague and unexplained description of injuries in service is unpersuasive, as it appears to be based on an inaccurate knowledge and understanding of the evidence. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). The same is true of Dr. Saifi’s November 2014 statement. Again, he relies on a vague and unsubstantiated reference to injuries or “the trauma” experienced in service, without identifying a specific injury, and without explaining how such injury caused or contributed to cause a current disability. Equally vague is the November 13, 2012, unidentified nexus statement, which simply states that the Veteran was involved in very strenuous/physical activities during his service and these activities resulted in muscle/bone/nerve injuries to various degrees. There is no identification of the injuries and no explanation of the causal mechanism. As with the statement of Dr. Saifi, this statement is not consistent with the service treatment records, and is not consistent with the findings of the medical examination at service separation, or with the Veteran’s concurrent report of medical history. To the extent the injuries described by these providers come directly from the Veteran’s statements, the Board must weigh those statements against his statements at the time of service separation. The Board notes that a description of an event which is closer to the time that event allegedly occurred is naturally less likely to be affected by errors in memory. See Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (noting that, notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Thus, the contemporaneous nature of the statement of medical history at discharge is significant. Furthermore, because that account was presented in the context of routine medical evaluation, it seems likely that he would report events carefully and accurately. The “medical diagnosis or treatment” exception to the hearsay rule (Fed. R. Evid. 803) provides that “statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care.” Recourse to the Federal Rules of Evidence is appropriate where they will assist in articulation of the Board of Veterans’ Appeals’ reasons. Rucker v. Brown, 10 Vet. App. 67 (1997). In contrast to the Veteran’s account at service separation, when the Veteran thereafter presented his account to treatment providers, it was in the context of a claim for VA benefits. The Board is of course cognizant of possible self-interest which any veteran has in promoting a claim for monetary benefits. While the Board must consider all competent lay assertions, in determining the credibility of such assertions, the Board may properly consider the personal interest a claimant has in his or her own case. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). There is no question that the Veteran is competent to relate lay-observable events as he remembers them. Thus, his competency is not at issue with regard to recounting injuries in service. Rather, it is the credibility of the Veteran’s recent account which the Board finds is lacking. Simply put, the report of medical history at separation from service is more convincing than the Veteran's later conflicting statements made in support of a claim for monetary benefits. Regarding the Veteran’s claimed GERD, the Board finds that the February 2012 opinion is persuasive evidence against any relationship between currently diagnosed GERD and service. This opinion is consistent with significant evidence, including the service treatment records, which reflect normal clinical findings for the digestive system, and which include the Veteran’s denial of any history of, or current, stomach problems or frequent indigestion. While Dr. Saifi appears to endorse a diagnosis of PTSD in his November 2014, he identified his specialty as internal medicine. It is unclear what expertise he has in psychiatric diagnoses. He certainly did not claim any. Moreover, he provided no discussion for the basis of this finding, and the Board accords it lesser probative weight in comparison to the better-explained VA Mental Disorders Examination. While the Veteran has related his back and knee disorders to his foot disability, on a secondary service connection basis, there is no support for this theory in the clinical evidence. Dr. Saifi, did not address this theory of etiology, but related the back disorder to unidentified injuries and trauma in service. Thus, the only evidence in support of this theory comes from the Veteran’s lay observations. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). The Board finds that establishing a relationship of secondary causation or aggravation of a back disability by a foot disability is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized medical knowledge, and is not capable of lay observation. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between the claimed back disability or other musculoskeletal disabilities and the service-connected foot disability. In addition, relating disorders such as sleep apnea and GERD to service also requires medical knowledge and is not subject to lay observation. While lay evidence may be competent to identify symptoms, such as snoring or abdominal pain, medical evidence is required to establish a diagnosis of sleep apnea and/or GERD, and to establish the timeframe of onset and causes. In sum, the Board finds that there is no current fibromyalgia, chronic fatigue syndrome, functional GI disorder, osteomyelitis, left hearing loss for VA purposes, or acquired psychiatric disorder. Moreover, there is no undiagnosed Persian Gulf War illness. The Board also finds that GERD, chondromalacia, lower extremity radiculopathy, and sleep apnea are not related to service and are not related by causation or aggravation to any service-connected disability. In light of these findings, the Board concludes that service connection for the claimed disorders is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Increased Rating Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Entitlement to a disability rating in excess of 0 percent for right ear hearing loss. In a May 2012 rating decision, VA granted service connection for right ear hearing loss and assigned an initial disability rating of 0 percent under Diagnostic Code 6100, effective February 16, 2012. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenman v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes 11 auditory hearing acuity levels based on average pure tone thresholds and speech discrimination. See 38 C.F.R. §§ 4.85. The report of a February 2012 VA Audiology Examination reveals pure tone thresholds as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 10 15 20 70 29 Speech recognition ability was 92 percent in the right. Applying these values to Table VI results in level I in the right ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating (Record 02/29/2012). The Veteran testified that he experiences difficulty hearing his wife and he has to raise the volume on the TV (Record 10/10/2017 at 17). After a review of all of the evidence, the Board finds that the criteria for a compensable disability rating for right ear hearing loss have not been met. The Veteran’s right ear hearing loss has been manifested by reduced auditory acuity and speech recognition, which impair the Veteran’s ability to communicate and to understand speech. However, the degree of impairment in this case is not compensable under VA law. In light of these findings, the Board concludes that the increased rating sought on appeal is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). See also Martinak v. Nicholson, 21 Vet. App. 447 (2007). Entitlement to a disability rating in excess of 10 percent for a right great toe disorder. In a May 1990 rating decision, VA granted service connection for right bunionectomy residuals and assigned an initial disability rating of 10 percent under Diagnostic Code 5280, effective February 9, 1990. In an April 2005 rating decision, the diagnostic code was changed to 5280-5284. However, the rating was not changed. Under Diagnostic Code 5280, hallux valgus is assigned a 10 percent rating if operated with resection of metatarsal head; or, if severe, equivalent to amputation of great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280. Under Diagnostic Code 5284, foot injuries are to be rated at 30 percent if severe; 20 percent if moderately severe; and 10 percent if moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The report of a February 2012 VA Foot Examination reveals complaint of constant pain, throbbing, and burning sensation. The examiner assessed mild or moderate symptoms of hallux valgus. The effect on employment was that the condition causes pain with prolonged standing and walking (Record 02/16/2012 at 30). After a review of all of the evidence, the Board finds that the criteria for a disability rating in excess of 10 percent for the Veteran’s bunionectomy residuals have not been met. The current residuals from the Veteran’s bunionectomy consist of hallux valgus, which associated pain and burning. Under Diagnostic Code 5280, 10 percent is the maximum rating contemplated for hallux valgus. The Board has considered whether a rating under any other diagnostic code is appropriate. However, as the only diagnosed condition is hallux valgus, and as the rating schedule provides a specific diagnostic code for that condition, the Board finds that application of other diagnostic codes is not appropriate. When a condition is specifically listed in the rating schedule, it may not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2016) (rejecting the appellant’s contention that to rate under Diagnostic Code 5284 for “Foot injuries, other,” would not be rating by analogy as, to do so would ignore the plain meaning of the term “other,” and would make the remaining eight foot-related diagnostic codes redundant), citing Suttmann v. Brown, 5 Vet. App. 127, 134 (1993) (providing that “[a]n analogous rating...may be assigned only where the service-connected condition is ‘unlisted’”). Specifically, the Board finds that application of Diagnostic Code 5284 (foot injuries, other) is not appropriate, as that code is only applicable to foot injuries that are not otherwise rated under the rating schedule. In sum, the Board finds that the Veteran’s bunionectomy residuals are manifested by hallux valgus, resulting in foot pain and discomfort. As 10 percent is the maximum rating contemplated for this condition, to include severe symptoms equivalent to amputation of the great toe, the Board concludes that the increased rating sought on appeal is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to a disability rating in excess of 0 percent for headaches. The current appeal arises from a claim of entitlement to service connection for headaches received at VA on August 15, 2011. In a May 2012 rating decision, VA granted service connection for right ear hearing loss and assigned an initial disability rating of 0 percent under