Citation Nr: 18149010 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-24 390 DATE: November 8, 2018 ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for erectile dysfunction (ED) is denied. Entitlement to an initial compensable disability rating for a service-connected lumbar spine disorder for the period prior to May 3, 2016, is denied. Entitlement to an initial disability rating in excess of 10 percent for a service-connected lumbar spine disorder for the period from May 3, 2016, is denied. Entitlement to an initial disability rating in excess of 10 percent for a service-connected left knee condition is denied. Entitlement to an initial compensable disability rating for a service-connected right ankle disability for the period prior to May 3, 2016, is denied. Entitlement to an initial disability rating in excess of 10 percent for a service-connected right ankle disability for the period from May 3, 2016, is denied. Entitlement to an initial disability rating of 10 percent, but no higher, for service-connected GERD is granted. Entitlement to an initial disability rating of 10 percent, but no higher, for service-connected migraine headaches is granted. Entitlement to an initial disability rating in excess of 10 percent for a service-connected acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) (hereafter referred to simply as an “acquired psychiatric disorder”), for the period prior to April 7, 2016, is denied. Entitlement to an initial disability rating in excess of 30 percent for a service-connected acquired psychiatric disorder for the period from April 7, 2016, is denied. FINDINGS OF FACT 1. The evidence of record shows that the Veteran has not, nor has had at any time during the appeal period, a current diagnosis of sleep apnea. 2. The evidence of record shows that the Veteran’s ED is neither proximately due to nor aggravated beyond its natural progression by his service-connected acquired psychiatric disorder, and is not otherwise related to an in-service injury, event, or disease. 3. Prior to May 3, 2016, the evidence of record shows that the Veteran’s lumbar spine disorder did not result in any limitation of motion. 4. From May 3, 2016, the evidence of record shows that the Veteran’s lumbar spine disorder resulted in flexion limited to 70 degrees. 5. The evidence of record shows that the Veteran’s service-connected left knee condition does not result in limitation of flexion to 30 degrees or less or a limitation of extension to 15 degrees or greater. 6. Prior to May 3, 2016, the evidence of record shows that the Veteran’s right ankle disability did not result in a moderate degree of limitation of motion. 7. From May 3, 2016, the evidence of record shows that the Veteran’s right ankle disability did not result in a marked degree of limitation of motion. 8. The evidence of record shows that the Veteran’s service-connected GERD results in pyrosis and regurgitation. 9. The evidence of record shows that the Veteran’s service-connected migraine headaches result in characteristic prostrating attacks averaging one in 2 months over the last several months. 10. Prior to April 7, 2016, the evidence of record shows that the Veteran’s service-connected acquired psychiatric disorder resulted in occupational and social impairment due to mild or transient symptoms. 11. From April 7, 2016, the evidence of record shows that the Veteran’s service-connected acquired psychiatric disorder results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for ED are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for an initial compensable disability rating for a service-connected lumbar spine disorder have not been met for the period prior to May 3, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5237. 4. The criteria for an initial disability rating in excess of 10 percent for a service-connected lumbar spine disorder have not been met for the period from May 3, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5237. 5. The criteria for an initial disability rating excess of 10 percent for a service-connected left knee condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260-5024. 6. The criteria for an initial compensable disability rating for a service-connected right ankle disability have not been met for the period prior to May 3, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5271-5024. 7. The criteria for an initial disability rating in excess of 10 percent for a service-connected right ankle disability have not been met for the period from May 3, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5271-5024. 8. The criteria for an initial disability rating of 10 percent for service-connected GERD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7399-7346. 9. The criteria for an initial disability rating of 10 percent for service-connected migraine headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100. 10. The criteria for an initial disability rating in excess of 10 percent for a service-connected acquired psychiatric disorder have not been met for the period prior to April 7, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. 11. The criteria for an initial disability rating in excess of 30 percent for a service-connected acquired psychiatric disorder have not been met for the period from April 7, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from May 2010 to May 2015. This case is on appeal before the Board of Veterans’ Appeals (Board) from August 2015, March 2016, and July 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. A review of the record indicates that additional medical evidence was added subsequent to the October 2016 Statement of the Case (SOC). Although this evidence was submitted without wavier of RO consideration, the evidence provided is duplicative of information previously considered. As such, no further action is required. Neither the Veteran nor his representative has raised any specific issues with the duty to notify or the duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence of record, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154(a); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran seeks service connection for sleep apnea and ED. However, the weight of the evidence is against the finding of a current disability of sleep apnea. Similarly, there is nothing in the claims file to show a link between the Veteran’s ED and another service-connected condition. Thus, those appeals are denied. The Veteran also seeks increased disability ratings for a service-connected lumbar spine disorder, a left knee condition, a right ankle disability, GERD, migraine headaches, and an acquired psychiatric disorder. He alleges that all of these conditions have worsened during the appeal period. The evidence of record supports the assignment of compensable ratings for the Veteran’s service-connected GERD and migraine headaches. Thus, those appears are granted. However, the rest of his claims are inconsistent with the evidence of record. As such, those appeals are denied. Service Connection The Veteran seeks service connection for sleep apnea and erectile dysfunction (ED), both of which he asserts are related to active service or other service-connected conditions. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Regulations provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Barr v. Nicholson, 21 Vet. App. 303 (2007); Pond v. West, 12 Vet. App. 341, 346 (1999). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). I. Sleep Apnea The Veteran contends that his sleep apnea is related to service or, alternatively, is secondary to his PTSD. See July 2016 correspondence. The Veteran’s service treatment records do not contain a diagnosis of sleep apnea. They are similarly devoid of complaints related to sleeping difficulties. In July 2015, the Veteran was afforded a VA examination in connection with his PTSD claim. The Veteran reported experiencing nightmares about once per week and stated that he had difficulty maintaining sleep at night. In February 2016, the Veteran underwent a VA examination in connection with his erectile dysfunction claim. The Veteran endorsed poor sleeping, claiming to only sleep about 4 hours per night. The examiner noted that the Veteran had never undergone a sleep study or had blood work done. The examiner also cited the Veteran’s alcohol use, poor sleep, over-30 body mass index (BMI), short stature, and enlarged neck as being risk factors for sleep apnea, but declined to make a diagnosis. The Veteran was afforded a second VA examination for his PTSD claim in April 2016. The Veteran reported sleeping 3 to 4 hours per night, and the examiner noted chronic sleep impairment as a symptom of PTSD. In December 2016, S.B., a former soldier who served with the Veteran in Afghanistan, submitted a letter in which he stated that he and the Veteran shared close sleeping quarters during their tour of duty. S.B. indicated that their sleep was often broken up, making it difficult to acquire a sleeping routine. He went on to say that the Veteran would snore loudly, keeping S.B. and their bunkmates awake. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the finding that the Veteran has a current disability of sleep apnea. The Board notes that the Veteran has never been diagnosed with sleep apnea, nor has he undergone a sleep study. Although the Board acknowledges the statements of the Veteran and S.B., both of whom allege that the Veteran has suffered from sleep apnea since service, these are not sufficient to establish the existence of a current disability. While lay witnesses are competent to provide evidence regarding matters that can be perceived by the senses, such as snoring loudly or getting 3 to 4 hours of sleep per night, they are not competent to diagnose a sleep disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, there is no competent medical evidence in the claims file to support a diagnosis of sleep apnea. The Board recognizes that the record contains numerous references to a chronic sleep impairment. However, sleep apnea is a respiratory disorder characterized by specific diagnostic criteria. Here, the evidence of record indicates that the Veteran’s sleep impairment is a symptom of his service-connected acquired psychiatric disorder. Accordingly, any resulting functional limitations are considered in the rating criteria for the Veteran’s acquired psychiatric disorder, which are discussed in greater detail below. The presence of a current disability is a threshold requirement in both the primary and secondary service connection analyses. Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512 (1998). Additionally, the burden of proof is on the Veteran to substantiate every element of his claim. Madden v. Gober, 125 F.3d 1477, 1480-81 (Fed. Cir. 1997). Here, the Veteran’s failure to establish the existence of sleep apnea with competent medical evidence precludes the claim from going forward. Thus, the appeal is denied. II. Erectile Dysfunction The Veteran alleges that his ED is secondary to his PTSD and alcohol use. See March 2015 correspondence; see also February 2016 VA examination. The Veteran’s service treatment records are absent for complaints of ED. The Veteran was afforded a VA examination in February 2016. The Veteran reported first noticing that he had difficulty maintaining an erection 2 years prior, and expressed the opinion that it could be related to his alcohol use. The Veteran also endorsed poor sleep habits, stating that he slept about 4 hours per night. Although the Veteran declined examination of his penis and testes, he reported that he did not take any medications for his ED. The examiner noted that the Veteran had not had any blood work studies done or seen his primary care provider about the matter. As such, the examiner opined that the Veteran’s ED was less likely than not caused or aggravated by his service-connected PTSD, citing the Veteran’s alcohol use, poor sleep, over-30 BMI, short stature, and enlarged neck as more likely contributory factors to his ED. The VA requested a supplementary medical opinion, which was issued in March 2016. The examiner reviewed the Veteran’s VA medical treatment records, noting that he takes TUMS, Excedrin, and NSAIDS for his various service-connected conditions. However, the examiner opined that there was no link between the Veteran’s ED and any of his service-connected disabilities, as none of these medications are known to aggravate or contribute to the etiology of ED. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the finding that the Veteran’s ED is related to another service-connected impairment. The Board notes that the opinions provided by the February 2016 and March 2016 VA examiners are the only medical opinions on record addressing the origin of the Veteran’s ED. The VA examiners had the benefit of examining the Veteran and the claims file, provided a clear basis for their medical opinions, and made the most recent evaluations of record. The VA examiners also had the opportunity to review the Veteran’s VA medical records associated with the claims file, and found no relationship between his current ED and any of his other service-connected conditions. The Board thus affords these opinions the greatest probative weight, and adopts the VA examiners’ conclusion that the Veteran’s ED is not secondary to another service-connected impairment. The Board acknowledges the Veteran’s statements attributing his ED to his service-connected acquired psychiatric disorder. Although lay witnesses are competent to provide evidence regarding matters that can be perceived by the senses, they are not competent to provide an opinion regarding etiology. See Jandreau, 492 F.3d 1372; see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). For the reasons discussed above, however, the Board finds that the opinions provided by the VA examiners in February 2016 and March 2016 are more probative than the Veteran’s lay assertions. The VA examiners have expertise, education, and training that the Veteran is not shown to have. As such, those opinions warrant more weight. The Board also recognizes the Veteran’s allegations that his ED may be related to his alcohol use. Indeed, the February 2016 VA examiner listed alcohol use as potential factor contributing to the development of this impairment. Furthermore, the Veteran’s representative argued that his alcohol use itself was secondary to his service-connected acquired psychiatric disorder; the Veteran’s representative went on to insinuate that the VA psychological examinations were inadequate because they allegedly did not address this possibility. See August 2016 correspondence. However, the Board finds no merit in these contentions. This is because the Veteran discussed his alcohol use with the both the July 2015 and April 2016 VA psychological examiners, reporting