Citation Nr: 18151034 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 13-35 007 DATE: November 19, 2018 ORDER The application to reopen the previously denied claim for service connection for diabetes mellitus, Type I is granted. Entitlement to service connection for diabetes mellitus is granted. Entitlement to service connection for erectile dysfunction (ED) is granted. Entitlement to service connection for a bilateral hand disability, claimed as a problem with both hands, is denied. Entitlement to service connection for toenail fungus, claimed as a problem with both feet, is granted. Entitlement to service connection for carpal tunnel syndrome (CTS) is denied. Entitlement to service connection for depression is denied. Entitlement to service connection for memory loss is denied. Entitlement to an initial rating of 40 percent, but no higher, for degeneration of intervertebral disk space L5-S1 is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to higher initial ratings for ischemic heart disease, currently rated as 10 percent prior to March 1, 2016 and 30 percent thereafter, is denied. Entitlement to an effective date prior to April 22, 2010 for service connection for ischemic heart disease is denied. Entitlement to an effective date prior to July 8, 2010 for service connection for degeneration of intervertebral disk space, L5-S1 is denied. REMANDED Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a December 2001 rating decision, the RO denied the Veteran's claim of entitlement to service connection for diabetes mellitus, Type I. The Veteran did not appeal and new and material evidence was not received within the one-year appeal period. 2. Evidence received since the December 2001 rating decision relates to the basis for the prior denial for diabetes mellitus, Type I and raises a reasonable possibility of substantiating the claim. 3. The evidence is at least evenly balanced as to whether current diabetes mellitus, regardless of type, has been shown to have had its onset in service or within one year of service. 4. The evidence is at least evenly balanced as to whether the Veteran’s erectile dysfunction is caused by his service-connected PTSD or now service-connected diabetes mellitus. 5. The evidence does not show a disorder in either hand that had its onset in service or is caused or aggravated by service-connected disease or injury. 6. The evidence is at least evenly balanced as to whether the Veteran’s bilateral toenail fungal infection is related to active service. 7. The evidence does not show CTS that had its onset in service or is secondary to service-connected disability. 8. The evidence does not show that the Veteran has a depressive disorder that is independent of service-connected PTSD. 9. The evidence does not show that the Veteran has a memory loss disorder that is independent of service-connected PTSD. 10. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine disability more nearly approximated flexion to 30 degrees or less with consideration to functional impairment, but it did not more nearly approximate ankylosis or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 11. Prior to March 1, 2016, the Veteran's ischemic heart disease required continuous medication; it did not more nearly approximate dyspnea, fatigue, angina, dizziness or syncope with a workload of 7 metabolic equivalents (METs) or less or cardiac hypertrophy or dilatation on cardiac testing. 12. From March 1, 2016, the Veteran's ischemic heart disease required continuous medication; it did not more nearly approximate dyspnea, fatigue, angina, dizziness or syncope with a workload of 5 metabolic equivalents (METs) or less or left ventricular dysfunction with an ejection fraction of 50 percent or less. 13. A service connection claim for ischemic heart disease was not received prior to April 22, 2010; there is no evidence of any unadjudicated formal or informal claim of service connection for ischemic heart disease prior to April 22, 2010. 14. A service connection claim for a lumbar spine disability was not received prior to July 8, 2010; there is no evidence of any unadjudicated formal or informal claim of service connection for lumbar spine disability prior to July 8, 2010. CONCLUSIONS OF LAW 1. The December 2001 rating decision that denied the claim of entitlement to service connection for diabetes mellitus, Type I is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b). 2. The evidence received since the December 2001 rating decision is new and material as to the issue of service connection for diabetes mellitus Type I and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for diabetes mellitus are met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for ED secondary to service connected diseases are met. 38 U.S.C. §§ 1110, 5103, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310(a). 5. The criteria for service connection for bilateral hand disability, claimed as problems with both hands, are not met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 6. The criteria for service connection for toenail fungus, claimed as a problem with both feet, are met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 7. The criteria for service connection for CTS are not met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 8. The criteria for service connection for depression are not met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 4.130. 9. The criteria for service connection for memory loss are not met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 4.130. 10. With reasonable doubt resolved in favor of the Veteran, the criteria for a 40 percent initial rating, but no higher, for degeneration of intervertebral disk space L5-S1 have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code (DC) 5243. 11. The criteria for initial ratings for ischemic heart disease in excess of 10 percent prior to March 1, 2016 and 30 percent thereafter are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.104, DC 7005. 12. The criteria for entitlement to an effective date prior to April 22, 2010 for the award of service connection for ischemic heart disease have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 3.816; 38 C.F.R. §§ 3.155, 3.157 (2015). 