Citation Nr: 18152229 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 15-08 160 DATE: November 21, 2018 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to an initial compensable rating for service connected lumbar degenerative disc disease is denied. Entitlement to an initial rating in excess of 10 percent for service connected left knee degenerative joint disease post ACL repair, tibial plateau fracture is denied. Entitlement to a separate compensable disability rating of 10 percent for limitation of extension of the left knee under Diagnostic Code 5261 from July 30, 2013 forward is granted. Entitlement to a separate compensable rating of 10 percent for instability of the left knee under Diagnostic Code 5257 is granted. Entitlement to an initial rating in excess of 10 percent for service connected left ankle degenerative joint disease is denied. Entitlement to an initial compensable rating for service connected erectile dysfunction is denied. Entitlement to an initial rating in excess of 40 percent for service connected radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer prior to March 9, 2015 is denied. Entitlement to an initial rating in excess of 60 percent for service connected radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer since to March 9, 2015 is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s sleep apnea is related to his active service or was otherwise incurred in service. 2. Throughout the appeal period, the Veteran’s lumbar degenerative disc disease has been manifested by subjective complaints of pain but with objective findings of normal range of motion, without evidence of painful motion, tenderness, muscle guarding, or muscle spasm. 3. For the entire period on appeal, the Veteran’s left knee disability was manifested by pain, limitation of flexion to 75 degrees at worst with pain; but not by flexion limited to 30 degrees or less. 4. For the period from July 30, 2013 forward, the Veteran’s left knee disability was manifested by limitation of extension to 20 degrees, but not by limitation of extension to 30 degrees or more. 5. For the period from July 30, 2013 forward, the Veteran’s left knee disability was manifested by slight instability, but not by moderate instability. 6. For the appeal period, the Veteran’s left ankle degenerative joint disease has been manifested by marked limitation of motion and complaints of pain, swelling, and instability. 7. For the entire appellate period, the Veteran’s erectile dysfunction has manifested by loss of erectile power without objective findings of deformity of the penis associated with the service connected disability. 8. The Veteran is already in receipt of the maximum level of SMC for loss of use of a creative organ. 9. Prior to March 9, 2015, the Veteran’s service connected radical prostatectomy was manifested by voiding dysfunction requiring the wearing of absorbent materials, which had to be changed two to four times per day. 10. Since March 9, 2015, the Veteran is in receipt of the maximum schedular rating for voiding dysfunction associated with his service connected radical prostatectomy, and there is no associated renal dysfunction. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 2. The criteria for entitlement to an initial compensable rating for lumbar degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.17a. Diagnostic Codes 5424, 5003 (2018). 3. The criteria for an initial disability rating in excess of 10 percent for the Veteran’s service connected left knee degenerative joint disease post ACL repair, tibial plateau fracture under Diagnostic Code 5259 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010-5259 (2018). 4. The criteria for a separate disability rating of 20 percent for a left knee disability, manifested by limitation of extension from July 30, 2013 have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010-5261 (2018). 5. The criteria for a separate disability rating of 10 percent for left knee instability have been met for the entire period on appeal. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5257 (2018). 6. The criteria for an initial rating in excess of 10 percent for right ankle degenerative joint disease have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5271-5010 (2018). 7. The criteria for an initial compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1114 (k), 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.14, 4.31, 4.115b, Diagnostic Code 7522 (2018). 8. Prior to March 9, 2015, the criteria for an initial rating in excess of 40 percent for residuals of radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105(e), 4.1, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2018). 9. Since March 9, 2015, the criteria for an initial rating in excess of 60 percent for residuals of radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105(e), 4.1, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1987 to June 2007. A February 2015 rating decision granted an increased disability evaluation of 60 percent for the Veteran’s service connected radical prostatectomy effective March 20, 2015. