Citation Nr: 18151808 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-21 383 DATE: November 20, 2018 ORDER Entitlement to service connection for tinnitus is denied. Entitlement to service connection for allergic rhinitis is granted. Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for tension headaches is granted. Entitlement to a compensable disability rating for hypertension is denied. Entitlement to a disability rating in excess of 60 percent for residuals of prostate cancer is denied. Entitlement to separate disability ratings for service-connected acute pulmonary embolism and sleep apnea is denied. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a higher disability rating for acute pulmonary embolism with sleep apnea, rated as 60 percent disabling prior to September 29, 2014, and 50 percent thereafter, is remanded. Entitlement to a disability rating in excess of 10 percent for degenerative disc disease of the thoracolumbar spine remanded. Entitlement to a disability rating in excess of 10 percent for left knee chondromalacia is remanded. Entitlement to an initial disability rating in excess of 10 percent for right knee degenerative joint disease is remanded. Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has tinnitus that arose during or is otherwise related to his military service. 2. There is not clear and unmistakable evidence showing that the Veteran’s allergic rhinitis preexisted service and that this disability was not aggravated by service. 3. The preponderance of the probative evidence is against finding that the Veteran had a heart disorder during the pendency of the claim 4. The probative evidence is at least in relative equipoise as to whether the Veteran’s headaches are caused or aggravated by his service-connected PTSD. 5. The preponderance of the evidence indicates that the Veteran’s hypertension is not manifested by diastolic pressure that is predominantly 100 or more; systolic pressure that is predominantly 160 or more; nor is there a history of diastolic pressure that is predominantly 100 or more that requires continuous medication for control. 6. The preponderance of the evidence indicates that the Veteran’s residuals of prostate cancer were manifested by voiding dysfunction causing urine leakage and the wearing of absorbent materials which must be changed 4 or more times per day, daytime voiding intervals between one and two hours, and awakening to void three to four times per night; it was not manifested by any renal dysfunction or local recurrence or metastasis of his prostate cancer. 7. VA regulations precluded assignment of separate disability ratings for the co-existing respiratory conditions of acute pulmonary embolism and sleep apnea. 8. The preponderance of the evidence indicates that the Veteran’s PTSD was productive of occupational and social impairment which most nearly approximates reduced reliability and productivity, but not productive of occupational and social impairment in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for service connection for allergic rhinitis have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 3. The criteria for service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 4. The criteria for service connection for tension headaches have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310(a) (2018). 5. The criteria for a compensable disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §4.104, Diagnostic Code 7101 (2018). 6. The criteria for a disability rating in excess of 60 percent for residuals of prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.115(a), (b), Diagnostic Code 7528 (2018) 7. The criteria for assignment of separate disability ratings for the co-existing respiratory conditions of acute pulmonary embolism and sleep apnea have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.14, 4.96, 4.97, Diagnostic Codes 6817 and 6847 (2018). 8. The criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Codes 9411 and 9434 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from September 2002 to December 2002, April 2003 to July 2003, and November 2004 to September 2007. He also had prior reserve service in Maryland Air National Guard and the United States Army Reserves, including a period of active duty for training from January 1999 to February 1999. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or 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.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease, injury, or event and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for disability which is proximately due to, the result of, or aggravated by service-connected disability. 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 disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic disabilities to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). Rebutting the presumption of soundness requires a two-part analysis. VA must demonstrate by clear and unmistakable evidence that a disorder preexisted military service and must demonstrate by clear and unmistakable evidence that a preexisting disorder was not aggravated by military service. 