13. The criteria for entitlement to an effective date prior to July 8, 2010 for the award of service connection for degeneration of intervertebral disk space L5-S1 have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. §§ 3.155, 3.157 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to January 1971 with service in the Republic of Vietnam. He received multiple decorations and medals, including the Distinguished Flying Cross, which is indicative of combat. See VA Adjudication Procedures Manual, IV.ii.1.D.1.e (updated March 31, 2017) (list of Decorations that are evidence of combat participation). Although VA’s Adjudication Manual is not binding on the Board, DAV v. Sec’y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) (“The M21-1 Manual is binding on neither the agency nor tribunals”), the list of decorations indicating combat is a useful guide in determining whether the Veteran engaged in combat with the enemy such that the laws and regulations relating to combat service are for application. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The November 2011 RO decision was an initial grant of service connection for the heart and back disabilities, and the Veteran timely appealed the assigned effective dates for these disabilities. Cf. Rudd v. Nicholson, 20 Vet. App. 296 (2006) (prohibiting freestanding earlier effective date claims). In his December 2013 substantive appeal, the Veteran requested a Decision Review Officer (DRO) hearing. In lieu of a hearing, the Veteran was afforded a DRO conference in March 2018. A copy of the DRO conference report is of record. Also in December 2013, the Veteran’s previously appointed attorney withdrew from the case with notice to the Veteran and the RO. The Veteran has not appointed another representative and remains unrepresented. The Board has added entitlement to TDIU to the appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). Although the Veteran has not filed a TDIU claim, there are multiple reports that he left his longstanding job due to service-connected PTSD symptoms. These PTSD symptoms are intertwined with the instant depression and memory loss claims. TDIU is addressed in the remand following the decision. I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The Board is taking fully favorable rating action by awarding service connection for diabetes mellitus, ED, and bilateral foot fungus. Discussion of VCAA compliance regarding these issues is unnecessary. In this case, an August 2011 letter notified the Veteran about the information and evidence needed substantiate service connection claims, division of responsibilities in obtaining evidence, and information on how VA assigns disability ratings and effective dates. This letter satisfies the duty to notify. For the duty to assist, VA obtained identified and available evidence needed to substantiate the claims. The Veteran was most recently afforded VA examinations for his service-connected back and heart disabilities in September 2018. The Veteran was not afforded a VA examination for bilateral hands, CTS, memory loss and depression claims. Under the VCAA, VA must provide an examination when there is (A) competent evidence of a current disability (or persistent or recurrent symptoms thereof) that (B) may be associated with service, but (C) there is insufficient medical evidence to make a decision on the claim. 38 U.S.C. § 5103A(d). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted under this statute. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be competent evidence of a current disability, competent evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being “routinely and virtually automatically” provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. For the claimed bilateral hand and CTS disabilities, the evidence does not suggest that the Veteran has a current disorder in either hand that could possibly be related to service or service-connected disability. The lay reports regarding these disabilities are vague and uncertain. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. For CTS, the evidence suggest post service labor is the cause. The medical records do not otherwise suggest any possible etiology to service for either disability. For the claimed depression and memory loss, the medical evidence does not suggest the Veteran has separate and distinct memory loss or depression symptoms that are not encompassed in the current PTSD disability rating. 38 C.F.R. § 4.130. The Veteran’s reports for these disabilities do not identify additional symptoms warranting further development or refer to medical records substantiating separate and distinct disorders apart from service-connected PTSD. Id. A remand for a VA medical examination or opinion is therefore not warranted for these claims. Id. The Veteran was afforded multiple VA examinations for his lumbar spine disability. To the extent any portion of these VA examinations are not totally complaint with the most recent holding regarding the adequacy of VA orthopedic examinations, the instant decision results in an award of the maximum schedular rating for lumbar spine motion loss. The Veteran is not prejudiced any VA examination inadequacy in ascertaining functional impairment. Cf. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). For these claims, the Board concludes that a remand for additional notice or development would result in additional delay without any benefit flowing to the Veteran. Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) ("[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant"); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of his claims. II. Application to reopen a previously denied Diabetes Mellitus, Type I claim Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purposes of establishing whether new and material evidence has been submitted, the credibility of the evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). In December 2001, the RO denied service connection for diabetes mellitus, Type I as associated with herbicide agent exposure. The Veteran did not appeal the decision, nor did he submit new and material evidence within the remaining appeal period. Accordingly, the December 2001 rating decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. In the December 2001 rating decision, the RO cited an absence of a nexus to service or presumed herbicide agent exposure as the reason for the denial. It cited the January 1973 hospitalization report and private medical records confirming a Type I diabetes diagnosis with initial manifestations appearing in December 1972. Since the December 2001 rating decision, the Veteran has submitted medical articles indicating that there is latency in diabetes symptoms and that it is difficult to distinguish diabetes mellitus Type I and Type II diagnoses. See May 2010 submission. He also reported a treating clinician initially informed him that he probably first developed Type II diabetes that later turned into Type I. See August 2011 Veteran report. In this case, the Veteran is competent to report his recollections of what a clinician told him. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("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"). His reports are presumed credible for purposes of reopening. Justus, 3 Vet. App. at 513. Then, the medical article received May 2010 suggests the initial diabetes symptoms manifested earlier than December 1972. In sum, the newly received items of evidence relate to the basis for the prior denial to suggest a military or presumptive nexus for this disability. The additional evidence raises a reasonable possibility of substantiating the claim. The Board consider it to be new and material. Reopening of the diabetes mellitus, Type I claim is therefore warranted. 38 C.F.R. § 3.156. III. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service is not in fact shown to be chronic or the diagnosis of chronicity may be legitimately questioned. The provisions of 38 C.F.R. § 3.303(b) apply only to the specific chronic diseases listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), which include diabetes mellitus and degenerative arthritis. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran also meets the criteria for a presumption of herbicide agent exposure. 38 C.F.R. § 3.307(a)(6). As relevant, diabetes mellitus, Type II is among several diseases presumptively related to herbicide agent exposure. 38 C.F.R. § 3.309(e). Alternatively, service connection may be established on a direct basis to presumed herbicide agent exposure. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Diabetes mellitus Service treatment records (STRs) do not show any symptoms or diagnosis relating to diabetes. January 1973 private hospital records showed that the Veteran sought medical attention for unexplained weight loss over the past couple of months. He also developed blurred vision. A physician found that he had markedly elevated fasting blood sugar. He then had a week-long hospitalization to control his blood sugar. The final diagnosis was diabetes mellitus with ketoacidosis. A January 1973 National Guard physical examination noted the recent diabetes diagnosis and deemed the Veteran unqualified for flying. In a February 1973 claim, the Veteran reported that he had diabetes symptoms of excessive thirst, insatiability, and fatigue from August 1969 to August 1970, which is the time he served in the Republic of Vietnam. April 1973 National Guard records confirmed that the Veteran was medically separated due to diabetes mellitus. In June 2000, the Veteran reported that he started taking insulin in November 1972 and asserted he had diabetes due to herbicide agent exposure. In a July 2000 Agent Orange Registry examination, in pertinent part, the Veteran reported that he had a history of diabetes dating to 1972. For the instant claim, in May 2010, the Veteran submitted a medical article from the American Diabetes Association. It provided an overview of diabetes mellitus. As relevant, it reported that many diabetic individuals do not easily fit into a single class. For Type I diabetes, it noted varying manifestations, including a presentation where symptoms gradually develop, particularly in adults. Private medical records from Dr. G. showed that the Veteran had had Type I diabetes since 1973. In August 2011, the Veteran reported that treating clinician informed him that he probably had Type II diabetes first, then acquired Type I. In August 2011, the Veteran had a VA diabetes examination. The examiner listed a diagnosis of diabetes mellitus, Type I. April 2013 VA treatment records noted a diagnosis of diabetes mellitus Type II or unspecified and that the Veteran was followed privately by Dr. G. for diabetes. Upon review, the record raises multiple theories of entitlement and the Board will only address a theory that supports the favorable finding. Review of the historical medical records refers to a diabetes diagnosis without a specific type. Current VA treatment records suggest the Veteran’s diabetes is Type II or unspecified while private medical records generally characterize it as Type I as well as the August 2011 VA examination report. However, the May 2010 medical article submitted by the Veteran indicates that distinguishing types of diabetes is difficult and that Type I diabetes may have a latency period particularly in adults. Overall, the medical evidence is not entirely clear as to what type of diabetes the Veteran initially had and there is some conflict as to current diagnosis since there is not a medical explanation supporting the Type I clinical assessments. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). As to initial symptoms, the Veteran made a February 1972 report that symptoms typically associated with diabetes initial appeared when he served in Vietnam. He is competent to report his history of symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Although STRs do not document such symptoms, the Board finds his report credible particularly in light of his service in a combat zone and limited ability to obtain medical care. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012) (Congress enacted the combat law and regulation because of its concern that combat veterans faced “major obstacle[s]” when seeking to assemble the medical records necessary to establish that they suffered an injury or disease while in service. In many instances, medical records do not survive combat conditions and due to the exigencies of battle, soldiers may not immediately seek medical treatment for combat-related injuries). Given the competent and credible reports of symptoms preceding the formal diagnosis in January 1973 and uncertainty of the current Type I diagnosis, the Board finds the evidence to be in a state of relative equipoise as to military nexus for a post service diabetes disease, regardless of type, is shown. Id. In sum, the evidence is thus at least evenly balanced as to whether the Veteran’s diabetes mellitus symptoms initially appeared in active military service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for diabetes mellitus is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Erectile dysfunction (ED) In his April 2010 claim, the Veteran reported he developed ED as a medication side effect. Specifically, Dr. R. switched his antidepressants due to ED side effects. In the August 2011 VA diabetes examinations report, the VA examiner listed it as a diabetes complication. The Veteran was also afforded a separate VA examination for ED. The examiner listed a ED diagnosis with a 2001 onset from the Veteran’s reports. As relevant, he related it to diabetes mellitus. September 2011 VA treatment records suggested that ED was related to psychiatric medication. May 2015 VA treatment records noted that the Veteran did not want to take psychiatric medication due to ED side effects. The Veteran is service-connected for PTSD and now diabetes mellitus. The medical evidence confirms that the Veteran has ED and it is related to these service-connected disabilities. 