Diagnostic Code 8100, effective August 15, 2011. Under Diagnostic Code 8100, migraine headaches are assigned a rating of 50 percent with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over last several months. A 10 percent rating is assigned with characteristic prostrating attacks averaging one in 2 months over last several months. A rating of 0 percent is assigned with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The criteria set forth in Diagnostic Code 8100 are both successive and conjunctive. Thus, to satisfy the criteria for a higher level, a claimant must satisfy all the requirements of the lower levels (successive); and, must show each element listed for the particular rating to be assigned (conjunctive). See Johnson v. Wilkie, No. 13-3808, 2018 U.S. App. Vet. Claims LEXIS 1253 (2018). Further, because Diagnostic Code 8100 contains successive rating criteria, 38 C.F.R. § 4.7 (a higher rating should be assigned where the disability “more nearly approximates” the criteria for the higher rating) and 38 C.F.R. § 4.21 ( all elements of a specific rating need not necessarily be found) are not applicable to Diagnostic Code 8100. The report of a February 2012 VA Headaches Examination reveals a diagnosis of tension headaches. The Veteran reported having headaches 4 times per week, which last from 30 to 60 minutes. He denied migraine symptoms. Symptoms included pain on both sides of the head, pain which worsens with physical activity, and pulsating or throbbing pain. No prostrating attacks were reported. The impact on work was characterized as a mild decreased concentration (Record 02/16/2012 at 1). In January 15, 2013, correspondence, Dr. Saifi stated the Veteran’s headaches were more frequent (several hours a week), lasting longer and were more severe. According to the Veteran, he is unable to perform work during these episodes. The headaches were also requiring medication for relief (Record 02/05/2013). The Veteran testified at the Board hearing that he experiences prostrating attacks about twice per month where he must take to bed for relief (Record 10/10/2017 at 11). After a review of all of the evidence, the Board finds that the criteria for a rating of 30 percent have been met; however, the criteria for a rating of 50 percent have not been met. There is no question that the symptoms reported on the VA examination do not satisfy the criteria for even a compensable rating. Neither do the symptoms reported by Dr. Saifi. However, the Veteran’s testimony at the Board hearing establishes that he has periods occurring roughly twice per month which require him to resort to bedrest. The Board finds that this symptomatology reasonably meets the definition of a characteristic prostrating attack, thus satisfying the criteria for a rating of 30 percent. However, the Board further finds that the criteria for a rating of 50 percent have not been met. These require attacks that are (1) very frequent, (2) completely prostrating, (3) and prolonged, as well as (4) severe economic inadaptability. Each of the criteria must be met in order establish entitlement. Moreover, 38 C.F.R. §§ 4.21, 4.7 do not apply. In this case, even the Veteran’s description does not establish prolonged attacks, nor does it establish severe economic inadaptability. The Veteran has testified that the headaches generally do not interrupt his flow of work, and that when he experiences non-prostrating headaches, they are not so severe to prevent operating a vehicle. Moreover, he testified that he is currently employed. In sum, the Board finds that the Veteran’s headaches have been manifested by characteristic prostrating attacks occurring on an average once a month over last several months, but have not been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In light of these findings, the Board concludes that a higher rating of 30 percent is warranted. To the extent any rating in excess of 30 percent is sought, the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). VA Medical Care Eligibility for hospital and medical treatment for a psychiatric/mental disorder under 38 U.S.C. § 1702. Under 38 U.S.C. § 1702(a), any veteran of the Persian Gulf War who developed an active psychosis (1) within two years after discharge or release from the active military, naval, or air service, and (2) before the end of the two-year period beginning on the last day of the Persian Gulf War, shall be deemed to have incurred such disability in the active military, naval, or air service, for the purposes of eligibility to Chapter 17 benefits. 38 U.S.C. § 1702. In addition, under 38 U.S.C. § 1702 (b), any veteran of the Persian Gulf War who develops an active mental illness (other than psychosis) shall be deemed to have incurred such disability in the active military, naval or air service if the disability develops (1) within two years after discharge or release from active service, and (2) before the end of the two-year period beginning on the last day of the Persian Gulf War. 38 U.S.C. § 1702(c) specifies that there is no minimum length of active-duty service required for presumptive eligibility for psychosis and mental illness under this section. Here, as discussed above, the Veteran has not been diagnosed with a psychosis or other mental disorder at any time pertinent to the appeal. Accordingly the Board concludes that entitlement to hospital and medical treatment for psychiatric/mental disorders under 38 U.S.C. § 1702 is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Cramp