no more than 3 drinks per day during either evaluation. Based on this information, the VA examiners concluded that the Veteran did not suffer from alcohol abuse nor any other substance use disorder. Similarly, neither VA examiner suggested that the Veteran’s alcohol use might be related to his service-connect acquired psychiatric disorder. See July 2015 VA examination; see also April 2016 VA psychological examination. While the Veteran is competent to report the effects of alcohol use, he is not competent to opine whether it is linked to a psychiatric disorder. Jandreau, 492 F.3d 1372; Barr, 21 Vet. App. 303. Here, there is no competent medical evidence in the claims file providing a nexus between the Veteran’s alcohol use and his service-connected acquired psychiatric disorder. The Board further recognizes that the Veteran bears the burden of proof to substantiate every element of his claim, including nexus. Madden, 125 F.3d at 1480-81. As such, although the evidence of record shows a possible nexus between the Veteran’s alcohol use and his ED, there is nothing to support a link between the Veteran’s alcohol use and another service-connected disability. Thus, even if the Veteran’s ED more likely than not resulted from his alcohol use, it cannot serve as a basis for service connection. In conclusion, the Board finds that the evidence of record does not support the Veteran’s contention that his ED is related to any of his service-connected disabilities. Although the evidence of record shows that the Veteran’s alcohol use may be contributing factor to the development of his ED, there is nothing to indicate a link between the Veteran’s alcohol use and his military service. While the Board acknowledges the Veteran’s statements disputing these findings, the majority of the evidence is inconsistent with his assertions. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49, 58 (1991). Thus, the Veteran’s claim for service connection for ED is denied. Increased Rating The Veteran seeks increased disability ratings for service-connected degenerative disc disease of the lumbar spine (lumbar spine disorder), patellar tendonitis and chondromalacia of the left knee (left knee condition), achilles tendonitis of the right heel (right heel disability), gastroesophageal reflux disease (GERD), migraine headaches, and an acquired psychiatric disorder. He alleges that all of these conditions have worsened during the appeal period. 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; 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. 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). I. Lumbar Spine Disorder The Veteran claims that his service-connected lumbar spine disorder warrants an initial increased disability rating throughout the entire period on appeal, which began on May 24, 2015, the date service connection was established. The Board notes that the RO originally assigned a noncompensable disability rating for this condition, which was then raised to 10 percent, effective May 3, 2016, in a May 2016 rating decision. In February 2017, the Veteran filed a notice of disagreement, seeking an earlier effective date. However, since the appeal period began one day after the Veteran’s separation from active service, it is not possible to grant an earlier effective date. Thus, the Board will treat the Veteran’s request as a staged rating claim. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. 38 C.F.R. § 4.45. The VA must consider such “functional losses” of a musculoskeletal disability; “functional loss” may occur as a result of weakness, fatigability, incoordination or pain on motion and should be equated to loss of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Disabilities of the spine are rated under either the General Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating. The Veteran is currently rated under Diagnostic Code 5010-5237, for arthritis resulting in lumbosacral or cervical strain. Hyphenated diagnostic codes are used when a disability rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.71a. Traumatic arthritis is rated under the same diagnostic criteria as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent will be applied for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent rating is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent rating is warranted for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purposes of this evaluation, the lumbar vertebrae are considered a single group of minor joints. 38 C.F.R. § 4.45. Under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes), a disability rating of 10 percent is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but less than 85 degrees; or, when the combined range of motion of the thoracolumbar spine is greater than 120 degrees but less than 235 degrees; or, muscle spasm, guarding, or, localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent disability rating is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but less than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is present. A 40 percent disability rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, Note (2); see also Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Formula, Note (5). Intervertebral disc syndrome (IVDS) is rated either under the General Rating Formula or alternatively under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in a higher disability rating. The Formula for Rating IVDS Based on Incapacitating Episodes provides for a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent disability rating is awarded for a disability with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, a 40 percent evaluation is in order. Finally, a maximum schedular rating of 60 percent is assigned for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). The Veteran underwent a VA examination in July 2015. The examiner reviewed the Veteran’s service and VA treatment records, noting a previous diagnosis of lumbosacral strain with degenerative disc disease. The Veteran reported flare-ups 2 times per week lasting a few hours; these were brought on by increased activity but did not result in functional loss. Upon examination, all range of motion testing was normal, with no evidence of pain on weightbearing or localized tenderness or pain on palpation. There was also no evidence of functional loss after repetitive testing. The examiner was unable to say if pain, weakness, fatiguability, or incoordination limited functional ability with repeated use because the exam did not take place during a flare-up. There was also no evidence of muscle spasms, radiculopathy, IVDS, or ankylosis. The sensory examination was normal, with negative straight leg raising tests bilaterally. Lastly, the Veteran reported no use of assistive devices. An X-ray from July 2015 revealed no fracture or subluxation, but a small posterior disc osteophyte at L5-S1 with mild disc height loss. Based on these findings, the examiner opined that the Veteran’s lumbar spine disorder affects his ability to work, with problems lifting and carrying, and flare-ups with increased activity. On May 3, 2016, the Veteran was afforded a second VA examination. The examiner reviewed the claims file, noting the previous diagnosis of degenerative disc disease. The Veteran reported flare-ups resulting in loss of motion. Upon examination, forward flexion was limited to 70 degrees and extension was limited to 20 degrees. The examiner found that limited range of motion does not result in functional loss. Although the Veteran endorsed tenderness on palpation over the lumbar spine region, there was no loss of function with repeated use. There was also no evidence of guarding or muscle spasm, and functional ability was not limited by pain, weakness, fatiguability, or incoordination during flare-ups. Similarly, straight leg raising tests were negative bilaterally, with no evidence of radiculopathy or ankylosis. There was no evidence of IVDS, and the Veteran did not use any assistive devices. Based on these findings, the examiner concluded that the Veteran’s lumbar spine disorder does not affect his ability to work. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the application of a compensable disability rating for the period prior to May 3, 2016. Similarly, the preponderance of the evidence is against the application of a disability rating in excess of 10 percent for the period from May 3, 2016. Under Diagnostic Code 5237, a 10 percent disability rating is warranted when flexion of the thoracolumbar spine is measured at greater than 60 degrees but less than 85 degrees. Here, during the July 2015 examination, which is the only assessment from the appeal period dating prior to May 3, 2016, the range of motion in the Veteran’s lumbar spine was normal. Additionally, there was no evidence of tenderness, pain on palpation, muscle spasms, or ankylosis. Although the July 2015 VA examiner opined that the Veteran’s lumbar spine disorder affects his ability to engage in the work-related tasks of lifting and carrying, difficulties such as these are contemplated by the noncompensable evaluation. As such, the Board finds that the evidence of record does not support the assignment of a compensable disability rating under Diagnostic Code 5237 for the period prior to May 3, 2016. Moreover, although an X-ray from July 2015 revealed mild disc height loss at L5-S1, these findings were not accompanied by any definitive evidence of limitation of motion. As such, despite the assignment of a noncompensable evaluation under Diagnostic Code 5237, the Veteran’s lumbar spine disorder would likewise warrant a noncompensable disability rating under Diagnostic Code 5010 for the period prior to May 3, 2016. Similarly, the evidence of record does not support the application of a disability rating in excess of 10 percent for the period from May 3, 2016. Under Diagnostic Code 5237, a 20 percent evaluation is assigned when flexion of the thoracolumbar spine is measured at greater than 30 degrees but less than 60 degrees. During the May 3, 2016 examination, flexion in the Veteran’s lumbar spine was measured at 70 degrees. Additionally, there was no evidence of guarding, muscle spasms, or ankylosis, and the Veteran ambulated without the use of an assistive device. As such, the criteria for a 20 percent disability rating under Diagnostic Code 5237 for the period from May 3, 2016 have not been satisfied. Furthermore, because a compensable evaluation has been assigned under Diagnostic Code 5237 for the period from May 3, 2016, a separate rating cannot be issued for this period under Diagnostic Code 5010. Lastly, due to the Veteran’s diagnosis of degenerative disc disease, the Board has considered whether he may be entitled to compensation under the Formula for Rating IVDS Based on Incapacitating Episodes found in Diagnostic Code 5243. However, there is no evidence that the Veteran has ever been prescribed bedrest by any of his treating physicians. Since physician-prescribed bedrest serves as the basis for compensation under Diagnostic Code 5243, the Veteran is not entitled to a separate rating under these criteria. Thus, the Board finds that the weight of the evidence is against the finding of an initial compensable disability rating under Diagnostic Code 5010-5237 for the Veteran’s service-connected lumbar spine disorder for the period prior to May 3, 2016. Likewise, the weight of the evidence is against the finding of an initial disability rating in excess of 10 percent for the period from May 3, 2016. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the claim is denied. II. Left Knee Condition The Veteran asserts that his service-connected left knee condition warrants an initial disability rating in excess of 10 percent throughout the entire appeal period, which began on May 24, 2015, the date service connection was established. The Veteran’s left knee condition is currently rated under Diagnostic Code 5260-5024, which provides the criteria for limitation of flexion and tenosynovitis. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional one to identify the basis for the rating assigned; the additional diagnostic code is shown after the hyphen. Id. In rating a disability of the musculoskeletal system, a number of factors must be considered. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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; DeLuca, 8 Vet. App. at 206-07. Under Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected parts as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion of the specific joint involved. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applied for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of two or more major joints or two or more minor joints warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purposes of this evaluation, the knee is considered a major joint. 38 C.F.R. § 4.45. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, a noncompensable rating is warranted when flexion of the leg is only limited to 60 degrees. A 10 percent rating is assigned when flexion is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. A 30 percent rating is assigned when flexion is limited to 15 degrees. Id. Under Diagnostic Code 5261, a noncompensable rating is warranted when extension of the leg is limited to 5 degrees. A 10 percent rating is assigned when extension is limited to 10 degrees. A 20 percent rating is warranted when extension is limited to 15 degrees. A 30 percent rating is assigned when the evidence shows extension limited to 20 degrees. A 40 percent rating is warranted when extension is limited to 30 degrees. A 50 percent rating is assigned when extension is limited to 45 degrees. Id. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings may be assigned for limitation of flexion, extension, instability, and a meniscal disability of the same knee under Diagnostic Codes 5260, 5261, 5237, 5258 or 5259. Lyles v. Shulkin, 16-0994, 2017 U.S. App. Vet. Claims LEXIS 1704 (Vet. App. Nov. 29, 2017); VAOPGCPREC 09-04 (September 17, 2004). The Veteran was afforded a VA examination in July 2015. The examiner reviewed the Veteran’s service and VA treatment records, noting a previous diagnosis of patellar tendonitis and chondromalacia of the left knee. The Veteran reported taking NSAIDS for treatment and attempted a knee tendon band without much relief. He also endorsed occasional sharp pain in the inferior portion of the knee when walking but stated that he had significantly more pain with increased activity. The Veteran reported no surgeries, injections, or current medications. He indicated that he experiences flare-ups 4 to 5 days per week lasting hours but with no functional loss. Upon examination, flexion was measured at 0 to 120 degrees, extension at 140 to 0 degrees. There was no evidence of pain with