38 C.F.R. § 3.304(b) (2018); VAOPGCPREC 3-03 (July 16, 2003), 69 Fed. Reg. 25178 (May 5, 2004); Wagner v. Principi, 370 F.3d 1089, 1093 (Fed. Cir. 2004). A veteran is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. See Cotant v. Principi, 17 Vet. App. 116, 132 (2003). If VA’s burden is met, then the veteran is not entitled to service-connected benefits. However, if the presumption of soundness is not rebutted under 38 U.S.C. § 1111, the veteran’s claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. Wagner, 370 F.3d at 1096. Clear and unmistakable evidence means that the evidence “cannot be misinterpreted and misunderstood, i.e., it is undebatable.” Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Yanerson v. West, 12 Vet. App. 254, 258-59 (1999)). The clear-and-unmistakable-evidence standard is an “onerous” one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)). Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied, “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Entitlement to service connection for tinnitus. The Veteran asserts that service connection for tinnitus is warranted. The Board acknowledges that the Veteran is competent to report the presence of observable symptoms, such as ringing in his ears. 38 C.F.R. § 3.159(a)(2) (2018); Charles v. Principi, 16 Vet. App. 370 (2002) (finding lay person competent to identify tinnitus). Therefore, his lay reports may be sufficient to prove his claim if they are credible and consistent with the other evidence of record. Here, however, the Board finds that the Veteran’s lay statements regarding the presence of tinnitus offered in support of his current claim are not credible. In this regard, numerous VA treatment records, including those from December 30, 2013, July 29, 2014, September 15, 2014, November 4, 2014, May 6, 2015, July 7, 2015, and September 15, 2015, indicate that the Veteran did not have tinnitus. As the Veteran’s routine denials of tinnitus were made in furtherance of treatment, they are accorded more probative value than the Veteran’s statements regarding tinnitus offered in support of his current claim. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Rucker v. Brown, 10 Vet. App. 67, 73 (1997). Absent competent and credible evidence of a current disability, the claim for service connection must be denied. Brammer v. Derwinski, 3 Vet. App. at 225 (1992). Nevertheless, for the sake of thoroughness, the Board will briefly address the second element for service-connection. Assuming arguendo, the Board was to concede a current disability, the preponderance of the evidence is against finding an in-event, injury, or disease. Aside from filing his claim for service connection and pursuing the instant appeal, the Veteran has not made any statement describing his tinnitus or attributing his reported tinnitus to an in-service event, injury, or disease. Additionally, he has not alleged that he experienced tinnitus during service or in the one-year presumptive period following his separation from service. Service treatment records are silent as to any complaints or treatment related to tinnitus. Additionally, the Veteran’s military occupational specialty was a chaplain, which has a low probability of noise exposure. Accordingly, the second element for service connection is also not met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 2. Entitlement to service connection for allergic rhinitis. The Veteran asserts that service connection is warranted for allergic rhinitis. On an October 1979 report of medical history, the Veteran noted that he was in good health and was not on any medications, but reported a history of ear, nose, and throat trouble. A history of mild hay fever was noted in the physician’s summary section. The associated report of medical examination was silent for any clinical abnormalities pertaining to allergic rhinitis. Subsequent reports of medical history and report of medical examination do not include a history of or clinical findings related to allergic rhinitis. Service treatment records from August 2006, October 2006, and August 2007 indicate that the Veteran was diagnosed with allergic rhinitis and was prescribed medication to manage his symptoms. Subsequent service treatment records continue to list allergic rhinitis on the Veteran’s “problems” list. Post-service VA treatment records showed that the Veteran was continuously prescribed allergy medication. The Veteran was afforded a VA examination in November 2016. The examiner noted that the Veteran was diagnosed with allergic rhinitis in 2007 and was prescribed medication. The examiner opined that it was at least as likely as not that his allergic rhinitis was related to service. The rationale was that the service treatment records include a diagnosis of rhinitis in 2007 with medication prescribed and continued since that time. The examiner acknowledged that the October 1979 service treatment record noted mild hay fever. The examiner explained that the Veteran had a diagnosis of “allergies” and therefore his allergic rhinitis was at least as likely as not incurred in service. The same examiner provided an addendum opinion in January 2017. The examiner opined that the Veteran’s allergic rhinitis, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, illness. The examiner explained that the Veteran’s