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for sleep apnea Though the Veteran’s service treatment records are negative for any treatment, complaint, or diagnosis of sleep apnea, he asserts that his sleep apnea is as a result of his active service. He contends that while he slept in service he would wake up abruptly as if he was prevented from breathing and that his symptoms began while he was on active duty and have continued to the present. Initially, the Board finds that the Veteran has been diagnosed with obstructive sleep apnea. Several lay statements from the Veteran’s wife and service bunkmate are of record. The Veteran’s wife maintains the Veteran has continually had snoring and sleeping problems. She specifically that he uses a CPAP machine and occasionally wakes up gasping for air. The Veteran’s service bunkmate asserted that while both he and the Veteran were sleeping, the Veteran would snore and “take long pauses and stop snoring and then gasp for air.” An April 2013 statement from private physician C.A. confirmed diagnosis of sleep apnea, and after review of a sleep study test, physical examinations, and lay statements, Dr. C.A. opined that it was more likely than not the Veteran’s sleep apnea was related to his military service. There is no evidence indicating that Dr. C.A. is not competent or credible, and as the opinion is supported by a rationale, it is entitled to probative weight At February 2015 VA exam, the examiner opined the Veteran’s sleep apnea was less likely than not related to his active service. As rationale, the examiner stated there was no evidence in the Veteran’s service treatment records which noted sleep problems, fatigue, or daytime somnolence. He also noted that the first complains of apnea occurred three years after service separation, and snoring itself lacked the specificity needed for a diagnosis of sleep apnea. As the opinion is based on accurate facts and supported by a well-reasoned rationale, the opinion is also entitled to probative weight. Nieves-Rodriguez, 22 Vet. App. at 302-05. A September 2015 Disability Benefits Questionnaire completed by a private physician confirmed diagnosis of sleep apnea, noted the Veteran’s present symptoms of weakness and fatigue, and opined that these symptoms were present when the Veteran was in active service. The physician provided no further rationale for his opinion. Upon review of all the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s currently diagnosed sleep apnea was incurred in service. Although the February 2015 VA examiner opined that the Veteran’s sleep apnea was less likely than not related to active service, after review of the Veteran’s record and a physical examination, Dr. C.A. opined that the Veteran’s currently diagnosed sleep apnea was related to service. As both opinions are competent, credible and supported by a reasoned rationale, there is no reason to prefer one opinion over the other. Similarly, the Veteran’s wife and service bunkmate are competent to report what they observed of his sleep habits, and they are consistent with each other regarding his snoring and breathing pauses. There is no basis upon which to question their credibility. Moreover, the symptoms manifested in service were ultimately diagnosed as sleep apnea. When, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Thus, following a full review of the record, and applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. The Veteran’s claim for service connection for sleep apnea is granted. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). Separate diagnostic codes identify the various disabilities. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (2018). In evaluating musculoskeletal disabilities, consideration is given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. 38 C.F.R. §§ 4.40 and 4.45 (2018); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59 (2018). Johnson v. Brown, 9 Vet. App. 7 (1996). However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the United States Court of Appeals for Veterans Claims (Court) clarified that there is a difference between joint motion pain as opposed to pain that places further limitation of the particular range of motion. Disability of the musculoskeletal system is the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The examination upon which ratings are based must adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2018). Pain must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. The provisions 38 C.F.R. §§ 4.40, 4.45, 4.59 should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the rating claim was filed until a final decision is made. Separate ratings can be assigned for separate periods of time based on the facts found. This is a practice known as “staged” ratings. An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved and contemplates staged ratings where warranted. Fenderson v. West, 12 Vet. App. 119 (1999). 2. Entitlement to an initial compensable rating for service connected lumbar degenerative disc disease The Veteran asserts that his service connected lumbar degenerative disc disease is more severe than his initial noncompensable rating reflects. He is currently rated as noncompensable for his service connected lumbar degenerative disc disease under Diagnostic Code 5242. All spine disabilities are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003 (2018). The General Rating Formula provides for assignment of a 10 percent rating where forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). See also 38 C.F.R. § 4.71a, Plate V. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance for rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Alternatively, disability involving disc disease may be rated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, which provides a 10 percent disability rating for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). A March 2013 VA examination recorded the Veteran’s assertions that his lumbar back disability limited his daily functions, and he reported the use of a back brace. The examiner measured forward flexion as greater than 90 degrees without objective evidence of painful motion, and extension at greater than 30 degrees without objective evidence of pain motion. After repetitive use testing, the Veteran measured forward flexion as greater than 90 degrees without objective evidence of painful motion, and extension at greater than 30 degrees without objective evidence of pain motion. No functional loss was noted upon examination. No symptoms of diagnosis of intervertebral disc syndrome (IVDS) was noted. A private doctor submitted a July 2013 disability questionnaire measured forward flexion as 15 degrees with objective evidence of painful motion at 15 degrees, and extension at 15 degrees with objective evidence of pain motion at 15 degrees. After repetitive use testing, the Veteran measured forward flexion 10 degrees and extension at 15 degrees. The private examiner noted functional loss of less movement than normal, pain on movement, and interference with standing and sitting. He also noted the Veteran had abnormal spinal contour, but did not diagnose IVDS or note incapacitating episodes. Medical treatment records reflect continuous complaints of back pain and the Veteran’s assertions of limitation of motion, but do not reflect any range of motion measurements. A February 2016 private medical treatment record notes the Veteran had normal range of motion in his spine with minimal thoracic narrowing of the spinal canal, mild facet hypertrophy, and minimal posterior bulging. The Board finds that the March 2013 VA examination report and private medical treatment records are more probative than the private July 2013 examination in determining the severity of the Veteran’s back disability during the period on appeal, as it is inconsistent with the March 2013 VA examination, which was conducted only four months prior and with the preferred method of measurement. See 38 C.F.R. § 4.46. Furthermore, the drastic decrease in range of motion noted by the July 2013 disability questionnaire is not supported by the other medical records, which generally show reports of stable back pain without severe limitation of motion or functional loss throughout the period on appeal. Importantly, during a February 2016 private doctor’s visit, the Veteran showed no decreased range of motion or functional loss upon examination. Moreover, while an abnormal spinal contour was noted by the July 2013 examination, no spinal abnormality was noted either by the March 2013 VA examiner or the February 2016 private treatment records. Accordingly, the Board finds that the July 2013 private examination is less probative than the VA examination and private treatment records in determining the severity of his service connected back disorder. After careful review of the evidence, the Board finds that throughout the entire appeal period, a compensable rating for lumbar degenerative disc disease under the General Rating Formula is not warranted. There is no probative evidence of lumbar flexion limited to 60 degrees. There is also no probative evidence of ankylosis, muscle spasm, or guarding severe enough to result in abnormal gait or abnormal spine contour. There is no indication that the Veteran was prescribed bedrest by a physician for IVDS during this period. As such, a higher rating is not warranted for IVDS based on Diagnostic Code 5242. Overall, the probative evidence of record, to include the Veteran’s range of motion testing and other physical findings, is consistent with a noncompensable percent disability rating during this period. In making this finding, the Board accords significant probative weight to the VA examinations provided in March 2013. The Board is cognizant of Correia v. McDonald, 28 Vet. App. 158 (2016), wherein the United States Court of Appeals for Veterans Claims (Court) elaborated on VA examination requirements with respect to joint testing for pain pursuant to 38 C.F.R. § 4.59. It is significant to note that the available medical evidence includes evaluations on range of motion that have been relatively consistent over the course of the appeal. Furthermore, there is no evidence suggesting that the Veteran’s passive range of motion would reveal any more restricted range of motion which would allow for the assignment of a higher rating, nor has the Veteran or his representative alleged any difference in his passive range of motion from the recorded active range of motion. The Board therefore finds that remanding this issue for further examination would not result in any further benefit to the Veteran and would cause an unnecessary delay in the adjudication of the case. Sabonis v. Brown, 6 Vet. App. 426 (1994); Soyini v. Derwinski, 1 Vet. App. 540 (1991) (remand not required when it would impose unnecessary burdens on VA adjudication system with no benefit flowing to the Veteran). The Board has also considered whether the Veteran is entitled to a higher rating due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 206-07. While the Veteran reports back pain, these symptoms cause functional loss that is specifically contemplated by his rating. Importantly, the Veteran’s rating is already based on the extent to which his symptoms limit his range of motion, including after repetitive use and during flare-ups. The Board therefore finds that the criteria for a compensable rating for the Veteran’s lumbar degenerative disc disease have not been met. As a preponderance of the evidence is against the assignment of a compensable rating, the benefit of the doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. 