weightbearing, localized tenderness or pain on palpation, or objective evidence of crepitus. However, the examiner was unable to say if pain, weakness, fatiguability, or incoordination significantly limit functional ability with repeated use because the exam did not take place during a flare-up. Nonetheless, there was full muscle strength and no evidence of atrophy or ankylosis. Similarly, there was no evidence of subluxation or joint instability; all joint stability testing was normal. Lastly, there was no meniscal condition or degenerative arthritis, and the Veteran did not use an assistive device. An MRI from December 2014 confirmed patellar chondrosis. Based on these findings, the examiner concluded that the Veteran’s knee condition interferes with his work at a tree service, preventing him from carrying as much weight. It also slows him down when climbing trees. In May 2016, the Veteran underwent a second VA examination. The examiner reviewed the claims file, noting previous diagnoses of left knee tendonitis and patellofemoral pain syndrome. The Veteran reported stiffness and increasing pain in his knee as the day goes on, with flare-ups that occur after prolonged standing or climbing ladders. Upon examination, flexion was limited to 0 to 130 degrees extension was limited to 130 to 0 degrees. Range of motion did not contribute to functional loss, and there was no evidence of pain with weightbearing or palpation. However, crepitus was present. There was also no loss of range of motion after repetitive testing. Similarly, the examiner found that pain, weakness, fatiguability, or incoordination do not significantly limit functional ability during flare-ups. Muscle strength was 5/5, with no evidence of atrophy or ankylosis. There was also no history of subluxation, lateral instability, or recurrent effusion. Likewise, there was no evidence of joint instability, and all testing was normal. Lastly, there was no meniscal condition or degenerative arthritis, and the Veteran did not use an assistive device. An X-ray from May 2016 showed no fracture, malalignment, or significant degenerative changes. There was also no joint effusion or other soft tissue abnormality. Based on these findings, the examiner opined that the Veteran’s knee condition would affect his ability to work based on his report that it flares when he climbs ladders. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the application of a disability rating in excess of 10 percent the Veteran’s service-connected left knee condition at any time throughout the appeal period. Diagnostic Code 5260 assigns a noncompensable disability rating when flexion of the leg is measured at greater than 45 degrees. Here, flexion in the Veteran’s left leg was measured at 0 to 120 degrees during the July 2015 examination and 0 to 130 degrees during the May 2016 examination. Given that both of these measurements are greater than 60 degrees, the Veteran’s left knee condition warrants a noncompensable disability rating under Diagnostic Code 5260. Similarly, Diagnostic Code 5261 assigns a noncompensable disability rating when extension of the leg is measured at less than 10 degrees. Here, the Veteran was able to extend his left leg to 0 degrees during both the July 2015 and May 2016 examinations. As such, the Veteran’s left knee condition is assigned a noncompensable disability rating under Diagnostic Code 5261. Nonetheless, under Diagnostic Code 5024, a 10 percent disability rating is warranted for each such major joint or group of minor joints affected by limitation of motion when the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic code. Here, the knee is considered a major joint. 38 C.F.R. § 4.45. As such, because the Veteran’s left knee condition warrants noncompensable evaluations under Diagnostic Codes 5260 and 5261, it is assigned a 10 percent disability rating under Diagnostic Code 5024. This is the evaluation that is currently assigned, and represents the maximum compensation available for the Veteran’s service-connected left knee condition with the available evidence. Lastly, the Board notes the Veteran’s argument that his left knee condition warrants a separate disability rating for instability. See August 2016 correspondence. However, joint stability testing at both the July 2015 and May 2016 examinations was normal, with no evidence of subluxation or lateral instability. Therefore, the Veteran would not be entitled to a separate disability rating under Diagnostic Code 5257. Thus, the Board finds that the weight of the evidence is against the finding of an initial disability rating in excess of 10 percent under any relevant diagnostic code for the Veteran’s service-connected left knee condition throughout the entire period on appeal. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the claim is denied. III. Right Ankle Disability The Veteran alleges that his service-connected right ankle disability warrants an initial increased disability rating throughout the entire period on appeal, which began on May 24, 2015, the date service connection was established. The Board notes that the RO originally assigned a noncompensable disability rating for this condition, which was then raised to 10 percent, effective May 3, 2016, in a May 2016 rating decision. In February 2017, the Veteran filed a notice of disagreement, seeking an earlier effective date. However, since the appeal period began one day after the Veteran’s separation from active service, it is not possible to grant an earlier effective date. Thus, the Board will treat the Veteran’s request as a staged rating claim. The Veteran’s right ankle disability is currently rated under Diagnostic Code 5271-5024, which provides the criteria for limitation of motion and tenosynovitis. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional one to identify the basis for the rating assigned; the additional diagnostic code is shown after the hyphen. Id. In rating a disability of the musculoskeletal system, a number of factors must be considered. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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; DeLuca, 8 Vet. App. at 206-07. Under Diagnostic Code 5271, limitation of motion of the ankle is rated as 10 percent disabling if “moderate,” and 20 percent disabling if “marked.” 38 C.F.R. § 4.71a. The VA considers normal range of motion of the ankle to be 20 degrees dorsiflexion and 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II. Words such as “moderate” and “marked” are not defined in the VA Schedule for Rating Disabilities. Rather than apply a mechanical formula, the Board must evaluate the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Under Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected parts as degenerative arthritis. Diagnostic Code 5003 provides that the severity of degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion of the specific joint involved. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applied for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of two or more major joints or two or more minor joints warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under VA regulations, the ankle is considered a major joint. 