38 C.F.R. § 3.310. There is no conflicting medical evidence. As the basic criteria for secondary service connection are met, service connection for ED is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Bilateral hands STRs do not show any specific disorder affecting either hand. In July 2000, the Veteran had a VA Agent Orange Registry examination. As relevant, he reported having fungus affecting the great toes and left middle finger. It started after his diabetes diagnosis. He reported having trigger fingers in both hands. Clinical evaluation showed fungus affecting the great toes, but otherwise did not suggest a hand or foot disorder. The clinician assessed bilateral trigger fingers and fungus of the great toes. In his April 2010 claim, he reported having problems with both hands and asserted this disability was due to herbicide agent exposure. The August 2011 VA diabetes examination report reflected that the examiner did not find evidence of a skin condition secondary to diabetes. April 2013 VA primary care records do not include treatment for a disorder of the hands. The March 2018 DRO conference report did not include any specific contention with respect to this claim. VA treatment records through September 2018 do not include any hand disorder as an active problem. The Board finds that the preponderance of the evidence weighs against this claim. Caluza, 7 Vet. App. at 511; 38 C.F.R. § 3.303. The evidence is limited. Although the Veteran referenced trigger fingers and fungus affecting the middle finger in 2000, he does not provide details about the current symptoms or manifestations for the instant claim to fulfill the expansive definition of current disability for VA compensation purposes. That definition reflects that a medical diagnosis is not required to meet the current disability requirement and that symptoms causing impairment can establish disability. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). See also 38 U.S.C. § 1701(1) (defining disability in the context of VA hospital, nursing, home, domiciliary, and medical care as “a disease, injury or other physical or mental defect”). In addition, disability need only be shown at any time during the pendency of the claim or even prior thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013). Here, however, there is no lay or medical evidence showing disability. The March 2018 DRO conference report only notes a skin problem affecting the feet and the other evidence does not show impairment of the hands. Moreover, the Veteran’s reports do not otherwise suggest continuous symptoms beginning in service. To the extent the Veteran asserts his hand disorder is related to herbicide agent exposure or service-connected disability, these issues raise questions concerning internal medical processes that the courts have deemed beyond the competency of lay witnesses. Jandreau, 492 F.3d at 1377, n. 4; Waters, 601 F. 3d at 1278. The Veteran has not identified any medical evidence to support such an assertion. For the above stated reasons, the preponderance of the evidence is against the claim for service connection for bilateral hand disability. The benefit of the doubt doctrine is therefore not for application and service connection for a bilateral hand disability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Bilateral foot fungus, claimed as a bilateral foot condition STRs do not show any complaints or treatment for this disability. As noted above, the July 2000 VA Agent Orange Registry examination reported a fungal infection affecting both toes. The examiner stated it occurred after the Veteran developed diabetes. In June 2010, the Veteran’s then-representative asserted that diabetes had caused fungus growth under the toenails. The August 2011 VA diabetes examination report showed that the examiner declined to report any skin condition as a complication. In September 2018, the Veteran had a VA skin disease examination. He reported noticing ingrown toe nails in service. He recalled in the 1970s being informed that he had fungus. He denied any medical treatment. Instead, he applied topical lotion to his feet every night. Clinical evaluation did not show symptoms related to any enumerated disorder. The examiner reported that there was no current diagnosis of bilateral feet fungus attributable to the wet and warm environment in Vietnam. The Veteran is competent to report toenail fungal symptoms and history of ingrown toenails beginning with service or following diabetes onset. Jandreau, 492 F.3d at 1377, n.4. His reports have varied as to whether it is directly related to service or secondary to diabetes. Regardless, his reports imply a direct nexus or secondary nexus to now service-connected diabetes. The Board observes that this disorder is readily observable and it is highly plausible that the Veteran self-managed it with due to the intermittent symptoms and its responsiveness to over the counter treatment (i.e. topical lotion). Caluza, 7 Vet. App. at 511. Accordingly, the Board finds the Veteran credible in his reports of current disability and nexus, whether under a direct or secondary theory of entitlement. As noted above, the expansive definition of current disability includes disability with intermittent symptoms and the history of symptoms prior to the claim must be considered. McClain, supra.; Romanowsky, supra. The September 2018 VA examiner’s findings are conclusory and she do not provide an adequate reason to reject the Veteran’s competent and credible lay reports. Thus, her medical opinion is not persuasive. See Nieves-Rodriguez, 22 Vet. App. at 304 (most of the probative value of a medical opinion comes from its reasoning); Caluza, 7 Vet. App. at 511. In this particular case, the Board resolves reasonable doubt in favor of the Veteran and finds that a nexus to service is demonstrated for the current toenail fungal infection. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board finds the Veteran credible in his reports about the nature and history of this disability. As satisfactory evidence of an in-service injury, current disability and nexus is of record, entitlement to service connection for toenail fungal infection is warranted. Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). Bilateral carpal tunnel syndrome (CTS) STRs do not show any symptoms or treatment related to CTS. April 2000 private medical records showed that the Veteran complained about numbness and tingling in the fingers of both hands. The clinician noted a diabetes medical history and work history at an electric firm. A recent nerve conduction study confirmed bilateral CTS. The clinician advised the Veteran about his treatment options and a course of conservative care was indicated. Another report from April 2000 showed that the Veteran filed a workers’ compensation claim against his employer for CTS. During the July 2000 Agent Orange Registry examination, the examiner noted bilateral CTS with a 1998 onset and that the Veteran received workers’ compensation. In his April 2010 claim, he reported having CTS and asserted this disability was due to herbicide agent exposure. The March 2018 DRO conference report did not include any specific contention with respect to this claim. The Board finds that the preponderance of the evidence weighs against this claim. Caluza, 7 Vet. App. at 511; 38 C.F.R. § 3.303. The evidence shows that this disability did not have its onset until many years following service and does not indicate any relationship to service, as opposed to the Veteran’s claim for workers compensation indicating that that it was due to post-service events. The Veteran does not provide details about why he believes CTS is related to military service or otherwise provide any reports elaborating a particular theory of entitlement. Id. To the extent the Veteran asserts CTS is related to herbicide agent exposure, these issues raise questions concerning internal medical processes that the courts have deemed beyond the competency of lay reporters. Jandreau, 492 F.3d at 1377, n. 4; Waters, 601 F. 3d at 1278. He does not identify any medical evidence to support such an assertion. For the above stated reasons, the preponderance of the evidence is against the claim for service connection for bilateral CTS. The benefit of the doubt doctrine is therefore not for application and service connection for bilateral CTS must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Memory loss and depression STRs do not include any complaints or assessments relating to either claimed disability. October 2000 VA treatment records showed that the Veteran complained about difficulty remembering new information, reasoning and subjective feelings of cognitive impairment. He denied getting lost in familiar surroundings or failing to recognize friends or family. He endorsed having low moods, frustration, crying spells and restlessness. The clinician assessed anxiety. October 2005 private medical records reflected that the Veteran had a psychological consultation for memory problems that had gradually become worse over the past 15 years. He had worked as a winder for an electric company for over 20 years. Mental status examination (MSE) was notable for a depressed mood and suspiciousness. Numerous clinical tests were administered. The clinician diagnosed amnestic disorder and depressive disorder. He reported that the Veteran had marked visual memory deficits that may be exacerbated by depression. He recommended individual therapy to learn basic relaxation techniques and coping skills. He also advised the Veteran to return for follow up testing in six to twelve months. The February 2014 VA PTSD examination report listed a PTSD diagnosis. The examiner did not find any additional mental disorder. As relevant, the Veteran reported seeing a private psychiatrist once for poor concentration and memory. In September 2015, a PTSD Disability Benefits Questionnaire (DBQ) again confirmed a current PTSD diagnosis without any additional mental disorder. VA treatment records through September 2018 included assessments of depression and anxiety, in addition to PTSD. The Veteran contends service connection is warranted for memory loss and depression as disabilities independent of service-connected PTSD. The Board finds the preponderance of the evidence is against these claims. Overall, the weight of the medical evidence does not suggest that the Veteran has a separate depression or memory loss disability. Mittleider v. West, 11 Vet. App. 181 (1998); 38 C.F.R. §§ 4.14, 4.130. Both February 2014 and September 2015 examiners reported that an additional psychiatric or cognitive disorder was not indicated. To the extent a separate diagnosis is reflected in medical records, the evidence fails to show symptoms that are not already encompassed by the service-connected PTSD rating. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. As to the assertions from the Veteran about a separate depressive or memory loss disability, these issues involve complex medical questions. He is not competent to provide a self-diagnosis for these issues because of the medical complexity. Jandreau, 492 F.3d at 1377, n. 4; Waters, 601 F. 3d at 1278. He has not otherwise identified additional medical evidence or reports given to him from a treating clinician that indicate a separate diagnosis. For the above stated reasons, the preponderance of the evidence is against the claims for service connection for memory loss disorder and depression. The benefit of the doubt doctrine is therefore not for application and service connection for memory loss disorder and depression must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. IV. Higher initial ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Staged ratings are appropriate for any 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) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). Lumbar spine disability The Veteran’s service-connected degeneration of intervertebral disk space L5-S1 is currently rated as 20 percent disabling under Diagnostic Code (DC) 5243. 38 U.S.C. § 4.71a, DC 5243. DC 5243 permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Under the General Rating Formula, as relevant, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine 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. A 40 percent evaluation is warranted where forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. The only higher schedular evaluations under the General Rating Formula are 50 percent for unfavorable ankylosis of the entire thoracolumbar spine and 100 percent for ankylosis of the entire spine. 38 C.F.R. § 4.71a, DC 5243. Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Formula), a 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. An "incapacitating episode" for purposes of totaling the cumulative time is defined as "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1. Additional considerations pertain to musculoskeletal disabilities. Such disability is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 enervation, 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. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. After accounting for functional loss or impairment, a rating is determined, in this case, based on the 38 C.F.R. § 4.71a criteria. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of 38 C.F.R. § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Turning to the evidence, in his July 2010 service connection claim, the Veteran reported that he injured his back in a military aircraft accident and from a fall. Currently, he could not sit up normally and had difficulty getting out of bed. In August 2011, the Veteran was afforded a VA spine examination. The examiner diagnosed degeneration of intervertebral disc space, L5-S1. The Veteran reported having flare-up episodes. His back pain was worse in the morning and did not improve until the afternoon. He had difficulty getting out of bed due to back pain. He described sharp back pain in the morning that dulled during the day. Lumbar spine flexion range of motion (ROM) was to 60 degrees with endpoint pain. Extension was to 15 degrees with endpoint pain. The additional planes of lumbar spine motion were normal. The Veteran could perform repetitive use testing without additional motion loss. The examiner identified pain on movement and interference with sitting, standing and/or weight-bearing as functional impairments. Mild tenderness and muscle spasm was noted. Muscle strength testing was complete (5/5) in both lower extremities. Reflex and sensation were normal in both lower extremities. Straight leg raise (SLR) test was negative bilaterally. The examiner stated that the Veteran had intervertebral disc syndrome (IVDS) but it had not caused incapacitating episodes. He noted the Veteran’s reports of difficulty bending, squatting and lifting objects over 25 pounds. The Veteran could not use the push mower or perform household chores during flare-ups. X-ray findings were reported. For occupational impact, the Veteran could not lift heavy objects, bend or sit for prolonged periods. In October 2013, VA reexamined the Veteran for his back disability. The examiner maintained the previous diagnosis. The Veteran reported that there was no change from the last examination. He continued to have back pain from prolonged sitting and movement. He used Naprosyn on occasion. The examiner reported that flare-ups were not present. Lumbar spine ROM forward flexion was to 80 degrees with endpoint pain. The additional planes of lumbar motion were to 20 degrees with endpoint pain. Repetitive ROM testing did not cause additional motion loss. The examiner identified functional impairment as less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing and/or weight-bearing. Localized tenderness was noted over L3-S1. Lumbar muscle spasms were noted, but not deemed significant enough to result in an abnormal gait or spinal contour. Neurological findings were normal. The examiner commented that estimating additional motion loss during flare-ups would require speculation. He would expect to find additional pain or discomfort and decreased ROM. March 2014 VA primary care records included reports about low back pain. In September 2018, a Disability Benefits Questionnaire (DBQ) was completed. The examiner maintained the previous diagnosis. The Veteran reported continued low back pain that was aggravated by prolonged sitting and lifting heavy objects. The pain was worse in the morning and improved during the day with walking and stretching. He denied any surgery or injections for treatment. The examiner indicated flare-ups and functional loss was not apparent. ROM was normal for all planes of lumbar spine motion. There was no evidence of localized tenderness or pain during examination. The Veteran performed repetitive ROM without additional motion loss. The examiner could not estimate motion loss due to functional impairment or flare-ups. He stated that there was no empirical basis for such a determination without observing the Veteran during repeated use or flare up episode. Neurological findings were normal. The examiner noted regular use of a cane and attributed it to a recent left ankle fracture. The Veteran contends a lumbar spine disability evaluation in excess of 20 percent is warranted. Resolving reasonable doubt in his favor, the Board finds an initial 40 percent rating for service-connected degeneration of intervertebral disk space L5-S1 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The ROM studies do not show the requisite motion loss to more nearly approximate the 40 percent rating criteria under the General Formula. 38 C.F.R. § 4.71a, DC 5242. However, motion loss from functional impairment must also be considered. English v. Wilkie, No. 17-2083 (Vet. App. Nov. 1, 2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. §§ 4.40, 4.45, 4.59. All of the examination reports showed that the examiners declined to estimate motion loss from functional impairment or during flare-up episodes due to their inability to observe the Veteran. Sharp, 29 Vet. App. at 33. Nonetheless, the Veteran is competent to report his symptoms and the Board considers his accounts of functional impairment credible. Jandreau, 492 F.3d at 1377; Caluza, 7 Vet. App. at 506. He has generally described noticeably worse symptoms in the morning and that his symptoms have remained stable throughout the course of the appeal. See August 2011 and December 2018 VA examination reports; July 2010 claim. It is reasonable to infer from his reports of difficulties with getting out of bed, prolonged sitting or heavy lifting, that he has noticeable lumbar spine motion loss due to back pain and/or stiffness. Mitchell, 25 Vet. App. at 44; Thompson, 815 F.3d at 785 (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5243. Given the above, the Board resolves reasonable doubt to find that the Veteran’s lumbar spine flexion motion loss more nearly approximate 30 degrees with consideration to functional impairment. English, supra.; Id. The Board has considered whether a rating greater than 40 percent is warranted under the General Rating Formula. 38 C.F.R. § 4.71a, DC 5243. As noted above, a higher 50 percent rating under the General Rating Formula contemplates ankylosis of the lumbar spine disability. There is no evidence suggesting ankylosis of the thoracolumbar spine. Moreover, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. See id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). A rating greater than 40 percent under the General Rating Formula is not for further consideration. Id. The Board has also considered whether a rating greater than 40 percent is warranted based upon the IVDS Formula. Id. The Veteran does not assert that bed rest is necessary to treat his back pain. Further consideration of the IVDS formula is not warranted. 