49. As a final matter, the Board finds that the Veteran has not raised the matter of an extraschedular rating and that the evidence does not present exceptional or unusual circumstances. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either a veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). 3. Entitlement to an initial rating in excess of 10 percent for service connected left knee degenerative joint disease post ACL repair, tibial plateau fracture The Veteran also asserts that his service connected left knee degenerative joint disease post ACL repair, tibial plateau fracture is more severe than his initial ratings reflect. His service connected left knee degenerative joint disease post ACL repair, tibial plateau fracture is currently rated as 10 percent disabling under Diagnostic Code 5010-5259. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. 38 C.F.R. § 4.20 (2018). A hyphenated diagnostic code generally reflects rating by analogy to a closely related condition that best approximates the disability picture. See 38 C.F.R. §§ 4.20 and 4.27. In this case DC 5259 is used for rating the Veteran’s symptomatic removal of the semilunar cartilage, while DC 5010 relates to traumatic arthritis, the underlying source of the disability. Diagnostic Code 5259 assigns a 10 percent rating for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a (2018). A higher rating is not available under DC 5259, as 10 percent is the highest rating available under that code. Diagnostic Codes relevant to knee disabilities include 5003, 5010 and 5256 through 5261. Under Diagnostic Codes 5003 and 5010, arthritis established by x-ray findings is rated on the basis of limitation of motion of the affected joints. When however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Limitation of motion of the knees is rated under Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Additionally, a knee disability may simultaneously be rated under Diagnostic Code 5257. The Board notes the Veteran was initially rated under Diagnostic Code 5257 as noncompensable effective March 31, 2011. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disability rating for a slight impairment, 20 percent disability rating for a moderate impairment, and 30 percent disability rating for a severe impairment. Descriptive words such as “slight,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6 (2018). The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a) (2012); 38 C.F.R. §§ 4.2, 4.6 (2018). In cases involving the knee, such as the immediate appeal, the Board also considers whether one or more separate evaluations may be warranted for instability in addition to limitation of extension and limitation of flexion. See VAOPGCPREC 23-97 (1997); (interpreting that arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating is based upon additional disability); VAOPGCPREC 9-98 (1998); (interpreting that if a veteran has a disability rating under Diagnostic Codes 5257 for instability of the knee, and there is X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59); VAOPGCPREC 9-04 (2004) ((interpreting that separate ratings may be granted based on compensable limitation of flexion (Diagnostic Code 5260) and compensable limitation of extension (Diagnostic Code 5261) of the same knee joint)). At a March 2013 VA examination, the Veteran asserted his left knee pain prevented him from exercising or walking. Initial range of motion measurements recorded for left knee flexion was 110 degrees without objective evidence of painful motion and without limitation of extension. After repetitive testing, the Veteran’s range of motion measurements recorded for left knee flexion was 110 degrees without objective evidence of painful motion and without limitation of extension. The examiner noted degenerative arthritis and functional loss of less movement than normal, but he noted no instability or subluxation/dislocation. The Veteran’s past meniscectomy was noted as was residual pain in the left knee. Finally, the examiner noted an asymptomatic scar. A June 2013 Disability Benefits Questionnaire completed by private physician C.A. recorded the Veteran’s assertion of knee instability, limitation of use, and difficulty with use on stairs and steps. The Veteran’s left knee flexion measured 75 degrees, and evidence of painful motion began at 70 degrees. Left knee extension measured to 20 degrees, and evidence of painful motion began at 20 degrees. After repetitive testing, the left knee flexion measured 80 degrees, and extension measured 10 degrees. The physician noted functional loss as less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting or standing. The examiner also noted the Veteran had inflamed lateral to patella soft tissue and 0 to 5 millimeters of anterior, posterior, medial, and lateral instability without evidence of subluxation or dislocation. The examiner was unaware of the Veteran’s previous meniscectomy, past arthroscopic surgery, or any of the Veteran’s past medical history concerning his left knee. He further noted no recent diagnostic tests were given to the Veteran for his left knee. Medical treatment records reflect the Veteran’s left knee disability treatment and complaints of pain, but they contain no range of motion measurements. The Board notes that under Diagnostic Codes 5010-5259 the Veteran is already service