38 C.F.R. § 4.45. In July 2015, the Veteran underwent a VA examination. The examiner reviewed the Veteran’s service and VA treatment records, noting a previous diagnosis of right achilles tendonitis. The Veteran reported being given a molded insole for his right boot for treatment, which improved his symptoms. However, he still noticed pain when he was having increased left knee pain. The Veteran indicated that the pain is intermittent, being 6/10 at worst and 0/10 at best. He reported no surgeries, injections, or medications, but stated that his pain increased with increased activity. The Veteran also endorsed flare-ups occurring 4 to 5 times per week lasting an hour or two. Upon examination, there was no functional loss on repeated use and range of motion was normal. The examiner was unable to say if pain, weakness, fatiguability, or incoordination significantly limited functional ability with repeated use because the examination did not take place during a flare-up. There was also full muscle strength and no evidence of ankylosis. Similarly, no joint instability or dislocation was suspected. The Veteran did not use assistive devices, and no degenerative arthritis was documented. An X-ray from July 2015 found a small plantar calcaneal enthesophyte but no acute osseous abnormalities. The examiner concluded that the Veteran’s right ankle disability affects his ability to work due to pain with increased activity. Additionally, it forces the Veteran to take more frequent breaks and prevents him from being able to lift as much. The Veteran was afforded a second VA examination on May 3, 2016. The examiner reviewed the claims file, noting a previous diagnosis of right achilles tendonitis. The Veteran claimed that his condition flares with prolonged standing and results in loss of range of motion. Upon examination, dorsiflexion was limited to 15 degrees and plantar flexion was limited to 40 degrees. There was no evidence of pain on weightbearing or localized tenderness on palpation. Additionally, there was no loss of function or range of motion with repetitive testing. However, the examiner found that pain, weakness, fatigability, or incoordination do not significantly limit the Veteran’s functional ability during a flare-up. Muscle strength was measured as 5/5 with no evidence of atrophy, ankylosis, or dislocation. The Veteran did not use assistive devices, nor was there any evidence of degenerative arthritis. As such, the examiner concluded that the Veteran’s right ankle disability does not affect his ability to perform occupational tasks. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the application of a compensable disability rating for the period prior to May 3, 2016. Similarly, the preponderance of the evidence is against the application of a disability rating in excess of 10 percent for the period from May 3, 2016. The evidence of record is inconsistent with the application of a compensable disability rating under any relevant diagnostic code for the period prior to May 3, 2016. Under Diagnostic Code 5271, a 10 percent disability rating is warranted for moderate limitation of motion of the ankle. Here, during the July 2015 examination, which is the only assessment from the appeal period dating prior to May 3, 2016, the range of motion in the Veteran’s right ankle was normal. Additionally, there was full muscle strength and no evidence of ankylosis, joint instability, or dislocation. These findings do not suggest a moderate level of impairment. As such, there is no evidence to support the assignment of a 10 percent disability rating under Diagnostic Code 5271 for the period prior to May 3, 2016. Although a contemporaneous X-ray revealed a small plantar calcaneal enthesophyte, these findings were not accompanied by any definitive evidence of limitation of motion. As such, despite the assignment of a noncompensable evaluation under Diagnostic Code 5271, the Veteran’s right ankle disability would likewise warrant a noncompensable evaluation under Diagnostic Code 5024 for the period prior to May 3, 2016. Similarly, the evidence of record does not support the application of a disability rating in excess of 10 percent for the period from May 3, 2016. Under Diagnostic Code 5271, a 20 percent evaluation is assigned for marked limitation of motion of the ankle. During the May 3, 2016 examination, dorsiflexion in the Veteran’s right ankle was limited to 15 degrees and plantar flexion was limited to 40 degrees. However, there was no evidence of pain on weightbearing or palpation, localized tenderness, or loss of function with repetitive testing. Additionally, the Veteran did not ambulate with an assistive device. While these findings suggest some degree of limitation, the range of motion in the Veteran’s right ankle has not been significantly reduced by his service-connected condition. As such, the difficulties he experiences are more accurately characterized as moderate than marked. Therefore, the criteria for a 20 percent disability rating under Diagnostic Code 5271 for the period from May 3, 2016 have not been satisfied. Lastly, because a compensable evaluation has been assigned under Diagnostic Code 5271 for the period from May 3, 2016, a separate rating cannot be issued for this period under Diagnostic Code 5024. Thus, the Board finds that the weight of the evidence is against the finding of an initial compensable disability rating under Diagnostic Code 5271-5024 for the Veteran’s service-connected right ankle disability for the period prior to May 3, 2016. Likewise, the weight of the evidence is against the finding of an initial disability rating in excess of 10 percent for the period from May 3, 2016. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the claim is denied. IV. GERD The Veteran claims that his service-connected GERD warrants an initial compensable disability rating throughout the entire period on appeal, which began on May 24, 2015, the date service connection was established. The Veteran’s GERD is currently assigned a noncompensable disability rating under Diagnostic Code 7399-7346, as analogous to a hiatal hernia. 38 C.F.R. § 4.114. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional one to identify the basis for the rating assigned; the additional diagnostic code is shown after the hyphen. Id. Under Diagnostic Code 7346, a 10 percent disability rating is assigned when there are two or more of the symptoms required for a 30 percent evaluation, but with less severity. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent disability rating is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. The Veteran underwent a VA examination in July 2015. The examiner reviewed the Veteran’s service treatment and VA treatment records, noting the previous diagnosis of GERD. The Veteran reported symptoms of pyrosis, reflux, and infrequent episodes of epigastric distress. However, upon examination, no esophageal stricture, spasm of the esophagus, or acquired diverticulum was noted. Based on these findings, the examiner concluded that this condition does not affect the Veteran’s ability to work. In May 2016, the Veteran was afforded a second VA examination. The examiner reviewed the claims file, noting the previous diagnosis of GERD. The Veteran reported symptoms of reflux and pyrosis. However, upon examination, there was no evidence of esophageal stricture, cardiospasm, achalasia, or acquired diverticulum. There were no other significant findings or results. Based on these findings, the examiner opined that the Veteran’s GERD does not affect his ability to work. After careful consideration of the claims file, the Board concludes that the