allergies were environmental and that the symptoms resolved when environmental allergies were removed. The examiner stated that the Veteran’s age affected his immune function, and as a result his inflammatory response was also affected, which may explain late onset or more chronic allergic rhinitis. On that basis, the examiner opined that the Veteran’s allergic rhinitis was less likely than not aggravated by his allergy complaints during service. Based on a review of the evidence of record, the Board finds that there is not clear unmistakable evidence that the Veteran’s allergic rhinitis both preexisted service and was not aggravated by service. While there is some evidence of allergies and hay fever prior to the Veteran’s active service, his service treatment records do not contain an enlistment examination noting a diagnosis of allergic rhinitis. With regard to the nexus opinions of record, the same examiner offered conflicting opinions. While the examiner initially concluded that the Veteran’s allergic rhinitis was incurred during service, in a subsequent she opined that the Veteran’s allergic rhinitis clearly and unmistakably preexisted service. With regard to whether there is clear and unmistakable evidence that the Veteran’s allergic rhinitis was not aggravated by service, in the January 2017 opinion the examiner appears to apply the incorrect standard. Specifically, she stated that it was less likely than not that the Veteran’s allergic rhinitis was aggravated by service. Contrary to the examiner’s statement, the standard requires clear and unmistakable evidence that the condition was not aggravated. Additionally, the examiner’s rationale in support of her finding was that the Veteran’s lessened immune function and increased inflammatory response due to aging may explain his more chronic allergic rhinitis. The examiner’s use of the word “may” renders the opinion speculative. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (finding that medical opinions expressed in terms of “may” also imply “may or may not” and are too speculative to establish medical nexus). In light of the above, the Board finds that the presumption of soundness has not been rebutted as there is not clear and unmistakable evidence that the Veteran’s allergic rhinitis preexisted service and was not aggravated by service. Therefore, the Veteran’s claim must be considered a normal claim for service connection without consideration of a preexisting disorder. Wagner, 370 F.3d at 1089. As noted above, the service treatment records indicate that the Veteran was treated for allergic rhinitis during service and was prescribed treatment at that time. Post-service medical records continued to show treatment for allergic rhinitis. Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that service connection for allergic rhinitis is warranted. 3. Entitlement to service connection for a heart disorder. The Veteran asserts that he is entitled to service connection for a heart disorder. Nevertheless, apart from filing a claim and pursing the appeal, the Veteran has not offered any details regarding the nature or onset of his claimed heart disorder. VA primary care records from February 14, 2012 and April 12, 2013 note that a review of the cardiovascular system was negative for rapid heartbeat, irregular heartbeat, loss of consciousness, chest pain, or ankle swelling. An October 2013 VA cardiology records showed that the Veteran presented with complaints of atypical chest pain. An exercise stress test was completed and a Duke Treadmill Score indicated that there was a low probability of any angiographic coronary disease. His heart rate recovery time was adequate, he did not have any symptoms during exercise, and there were no significant arrhythmias evident. The conclusion was no evidence of myocardial ischemia by electrocardiography criteria. The cardiologist stated that his electrocardiography findings appeared to have no worrisome findings. In November 2013, the Veteran was admitted to the hospital due to a pulmonary embolism. At that time, he underwent a computed tomography angiography of the chest, a chest x-ray, and an electrocardiography, none of which revealed a heart disorder. A September 15, 2014 VA record notes that the Veteran denied chest pain or palpations. Upon examination, his heart rate and rhythm were normal and there was no evidence of any murmur. A December 30, 2014 VA record indicated that there the Veteran heart rate, and rhythm were normal, there was no evidence of a murmur, or signs of cardiac enlargement. An April 28, 2016 VA record noted that a review of cardiovascular system was negative for chest pain, near falling dizziness, ongoing leg and foot swelling, and unexplained sweating. While the Board acknowledges the Veteran’s assertion that he has a heart disability, as a lay person, he has not shown that he has specialized training sufficient to render such a diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis or etiology). As the diagnosis of heart disabilities are matters not capable of lay observation and require medical expertise to determine, his assertions that he has a current heart disability are not probative. Accordingly, the Board finds that the weight of the evidence is against finding a current heart disability at any time during the period on appeal. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. at 225 (1992). 4. Entitlement to service connection for headaches. The Veteran was provided a VA examination in May 2016. The Veteran reported that his headaches were related to stress or elevated blood pressure. His primary care provider recently changed his hypertension medication, but he did not notice a change in his headaches. He reported that he bumped his head multiple times during service because of his height. The examiner opined that the Veteran’s headaches were less likely than not related to service. An addendum opinion was completed by another examiner in September 2017. The examiner opined that the Veteran’s tension headaches were less likely than not proximately due to or the result of his hypertension or PTSD. The examiner explained that the Veteran had high blood pressure since 2004 and that his headaches started around 2015, therefore the timeline did not support causality by hypertension. The examiner also stated that the type of headaches that the Veteran had were not the typical headache seen in headaches triggered by high blood pressure. Regarding the Veteran’s PTSD, the examiner stated that there was no documentation in the medical records associating headaches with PTSD and the type of headache the Veteran had was not typically associated with PTSD. The examiner also noted that there was no evidence that the medication used for the Veteran’s PTSD triggered his headaches. The Veteran submitted a private examination and opinion in February 2018. Following an interview of the Veteran and a review of the claims file, Dr. H. S. opined that the Veteran’s PTSD aided in the development of and permanently aggravated his headaches. Dr. H. S. noted that the Veteran experienced headaches when he was bothered by his psychiatric symptoms. In support of the opinion, it was noted that medical literature showed that patients with mental health disorders were more likely to develop headaches because pain and mood are regulated by the same part of the brain. Therefore, it was well established that mental disorders both cause and aggravated headaches. After considering the conflicting medical opinions, the Board finds that service connection for tension headaches is warranted. In cases where there are conflicting statements or opinions from medical professionals, it is within the Board’s province to weigh the probative value of those opinions. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the credibility and weight to be attached to medical opinions is within the province of the adjudicators). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings. See Sklar v. Brown, 5 Vet. App. 140 (1993). So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The May 2016 VA medical examiner addressed direct service connection, but did not provide any rationale in support of the opinion. Accordingly, it is afforded little probative weight. The September 2017 VA examiner addressed secondary service connection and explained that the type of headaches that the Veteran experienced were not typically associated with PTSD. Nevertheless, as the examiner provided no rationale for the finding that the Veteran’s headaches were inconsistent with the type of headaches associated with hypertension or PTSD, it is also afforded little probative weight. The February 2018 private examiner found that the Veteran’s service-connected PTSD caused or aggravated his headaches. The private examiner bolstered his opinion with medical literature indicating that people with mental health disorders were more likely to experience headaches because mood and pain were regulated by the same part of the brain. Accordingly, the Board finds that the private opinion is the most probative evidence of record. Accordingly, the Board finds that the Veteran’s tension headaches were caused or aggravated by his service-connected PTSD. Therefore, service connection for tension headaches is warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2018). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2018); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2018); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2018); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10 (2018). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2018). 5. Entitlement to a compensable disability rating for hypertension. The Veteran’s hypertension is currently rated as noncompensable pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101 (2018). A 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Id. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. Id. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. Id. A 60 percent rating is warranted for diastolic pressure predominantly 130 or more. Id. In every instance where the rating schedule does not provide for a noncompensable evaluation, a noncompensable evaluation shall be assigned where the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2018). Following a review of the evidence of record, the Board finds that the evidence does not support granting a compensable rating at any point during the appeal period. At his September 2014 VA examination, the Veteran reported that he regularly checked his blood pressure at home and that it averaged 135/85. On examination, his blood pressure readings were 134/79, 152/85, and 148/81. While the examiner noted that the Veteran’s hypertension was treated with amlodipine, the examiner also indicated that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. The examiner stated that his hypertension did not impact his ability to work. VA treatment records also consistently showed diastolic pressures below 100 and systolic pressures below 160. Accordingly, the Board finds that the Veteran is not entitled to a compensable rating for his service-connected hypertension. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) (2018) regarding reasonable doubt are not applicable. The claim of entitlement to a compensable rating for hypertension must be denied. 6. Entitlement to a disability rating in excess of 60 percent for residuals of prostate cancer. The Veteran’s residuals of prostate cancer disability are evaluated under Diagnostic Code 7528. Malignant neoplasms of the genitourinary system are evaluated as 100 percent disabling. 38 C.F.R. § 4.115(b), Diagnostic Code 7528 (2018). Following the cessation of surgical, X-ray, antineoplastic, chemotherapy, or other therapeutic procedure, the evaluation of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, as here, the disability will be rated on the residuals as voiding dysfunction or renal dysfunction, whichever is predominant. Id, at Note. Voiding dysfunction is evaluated as either urine leakage, frequency, or obstructed voiding. 38 C.F.R. § 4.115(a) (2018). With continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, a 40 percent evaluation is warranted for a disability requiring the wearing of absorbent materials which must be changed two to four times per day. Id. A 60 percent evaluation is warranted for the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. Id. For urinary frequency, a 40 percent evaluation is warranted for daytime voiding interval less than one hour, or; awakening to void five or more times per night. Id. For obstructed voiding, a 30 percent evaluation is warranted for urinary retention requiring intermittent or continuous catheterization. Id. For urinary tract infection, poor renal function is evaluated as renal dysfunction. Id. A 30 percent evaluation is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Id. For renal dysfunction, a 60 percent evaluation is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. Id. An 80 percent evaluation is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Id. A 100 percent evaluation is warranted for regular dialysis or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decease function of kidney or other organ systems, especially cardiovascular. Id. Following a review of the evidence of record, the Board finds that a rating in excess of 60 percent for residuals of prostate cancer is not warranted. Initially, the Board notes that a higher schedular rating under Diagnostic Code 7528 is only available under the criteria for rating renal dysfunction. However, the evidence is against finding that the Veteran has any renal dysfunction as a residual of his prostate cancer. Rather, his residuals have been characterized by voiding dysfunction. Therefore, consideration of an evaluation based on renal dysfunction is not warranted. Additionally, the medical evidence shows that the Veteran’s residuals of prostate cancer are consistent with the currently assigned 60 percent disability rating. The Veteran was afforded a VA examination in September 2014. The examiner noted that prostate cancer was diagnosed in 2006 and that he underwent a perineal prostatectomy in January 2007. At the time of the examination, the Veteran’s prostate cancer was noted to be in remission. The examiner noted voiding dysfunction with urine leakage that required absorbent material that must be changed more than four times per day. He was also noted to have increased urinary frequency, with daytime voiding intervals between one and two hours and nighttime awakening to void three to four times per night. His voiding dysfunction was also manifested by postvoid dribbling. There was no need for use of an appliance for his voiding dysfunction and he did not have a history of recurrent symptomatic urinary tract or kidney infections. Again, the Veteran did not have any renal dysfunction due to his prostate cancer. The examination revealed a scar, but it was not painful and/or unstable, and the total area was not greater than 39 square centimeters. Accordingly, the Board finds that the Veteran is not entitled to a disability rating in excess of 60 percent for his service-connected residuals of prostate cancer. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The claim of entitlement to a disability rating in excess of 60 percent must be denied. 