38 C.F.R. § 4.71a, DC 5243 IVDS Rating Formula. For the foregoing reasons, an initial 40 percent rating is granted for degeneration of intervertebral disk space L5-S1. The preponderance of the evidence reflects the symptoms of the Veteran's lumbar spine disability do not more nearly approximate the criteria for an initial rating higher than 40 percent. Thus, the benefit of the doubt doctrine is not for application and an initial rating greater than 40 percent must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his prior representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). Ischemic heart disease The Veteran’s service-connected ischemic heart disease has initial disabilities ratings of 10 percent disabling rating prior to March 1, 2016 and 30 percent thereafter pursuant to DC 7005. 38 C.F.R. § 4.104, DC 7005. Pursuant to DC 7005 for evaluating coronary artery disease, a workload of greater than 7 METS but not greater than 10 METS resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required warrants a 10 percent disability rating. A workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray warrants a 30 percent evaluation. More than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent rating. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. July 2011 private medical records showed that the Veteran underwent a stress test. The left ventricular chamber size was normal and gated stress ejection fraction was 58 percent. In August 2011, the Veteran was afforded a VA heart examination. The examiner diagnosed coronary artery disease and stable angina. The Veteran first developed chest pain in 2006 and underwent cardiac catheterization. He again developed chest pain the month prior and had a repeat cardiac catheterization. The chest pain then resolved and he was asymptomatic. Clinical findings were reported. Diagnostic testing did not reveal cardiac hypertrophy or dilatation. As relevant, echocardiogram showed LVEF of 65 percent. Recent exercise stress test did not reveal chest pain, but the Veteran developed shortness of breath at peak exercise. METs was 8.30. The examiner reported limitation in METs was not solely due to the heart condition. August 2013 private medical records showed that the Veteran underwent another cardiac catheterization following a myocardial infarction (MI). He recently developed unstable angina. Following catheterization, the chest pain ceased and no arrhythmia was found. Echocardiogram showed LVEF of 55 percent. August 2013 private medical records included an echocardiogram. The LVEF ejection fraction was estimated between 55 and 60 percent and deemed to be normal. In October 2013, the Veteran was afforded another VA heart examination. The examiner diagnosed ischemic heart disease with a 2006 onset and myocardial infarction from August 2013. He noted the recent stent placement. He estimated the level of activity between greater than 7 to 10 METs before dyspnea and fatigue appear. Diagnostic test results were reviewed. They did not show cardiac hypertrophy or dilatation. LVEF was reported as 60 to 65 percent. The examiner reported that the Veteran was recovering from the recent myocardial infarction. He was basically asymptomatic. However, once he fully recovered, he would be able to perform moderate physical work. March 2016 private cardiologist records showed that the Veteran was doing well. He denied chest pain or shortness of breath. Clinical findings were reported and included an electrocardiogram (EKG) report. The cardiologist assessed the Veteran as doing well from a cardiac standpoint. He adjusted the Veteran’s medications and advised him to return in a year. April 2018 private medical records showed that the Veteran’s most recent echocardiogram showed LVEF of 55 percent. The cardiologist described the Veteran as doing well. The Veteran did not have chest pain or shortness of breath. Clinical findings were reported. The cardiologist assessed the Veteran as stable from a cardiac standpoint. He advised the Veteran to return in a year. In September 2018, a cardiac DBQ was obtained. The examiner diagnosed a MI from August 2013 and ischemic heart disease. The Veteran reported that experienced mild fatigue with activity such as chopping wood or prolonged walking. He denied angina. Clinical findings were reported and included a March 1, 2016 electrocardiogram confirming cardiac hypertrophy. As relevant, the examiner reported that exercise stress was not indicated as part of the current treatment plan. Interview based METs test showed estimated results of between greater than 7 and 10 METs due to the heart disability. He noted the Veteran’s back and ankle condition would affect his level of activity. The Board has considered the medical and lay evidence of record and finds that a preponderance of the evidence is against initial ratings for ischemic heart disease higher than the currently assigned 10 percent rating prior to March 1, 2016 and 30 percent rating thereafter. 38 C.F.R. §§ 4.3, 4.104, DC 7005. Prior to March 1, 2016, the Veteran’s service-connected ischemic heart disease did not approximate METs workload requirements for a 30 percent rating or include clinical evidence of cardiac hypertrophy or dilatation. Id. Although the Veteran had a MI and repeated cardiac catheterization in August 2013, the post procedure findings do not show that the cardiac symptoms worsened. From March 1, 2016, the Veteran’s service-connected ischemic heart disease did not approximate METs workload requirements for a 60 percent rating or include LVEF of 50 percent or less. Id. The Veteran is not shown to have congestive heart failure. The Board notes the Veteran’s contentions that his service-connected ischemic heart disease is worse than currently rated. However, with the exception of the August 2013 MI and catheterization, the medical records indicate Veteran is generally asymptomatic. See private cardiology records from July 2011 to September 2018. For the foregoing reasons, the preponderance of the evidence weighs against assignment of higher initial ratings for service connected ischemic heart disease. Thus, the benefit of the doubt doctrine is not for application and higher initial ratings must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his prior representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). V. Earlier effective date If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The Board notes 38 C.F.R. § 3.157(b)(1) in effect prior to March 24, 2015 provides that the date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. However, 38 C.F.R. § 3.157(b)(1) "makes clear that a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability.” MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006); Massie