evidence of record supports the application of a 10 percent disability rating for the Veteran’s service-connected GERD throughout the appeal period. In order to qualify for a 10 percent disability rating under Diagnostic Code 7346, the Veteran must exhibit two or more of the symptoms required for a 30 percent evaluation, but with less severity. The symptoms that characterize the 30 percent rating are: persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The Board notes that the Veteran reported reflux and pyrosis during both the July 2015 and May 2016 VA examinations. Additionally, he endorsed episodes of epigastric distress during the July 2015 VA examination, which he described as infrequent. The evidence of record therefore shows that the Veteran’s service-connected GERD results in reflux, pyrosis, and episodes of epigastric distress, all of which are symptoms listed in the 30 percent evaluation under Diagnostic Code 7346. As such, the Board finds that the Veteran is entitled to a 10 percent disability rating for his service-connected GERD because at least two symptoms required for the 30 percent evaluation are present. However, the Board declines to assign a higher evaluation because there is no indication that the reflux, pyrosis, and episodes of epigastric distress resulting from the Veteran’s service-connected GERD meet the required severity of the 30 percent disability rating. Indeed, the Veteran stated during the July 2015 VA examination that his episodes of epigastric distress were infrequent rather than persistent or recurrent. Moreover, there is nothing in the evidence of record to suggest that the Veteran’s service-connected GERD results in substantial arm or shoulder pain. Thus, the Board finds that the evidence of record warrants the assignment of a 10 percent disability rating, but no higher, under Diagnostic Code 7399-7346 for the Veteran’s service-connected GERD throughout the entire period on appeal. Accordingly, the Veteran’s claim for an initial compensable disability rating for his service-connected GERD is granted. V. Migraine Headaches The Veteran alleges that his service-connected migraine headaches warrant an initial compensable disability rating throughout the entire period on appeal, which began on May 24, 2015, the date service connection was established. The Veteran’s headache condition is currently assigned a noncompensable disability rating under Diagnostic Code 8100, which provides the rating criteria for migraines. 38 C.F.R. § 4.124a. Under this diagnostic code, the maximum schedular disability rating of 50 percent is assigned for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on average of once per month over the last several months. A 10 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months. A noncompensable disability rating is warranted for migraine headaches with less frequent attacks. Id. The rating criteria do not define “prostrating,” nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what constitutes a prostrating attack). By way of reference, the Board notes that according to Wester’s New World Dictionary of American English, Third College Edition, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” The Veteran was afforded a VA examination in July 2015. The examiner reviewed the Veteran’s service and VA treatment records, noting an earlier diagnosis of migraine headaches. The Veteran reported photophobia and nausea, stating that he gets a significant headache every 7 to 9 days. He claimed that his headaches are characterized by throbbing pain and are localized to one side of the head, usually the left. The Veteran indicated that he copes by getting hydrated and drinking caffeine; if these remedies do not work, he takes Excedrin and rests. He stated that his headaches last for 6 to 8 hours on average. The examiner noted that the Veteran’s headaches are often associated with tension or tightness of the neck. However, there is no previous imaging, nor is the Veteran on prescription medication for this condition. The examiner concluded that the Veteran’s headaches affect his ability to work based on his reports that they interrupt his productivity and force him to stay inside and rest. The Veteran indicated that he is self-employed and has the ability to rest if he has a headache. In May 2016, the Veteran underwent a second VA examination. The examiner reviewed the claims file, noting the previous diagnosis of migraine headaches. The Veteran reported headaches once per week, and indicated that he takes over-the-counter medication. He listed his symptoms as constant pain on both sides of the head, nausea, and sensitivity to light and sound. The Veteran stated that his head pain typically lasts less than one day. Based on these statements, the examiner opined that the Veteran’s headache condition does not affect his ability to work. After careful consideration of the claims file, the Board concludes that the evidence of record supports the application of a 10 percent disability rating for the Veteran’s service-connected migraine headaches throughout the appeal period. In order to qualify for a 10 percent disability rating under Diagnostic Code 8100, the Veteran must demonstrate migraine headaches characterized by prostrating attacks averaging one in two months over the last several months. During both the July 2015 and May 2016 VA examinations, the Veteran claimed that his migraine headaches occur approximately once per week. Although he did not specify how often these attacks are “prostrating,” the Board notes that the Veteran has consistently reported symptoms of nausea, photophobia, sensitivity to sound, and throbbing pain throughout the appeal period. Given the severity of these symptoms, as well as the likelihood that they could result in the inability to engage in any kind of productive activity while they are present, the Board finds sufficient evidence to assign a 10 percent disability rating under Diagnostic Code 8100. However, the Board declines to assign at higher evaluation at any point during the appeal period because the evidence of record does not indicate that the Veteran suffers from more frequent prostrating attacks. Indeed, the Veteran stated that he usually copes with his symptoms by drinking water or caffeine, or by taking over the counter medications. The Veteran went on to say that he only rests when these methods are ineffective. Moreover, there is no evidence of prescription medication, regular treatment, or imaging studies relating to the Veteran’s migraine headaches anywhere in the claims file. These factors suggest that the Veteran’s migraine headaches do not result in a degree of impairment warranting a disability rating in excess of 10 percent under Diagnostic Code 8100. Thus, the Board finds that the evidence of record supports the assignment of a 10 percent disability rating, but no higher, under Diagnostic Code 8100 for the Veteran’s service-connected migraine headaches throughout the entire period on appeal. Accordingly, the Veteran’s claim for an initial compensable disability rating for his service-connected migraine headaches is granted. VI. Acquired Psychiatric Disorder The Veteran asserts that his service-connected acquired psychiatric disorder warrants an initial increased disability rating throughout the entire period on appeal, which began on May 24, 2015, the date service connection was established. The Board notes that the RO originally assigned a 10 percent disability rating for this condition, which was then raised to 30 percent, effective April 7, 2016, in a May 2016 rating decision. In February 2017, the Veteran filed a notice of disagreement, seeking an earlier effective date. However, since the appeal period began one day after the Veteran’s separation from active service, it is not possible to grant an earlier effective date. Thus, the Board will treat the Veteran’s request as a staged rating claim. Under the General Rating Formula for Mental Disorders, the Veteran’s acquired psychiatric disorder is evaluated under Diagnostic Code 9411. 