7. Entitlement to separate disability ratings for acute pulmonary embolism and sleep apnea. The Veteran asserts that he is entitled to separate disability ratings for acute pulmonary embolism and sleep apnea. In December 2009, the RO granted service connection for pulmonary embolism and assigned a noncompensable disability rating pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6817, effective December 15, 2008. In the September 2014 rating decision on appeal, the RO increased the disability rating to 30 percent, effective September 8, 2014. In April 2016, the RO granted service connection for sleep apnea and included it in the rating for acute pulmonary embolism. A single 60 percent was assigned prior to September 29, 2014, pursuant to Diagnostic Code 6817. Thereafter, a single 50 percent rating was assigned pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6847. Rating co-existing respiratory conditions is governed by 38 C.F.R. § 4.96(a) (2018), which states that ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. “A fundamental canon of statutory construction is that when interpreting a statute, the words of a statute are given ‘their ordinary, contemporary, common meaning.’” See Gordon v. Nicholson, 21 Vet. App. 270, 277 (2007). The canons of statutory construction apply to regulations as well as statutes. See Smith (William) v. Brown, 35 F.3d 1516, 1523 (Fed. Cir. 1994). Based on the foregoing, separate ratings for acute pulmonary embolism under Diagnostic Code 6817 and sleep apnea under Diagnostic Code 6847 are not permitted. The Board acknowledges that under 38 C.F.R. § 4.14 it is permissible to have separate and distinct manifestations attributable to two different disability ratings, and, in such a case, the veteran should be compensated under different diagnoses. In addition, separate ratings may be assigned for distinct manifestations resulting from the same disability so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Although a review of the medical evidence appears to suggest that the symptomatology of acute pulmonary embolism and sleep apnea do not overlap, the Board is still bound by 38 C.F.R. § 4.96(a) (2018), which specifically prohibits the assignment of separate ratings for acute pulmonary embolism and sleep apnea. Therefore, as the Veteran’s acute pulmonary embolism is rated under Diagnostic Code 6817 and his sleep apnea is rated under Diagnostic Code 6847, separate ratings are prohibited as a matter of law. 8. Entitlement to a disability rating in excess of 50 percent for PTSD. At the outset, the Board notes that it has reviewed all the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran’s service-connected PTSD is currently rated as 50 percent disabling pursuant to the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130 (2018). According to the General Rating Formula for Rating Mental Disorders a 50 percent disability rating is warranted when there is 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 and long-term memory (e.g., 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. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The maximum 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. After a review of all the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence of record does not support a rating greater than 50 percent for the Veteran’s PTSD. Throughout this period, the Veteran’s PTSD symptoms predominantly included well-controlled nightmares, stable mood and sleep, some anxiety, mild depressive symptoms, irritability, hypersomnolence, and low motivation. His nightmares were less frequent and less intense. The September 2014 VA examiner was unable to determine the current severity of his PTSD or his psychosocial functioning due to possible malingering. The examiner administered multiple psychiatric assessments and concluded that the Veteran exaggerated his symptoms. Mental status examinations showed appropriate grooming and appearance, interested and cooperative attitude, normal behavior, normal speech, congruent affect, mildly dysphoric mood, organized thought process, full orientation, no memory impairment, fair judgment, and fair insight. There were no obvious delusions or paranoia. The medical evidence shows that he denied suicidal thoughts. Regarding social and occupational impairment, the Veteran worked as a Baptist minister and felt appreciated when he was asked to return as a minister. He was married to his wife of six years and described their relationship as good and denied any separations. He also described his relationship with his son as pretty good. He also reported having several acquaintances that he socialized with and ate dinner with. His leisure activities included watching television, playing with his grandchildren, and attending high school football games. The Veteran worked fulltime as a mental health worker and a minister. He reported that he did not have any difficulty with his supervisors or coworkers. In light of the above, the Board finds that the Veteran is not entitled to a higher rating for his service-connected PTSD. Specifically, the record indicates that the Veteran has worked full-time, he denied having trouble with his supervisors or coworkers, he described his relationship with his wife and son as “good” or “pretty good,” and he has several acquittances with whom he socializes. While the manifestations of the Veteran’s PTSD may have fluctuated throughout the appeal period, at no point have his symptoms more nearly approximated the criteria for 70 percent rating, which requires “deficiencies in most areas.” Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) (2012) regarding reasonable doubt are not applicable. The claim of entitlement to an evaluation in excess of 50 percent for PTSD must be denied. REASONS FOR REMAND 1. Entitlement to a higher disability rating for acute pulmonary embolism with sleep apnea, rated as 60 percent disabling prior to September 29, 2014, and 50 percent thereafter. The Veteran’s most recent VA examination to assess the severity of his service-connected acute pulmonary embolism with sleep apnea was in September 2014. VA treatment records subsequent to that examination indicate that his symptoms may have worsened. Specifically, an October 2014 VA treatment records indicates that the Veteran stopped anticoagulation medication on September 29, 2014. In October 2014, he was treated for a superficial clot in his leg. A November 2014 VA primary care note indicates that the Veteran had a history of two pulmonary embolisms and one superficial venous thrombosis. He was then started on permanent anticoagulation medication. Accordingly, a new VA examination is warranted to determine the current severity of the Veteran’s service-connected acute pulmonary embolism with sleep apnea. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). 2. Entitlement to a disability rating in excess of 10 percent for degenerative disc disease of the thoracolumbar spine. 3. Entitlement to a disability rating in excess of 10 percent for left knee chondromalacia. 4. Entitlement to an initial disability rating in excess of 10 percent for right knee degenerative joint disease. A recent decision, Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court explained that VA examiners must do all that can be reasonably done to become informed about a veteran’s reported musculoskeletal flare-ups prior to providing an opinion on functional loss during flares. Specifically, the Court found an examiner must consider and discuss all procurable and assembled data such as the frequency, duration, characteristics, precipitating and alleviating factors, and the severity of the flare-ups, before concluding an assessment of the functional loss during flares could not be provided without resorting to speculation. The Veteran was provided VA thoracolumbar and knee examinations in September 2014. While the Veteran endorsed lumbar spine and bilateral knee flare-ups, the examiner indicated that she was unable to describe the Veteran’s functional loss due to flare-ups because the Veteran was not examined during a lumbar spine or bilateral knee flare-up. Accordingly, a remand for additional VA thoracolumbar spine and knee examinations is required. 5. Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity. The Veteran’s most recent VA examination to assess the severity of his service-connected radiculopathy of the left lower extremity was in September 2014. Subsequent VA treatment records indicate that his symptoms may have worsened since that time. VA treatment records from April 2016 indicate a possible decrease in the Veteran’s left lower extremity sensation and note that his primary care physician started him on gabapentin for nerve pain. Accordingly, a new VA examination is necessary to determine the severity of his service-connected radiculopathy of the left lower extremity. See Snuffer v. Gober, 10 Vet. App. at 403; Green v. Derwinski, 1 Vet. App. 121. The matters are REMANDED for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e) (2018). 2. After the above is completed to the extent possible, the Veteran should be afforded a VA examination by an examiner with sufficient expertise to determine the current severity of his service-connected acute pulmonary embolism with sleep apnea. The electronic records should be made available to and reviewed by the examiner. Any indicated studies should be performed. 3. Then, the Veteran should be afforded a VA examination by an examiner with sufficient expertise to determine the current severity of his service-connected thoracolumbar spine and bilateral knee disorders. The electronic records should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In addition, the examiner must determine the extent of any additional limitation of joint motion (in degrees) due to weakened movement, excess fatigability, incoordination, or pain during flare-ups and/or with repeated use. In doing so, the examiner must consider and discuss all procurable and assembled data such as the frequency, duration, characteristics, precipitating and alleviating factors, and the severity of the flare-ups, and then provide an assessment of the functional loss during flares, if possible in degrees of motion lost. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Then, the Veteran should be afforded a VA examination by an examiner with sufficient expertise to determine the current severity of his service-connected radiculopathy of the left lower extremity. The electronic records should be made available to and reviewed by the examiner. Any indicated studies should be performed. 5. Finally, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. J. A. Anderson Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. N. Nolley, Associate Counsel