v. Shinseki, 25 Vet. App. 123, 134 (2011), aff'd 724 F.3d 1325 (Fed. Cir. 2013) (§ 3.157(b)(1) requires that a report of examination or hospitalization indicate that the veteran's service-connected disability worsened since the time it was last evaluated because, "[w]ithout such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1)," creating an unnecessary and unwarranted adjudicative burden on VA). This regulation is therefore not for application in connection with the instant claims since they concern the service connection awards. Recent amendments to VA’s regulations, effective March 24, 2015, describe the specific and limited manner and methods by which a claim can be initiated and filed. See 38 C.F.R. §§ 3.1(p), 3.150, 3.155, 3.160 (2015). However, the instant claim was filed prior to these amendments and they do not apply retroactively. The prior version of 38 C.F.R. § 3.155 provided that an informal claim is “[a]ny communication or action, indicating an intention to apply for one or more benefits.... Such informal claim must identify the benefit sought.” 38 C.F.R. § 3.155(a). Thus, the essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have an intent to file a claim for VA benefits); Rodriguez v. West, 189 F.3d 1351, 1354 (Fed. Cir. 1999) (noting that even an informal claim must be in writing); Brannon v. West, 12 Vet. App. 32, 35 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert, 1 Vet. App. at 53. Ischemic heart disease Entitlement to service connection for ischemic heart disease was granted in November 2011, effective August 19, 2011. In a September 2018 rating decision, the RO assigned an April 22, 2010 effective date. The Veteran contends that an earlier effective date is warranted. Generally, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. However, there is an exception for this specific claim. The November 2011 rating decision granted service connection for ischemic heart disease because it had recently been added to the list of diseases that are presumptively due to exposure to herbicide agents, effective August 31, 2010. See Nehmer v. U.S. Veterans Admin., 32 F. Supp. 1404 (N.D. Cal. 1989) (Nehmer I); Nehmer v. U.S. Veterans Admin., 32 F. Supp. 2d 1175 (N.D. Cal. 1999) (Nehmer II); Nehmer v. U.S. Veterans Admin., 284 F.3d 1158 (9th Cir. 2002) (Nehmer III). Where a Nehmer class member is entitled to disability compensation for a covered herbicide disease, and the claim was either pending before VA on May 3, 1989, or was received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose except as otherwise provided in paragraph (c)(3). 38 C.F.R. § 3.816(c)(3) applies to claims filed within one year from the date of separation from service, which did not occur in this case. See 38 C.F.R. § 3.816 (c)(2), (3). A claim will be considered a claim for compensation for a particular covered herbicide disease if: (i) the claimant's application and other supporting statements and submission may reasonably be viewed, under the standards ordinarily governing compensation claims, as indicating an intent to apply for compensation for the covered herbicide disability; or (ii) VA issued a decision on the claim, between May 3, 1989 and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, in which VA denied compensation for a disease that reasonably may be construed as the same covered herbicide disease for which compensation has been awarded. Id. The Veteran has not provided a specific reason why an effective date prior to April 22, 2010 is warranted. Notably, the RO corrected its initial error in not considering the liberalizing Nehmer rules in the September 2018 rating decision. Prior to April 22, 2010, there is nothing from any prior communication that indicates or implies that the Veteran intended to file a claim for compensation for heart disease. Consequently, an informal claim is not shown. For the foregoing reasons, the evidence preponderates against any contention that the Veteran intended to file a claim for compensation for heart disease prior to April 22, 2010. There is also no other document that could be construed as an informal claim and no other exception to general earlier effective date principle applies. An effective date prior to April 22, 2010 for service connection for ischemic heart disease is therefore not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lumbar spine disability The Veteran has not provided a specific reason why an effective date prior to July 8, 2010 is warranted for service-connected degeneration of intervertebral disk space, L5-S1. Prior to July 8, 2010, there is nothing from any prior communication that indicates or implies that the Veteran intended to file a claim for compensation for a back disability. The prior communications beginning in March 2010 concern other disabilities. See April 22, 2010 Report of General Information. Consequently, an informal claim is not shown. For the foregoing reasons, the evidence preponderates against any contention that the Veteran intended to file a claim for compensation for a back disability prior to July 8, 2010. There is also no other document that could be construed as an informal claim and no other exception to general earlier effective date principles applies. An effective date prior to April 22, 2010 for service connection for ischemic heart disease is therefore not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to a TDIU is remanded. Since the Veteran has submitted service connection claims for symptoms associated with PTSD, the Board finds entitlement to TDIU is raised by the record. The Veteran has an occupational history in labor and reports leaving work in sometime in 2011 due occupational interference from PTSD type symptoms. (See VA treatment records from April 2013 and November 2013; July 2013 statement; February 2014 VA PTSD examination report). The Veteran is service-connected for PTSD from February 9, 2012. He has not submitted a formal TDIU claim as to when he last worked and the reason for leaving work. More information is needed as to the Veteran’s employment history. Then, the RO must have an opportunity to implement the initial ratings for the newly service-connected disability awards from the instant decision and determine whether the schedular criteria are met for the entire claims periods from April 22, 2010. The matter is REMANDED for the following action: 1. Furnish VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) to the Veteran and request that he complete and return the form detailing when and why he left his longstanding job in 2011. 2. Adjudicate the issue of entitlement to a TDIU. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. D. Simpson, Counsel