38 C.F.R. §§ 4.130. Diagnostic Code 9411 assigns a 10 percent disability rating when the psychiatric condition produces occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Id. A 30 percent disability rating is warranted when the psychiatric condition results in 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability rating is assigned when the psychiatric condition produces occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. In applying the above criteria, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so)). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-4 or DSM-5). Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Id. Effective August 4, 2014, the VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-4. The amendments replace those references with references to the recently updated “DSM-5.” As the Veteran’s claim was certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093 (August 4, 2014). The Veteran was afforded a VA psychological examination in July 2015. The examiner reviewed the claims file and diagnosed the Veteran with PTSD under the DSM-5 criteria. No other mental disorders were diagnosed. The Veteran stated that he planned to return to college, but at the time did part time work driving a truck for his friend, who works as a landscaper. The Veteran reported having 1 or 2 alcoholic drinks per day and denied drug or tobacco use. The Veteran also indicated that he has a nightmare about once per week and has difficulty maintaining sleep at night. The examiner noted no history of prior mental health treatment or prescription medications. The Veteran was found to be fairly isolative and not have much social interaction, but the examiner characterized his PTSD as mild. Lastly, the examiner opined that the Veteran’s PTSD results in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. On April 7, 2016, the Veteran underwent a second VA psychological examination. The examiner reviewed the claims file, diagnosing the Veteran with PTSD under the DSM-5 criteria. No other mental disorders were present. The Veteran reported that he lives alone and that his hobbies include motorcycles, golf, and Netflix. He indicated that his social network consists of his father and a friend in the area. The Veteran also stated that he is self-employed as a land development consultant and works for and by himself. He reported no suicide attempts or psychiatric hospitalizations, but stated that he only sleeps 3 to 4 hours per night due to being on alert for noises around his house. The Veteran claimed to be tired throughout the day and endorsed some social withdrawal. He stated that he drinks 2 to 3 shots of whiskey per night and claimed symptoms of symptoms depressed mood, suspiciousness, and chronic sleep impairment. The examiner noted that the Veteran was neatly dressed and well-groomed. He was cooperative during the exam, with good concentration, attention, insight, and judgment, and his speech was logical and goal-directed. The Veteran described his mood as “kind of depressed most days,” but his affect was calm and no objective distress was observed. The examiner found that the Veteran’s PTSD is chronic with mild symptoms resulting in mild social impairment. The examiner also noted that the Veteran has not had any psychological treatment since the precious evaluation. Finally, the examiner opined that the Veteran’s PTSD results in occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against the application of a disability rating in excess of 10 percent for the period prior to April 7, 2016. Similarly, the preponderance of the evidence is against the application of a disability rating in excess of 30 percent for the period from April 7, 2016. The evidence of record is inconsistent with the application of a 30 percent disability rating under Diagnostic Code 9411 for the period prior to April 7, 2016. During the July 2015 examination, which is the only evaluation within the appeal period dating prior to April 7, 2016, the Veteran endorsed having nightmares once per week and difficulty sleeping. However, there was no evidence of a chronic sleep impairment. Although the Veteran was fairly isolated and did not report much social interaction, he was nonetheless able to hold a part-time job as a landscaper. Additionally, the Veteran had no history of prior mental health treatment or prescription medications, which led the examiner to characterize his PTSD as mild. As such, there is no evidence that the Veteran’s acquired psychiatric disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, or mild memory loss. Thus, a 10 percent disability rating under Diagnostic Code 9411 most accurately reflects the Veteran’s degree of impairment for the period prior to April 7, 2016. Likewise, the evidence of record does not support the application of a 50 percent disability rating under Diagnostic Code 9411 for the period from April 7, 2016. During the April 2016 examination, the Veteran indicated that he lives alone and listed golf and motorcycles as his hobbies. Although he did not have a large social network, the Veteran reported regular interactions with his father and one friend in the area. He was also self-employed as a land development consultant. However, the Veteran did endorse a chronic sleep impairment due to hypervigilance and reported feeling depressed most days. Nonetheless, the examiner noted that the Veteran was well-groomed and neatly dressed, and did not observe any objective distress. The Veteran was also cooperative during the examination, with good concentration, attention, insight, and judgment, and his speech was logical and goal-directed. Significantly, the Veteran stated that he had not had any psychological treatment since the previous evaluation. Given this evidence, there is nothing to indicate that, from April 7, 2016, the Veteran’s acquired psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity due to any of the symptoms listed in the 50 percent evaluation. As such, a 30 percent disability rating under Diagnostic Code 9411 most accurately reflects the Veteran’s degree of impairment for the period from April 7, 2016. Thus, the Board finds that the weight of the evidence is against the finding of an initial disability rating in excess of 10 percent under Diagnostic Code 9411 for the Veteran’s service-connected acquired psychiatric disorder for the period prior to April 7, 2016. Likewise, the weight of the evidence is against the finding of an initial disability rating in excess of 30 percent for the period from April 7, 2016. To the extent that any higher level of compensation is sought, the preponderance of the evidence is against this claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the claim is denied. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD MJS, Associate Counsel