connected at a 10 percent rating, which is the highest rating allowed by law for removal of semilunar cartilage of the knee. The Court has held that a rating under DC 5259 does not automatically preclude the assignment of separate evaluations and as will be discussed in detail below, the record clearly reflects residuals separate and distinct from the x-ray evidence of arthritis with cartilage removal to warrant the assignment of such ratings. See Lyles v. Shulkin,2017 U.S.App.Vet.Claims LEXIS 1704 *2 (Vet. App. 2017) (holding that evaluation of a knee disability under DCs 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DC 5258 or 5259, and vice versa); 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 261. The Board finds that the Veteran is entitled to a separate compensable rating for Diagnostic Code 5261 from July 30, 2013. Under Diagnostic Code 5261 the Veteran is entitled to a disability rating of 10% for limitation of extension to 20 degrees. Limitation of flexion to 20 degrees was noted in the July 2013 private disability questionnaire. Accordingly, a separate compensable rating of 30 percent is appropriate. A higher rating is not available because there was no limitation of extension to 30 degrees noted. Rather, as outlined above, the extension ranged from no limitation in extension to 20 degrees throughout the appeal period. Nor is a higher disability rating warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also Mitchell, Burton, and DeLuca. Even factoring the effect of pain and repetitive motion, the functional limitation does not more nearly approximate limitation of extension to 30 degrees to warrant a higher rating. Accordingly, a separate evaluation of 30 percent, but no higher, for limitation of extension from July 30, 2013 is warranted. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. The Board finds that the Veteran is also entitled to a separate compensable rating under Diagnostic Code 5257 for the period beginning July 30, 2013. Both the March 2013 VA examination and the July 2013 disability questionnaire noted the Veteran used a brace for ambulation. The July 2013 private disability questionnaire noted he could not walk very far, squat, or go up and down steps without losing balance. The July 2013 examiner performed joint stability testing and found 0 to 5 millimeters of anterior, posterior, medial, and lateral instability. As the joint stability testing did not find lateral instability of greater than 5 millimeters, and medical records reflect no further objective medical evidence of instability, the Board finds the Veteran is entitled to a 10 percent disability rating, but no higher, for left knee instability effective July 30, 2013. A higher rating is not appropriate because the objective testing for left knee instability performed in the VA examination was negative, the July 2013 examination noted only slight instability without subluxation or instability, and accordingly, the evidence does not more nearly approximate moderate recurrent subluxation or instability. Again, the Board has considered the recent holding of the Court in Correia v. McDonald, 28 Vet. App. 158 (2016), addressing the proper interpretation of the final sentence of 38 C.F.R. § 4.59, which states “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with the range of the opposite undamaged joint.” In this regard, the Court concluded that VA examinations should include joint testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The VA examination report of record does not reflect active and passive range of motion testing in both weightbearing and non-weight bearing, as well as in passive and active range. However, the Board notes that at March 2013 examination, the Veteran’s non-service connected right knee was examined and the range of motion for the undamaged right knee is of record. Additionally, joint testing for pain in both active and passive motion, in weight-bearing and non-weight bearing, was accomplished during the July 2013 evaluation report by a non-VA medical professional, who examined the Veteran’s left knee and submitted his findings on a Disability Benefits Questionnaire. As a result, a remand to evaluate the Veteran’s left knee symptoms under Correia would result in an undue delay of the adjudication of his claim, since the most recent evaluation of the Veteran’s left knee symptoms comports with the Correia holding. Moreover, the Veteran has not alleged, and the record does not show, that such examinations are inadequate to decide his rating claim, or otherwise argued that his range of motion would have been further limited if tested in such capacities. Consequently, as he has not argued that the examinations of record are inadequate on such grounds, the Board need not address such matter further. Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); see Robinson v. Peake, 21 Vet. App. 545, 553 (2008) (holding that the Board is not required “to assume the impossible task of inventing and rejecting every conceivable argument in order to produce a valid decision”), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); cf. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (“Having initially failed to raise the procedural issue, the Veteran should not be able to resurrect it months or even years later when, based on new circumstances, the Veteran decides that raising the issue is now advantageous.”) Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran’s rating claim and no further examination is necessary. As a final matter, the Board finds that the Veteran has not raised the matter of an extraschedular rating and that the evidence does not present exceptional or unusual circumstances. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either a veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). 4. Entitlement to an initial rating in excess of 10 percent for service connected left ankle degenerative joint disease The Veteran asserts that his service connected left ankle degenerative joint disease is more severe than his initial disability rating reflects. The initial 10 percent rating for the Veteran’s left ankle disability has been assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271-5010. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Thus, in this case, Diagnostic Code 5010, which pertains to traumatic arthritis, acknowledges the disability resulting from the Veteran’s in-service ankle injury, and Diagnostic Code 5271, which pertains to limited ankle motion, contemplates the current manifestations of the Veteran’s disability. In other words, his left ankle degenerative joint disease is rated on the basis of limited motion. Degenerative or traumatic arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis) and Diagnostic Code 5010 (traumatic arthritis). For the purpose of rating disability from arthritis, the ankle is considered a major joint. 38 C.F.R. § 4.45. Under Diagnostic Code 5271, for limitation of motion of the ankle, a 10 percent rating is assigned for moderate limitation of motion, and a 20 percent rating is warranted for marked limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71. Normal dorsiflexion of the ankle is from 0 to 20 degrees. Normal plantar flexion of the ankle is from 0 to 45 degrees. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Also, the use of terminology such as “severe” by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. A March 2013 VA examination noted the Veteran’s assertion of left ankle pain which precludes him from use or walking. Left ankle plantar flexion measured 40 degrees without evidence of objective painful motion, and left ankle dorsiflexion measured 15 degrees without evidence of painful motion. The examiner noted less movement than normal for the left ankle as functional loss without ankylosis. At an April 2013 VA examination, the Veteran reported swelling in his left ankle and a feeling that it would occasionally “give out”. Left ankle plantar flexion measured 45 degrees or greater without evidence of painful motion, and left ankle dorsiflexion measured 20 degrees or greater without evidence of painful motion. After repetitive testing, the left ankle plantar flexion measured 45 degrees of greater, and left ankle dorsiflexion measured 20 degrees or greater. The left ankle had muscle strength of 4/5 in plantar and dorsiflexion. The examiner noted functional loss of weakened movement for the left ankle without ankylosis or arthritis. A July 2013 disability questionnaire completed by a private physician noted left ankle planter flexion measured 40 degrees with evidence of painful motion at 35 degrees. Left ankle dorsiflexion measured 0 degrees with objective evidence of painful motion at 0 degrees. After repetitive testing, the left ankle plantar flexion measured 35 degrees, and left ankle dorsiflexion measured 0 degrees. The examiner noted functional loss of less movement than normal, weakened movement, pain on movement, swelling, disturbance of motion, and interference with sitting and standing for the left ankle without ankylosis. The Veteran reported the use of a brace for all standing and walking. Medical treatment records reflect the Veteran’s left ankle disability treatment and complaints of pain, but they contain no range of motion measurements. Based on the evidence of record, the Board finds that the evidence warrants finding a 20 percent rating, but no higher, as to the Veteran’s left ankle disability. The Veteran’s left ankle disability has been manifested, at worst, by plantar flexion to 40 degrees and dorsiflexion to 0 degrees with pain at each endpoint of motion; and complaints of pain, swelling and instability. These findings are consistent with the 20 percent disability rating currently assigned on the basis of marked limited motion of the right ankle. See 38 C.F.R. § 4.71a, Diagnostic Codes 5271, 5010. As noted above, a 20 percent rating is the maximum rating assignable under Diagnostic Code 5271. The Board has also considered whether higher evaluations are available under other provisions of the code. However, the Veteran’s left ankle disability has not shown to involve any other factor that would warrant evaluation of the disability under other provisions of the rating schedule. Specifically, the Veteran is not shown to have ankylosis of the ankle to warrant an evaluation under Diagnostic Code 5270. See 38 C.F.R. § 4.71a. VA examinations, treatment records, and private treatment records are absent for evidence of ankylosis. In addition, there is also no evidence of ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy to warrant ratings under Diagnostic Codes 5272-5274. Id. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran’s disability does not warrant a higher rating because he does not have ankylosis. Further, as in this case, if a musculoskeletal disability is currently evaluated at the highest schedular evaluation based upon limitation of motion, then a higher rating under 38 C.F.R. §§ 4.40, 4.45, and 4.59 is not warranted. See Johnston v. Brown, 10 Vet. App. 80 (1997). As such, the Veteran would not be entitled to a higher rating than 20 percent. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board finds the evidence of record more closely approximates the criteria for a 20 percent rating, but no higher. Again, the Board has considered the recent holding of the Court in Correia v. McDonald, 28 Vet. App. 158 (2016), addressing the proper interpretation of the final sentence of 38 C.F.R. § 4.59, which states “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with the range of the opposite undamaged joint.” In this regard, the Court concluded that VA examinations should include joint testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The VA examination reports of record do reflect active range of motion testing in both weightbearing and non-weight bearing, and the Board notes that at the July 2013 examination, the Veteran’s non-service connected right ankle was examined and the range of motion for the undamaged right knee is of record. Additionally, joint testing for pain in both active and passive motion, in weight-bearing and non-weight bearing, was accomplished during the July 2013 evaluation report by a non-VA medical professional, who examined the Veteran’s left ankle and submitted his findings on a Disability Benefits Questionnaire. As a result, a remand to evaluate the Veteran’s left ankle symptoms under Correia would result in an undue delay of the adjudication of his claim, since the most recent evaluation of the Veteran’s left ankle symptoms comports with the Correia holding. Moreover, the Veteran has not alleged, and the record does not show, that such examinations are inadequate to decide his rating claim, or otherwise argued that his range of motion would have been further limited if tested in such capacities. Consequently, as he has not argued that the examinations of record are inadequate on such grounds, the Board need not address such matter further. Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); see Robinson v. Peake, 21 Vet. App. 545, 553 (2008) (holding that the Board is not required “to assume the impossible task of inventing and rejecting every conceivable argument in order to produce a valid decision”), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); cf. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (“Having initially failed to raise the procedural issue, the Veteran should not be able to resurrect it months or even years later when, based on new circumstances, the Veteran decides that raising the issue is now advantageous.”) Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran’s rating claim and no further examination is necessary Accordingly, given the totality of the evidence, the Board finds that the criteria for a 20 percent disability rating, but no higher, for left ankle degenerative joint disease have been met. 38 C.F.R. §§ 4.7, 4.59, 4.71a, Diagnostic Codes 5271-5010. As a final matter, the Board finds that the Veteran has not raised the matter of an extraschedular rating and that the evidence does not present exceptional or unusual circumstances. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either a veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). 5. Entitlement to an initial compensable rating for erectile dysfunction The Veteran contends his service connected erectile dysfunction disability is more severe than his initial noncompensable rating reflects. Historically, a February 2015 rating decision granted service connection for erectile dysfunction with a noncompensable disability evaluation effective March 31, 2011 and awarded special monthly compensation (SMC) based on loss of use of creative organ pursuant to 38 U.S.C. § 1114 (k) effective March 31, 2011. Erectile dysfunction is rated by analogy, to “penis, deformity, with loss of erectile power,” Diagnostic Code 7522. See 38 C.F.R. § 4.20 (2016). The rating schedule provides a 20 percent rating for deformity of the penis with loss of erectile power. This is a conjunctive set of criteria; both must be present to warrant compensation at the sole authorized level, 20 percent. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for an increased rating to be assigned). In this case, the medical evidence does not indicate that the Veteran has a penile deformity. The Veteran’s January 2015 VA examination did not show a deformity, but rather erectile dysfunction and the inability to achieve an erection sufficient for penetration and ejaculation without the use of medication. Likewise, his April 2017 VA examination also diagnosed erectile dysfunction not involving any deformity. A review of his VA and private treatment records does not document a deformity. The Veteran’s report of difficulty maintaining erections is compensated by his award of SMC for such impairment. Additional compensation is not warranted unless there is related deformity of the penis with loss of erectile power (or some other compensable impairment of function). The record does not show or suggest that at any time the Veteran has had penile deformity. Consequently, a compensable rating separate from the Veteran’s award of SMC for such disability is not warranted. Where the criteria for a compensable rating under a diagnostic code are not met, as here, a noncompensable rating is awarded. See 38 C.F.R. § 3.31 (2018). Consequently, there is no basis for a separate rating for erectile dysfunction under the rating schedule. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As a final matter, the Board finds that the Veteran has not raised the matter of an extraschedular rating and that the evidence does not present exceptional or unusual circumstances. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either a veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). 6. Entitlement to an initial rating in excess of 40 percent for service connected radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer prior to March 9, 2015 7. Entitlement to an initial rating in excess of 60 percent for service connected radical prostatectomy with loss of bladder control, scar, and erectile dysfunction as residual of prostate cancer since March 9, 2015 The Veteran further asserts that his residuals of radical prostatectomy with loss of bladder control is more severe than his initial ratings reflect. Specifically, the Veteran asserted in his March 9, 2015 notice of disagreement that he changes absorbent pads more than four times a day. Initially, the Board notes an October 2015 rating decision granted a temporary total evaluation of 100 percent for the Veteran’s service connected radical prostatectomy effective March 20, 2012 to September 1, 2013. Here, the Veteran is not appealing the beginning or end dates of these periods of temporary total evaluation, and as such, the temporary total evaluations pertinent to the issues on appeal need not be discussed. The Veteran’s prostate cancer has been rated under Diagnostic Code 7528. Active malignant neoplasms of the genitourinary system are rated as 100 percent disabling. Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedures, the rating of 100 percent continues with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination is subject to the provisions of 38 C.F.R. § 3.105 (e). If there has been no local recurrence or metastasis, the evaluation is to be based upon residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115a, DC 7528. The evidence, as well as the Veteran’s own contentions clearly establish that the predominant residual of the Veteran’s prostate cancer is voiding dysfunction. There is no evidence of significant renal dysfunction or urinary tract infection. Cases of voiding dysfunction are rated as either urine leakage, frequency, or obstructed voiding. With continual urine leakage, post-surgical urinary diversion, urinary incontinence or stress incontinence, a 40 percent evaluation is in order for a disability requiring the wearing of absorbent materials which must be changed two to four times per day. A 60 percent evaluation contemplates the use of an appliance or the wearing of absorbent materials, which must be changed more than four times per day. 38 C.F.R. § 4.115a. In cases of urinary frequency, a maximum 40 percent schedular evaluation is assigned in cases of a daytime voiding interval less than one hour, or awakening to void five or more times per night. Medical treatment records reflect the Veteran underwent a prostatectomy in December 2008. Medical records dated August 2008 reflect the Veteran voided four times throughout the day with elevated PSA. Records dated November 2012 note elevated PSA levels of 0.16, and a biochemical recurrence of cancer was treated in February 2013. Records dated April 2013 note the Veteran voided three to four times an hour. Records dated December 2015 note no evidence of prostate cancer with PSA levels notes as undetectable. A January 2015 VA examination report noted the Veteran’s prostate cancer was in remission. The examiner noted the Veteran’s voiding dysfunction required changing of absorbent material two to four times a day, daytime voiding intervals of one to two hours, and night time awakening to void three to four times. No urinary tract or kidney infections were noted. An April 2017 VA examination report noted the Veteran has had his PSA levels checked every six months without detectable levels for the preceding two years. The Veteran’s prostate cancer was in remission. The examiner noted the Veteran’s voiding dysfunction required changing of absorbent material more than four times a day, daytime voiding intervals of less than one hour, and night time awakening to void five or more times. No urinary tract or kidney infections were noted. After considering all of the evidence of record, including that set forth above, the Board finds that the criteria for a rating in excess of 40 percent for the Veteran’s service connected radical prostatectomy with loss of bladder control were not met prior to March 9, 2015. Prior to March 9, 2015, evidence of record supports that the Veteran used absorbent material, voided four or less times a day without use of an appliance, and had no urinary tract or kidney infections. Since March 9, 2015, the evidence of record does not warrant assignment of a disability rating in excess of 60 percent. In this instance, the only criteria which would afford the Veteran a rating in excess of 60 percent is under 38 C.F.R. § 4.115 (b), DC 7528, malignant neoplasms of the genitourinary system; specifically, a recurrence or metastasis of the Veteran’s prostate cancer would entitle the Veteran to a 100 percent disability evaluation. The medical evidence does not reflect, and the Veteran does not contend, that there has been a recurrence or metastasis of prostate cancer at any time during the period on appeal. Since March 9, 2015, the residuals of the Veteran’s prostate cancer have been characterized by a voiding dysfunction requiring 4 or more absorbent materials per day. Further, the Veteran’s prostate cancer with radical prostatectomy has not been characterized as malignant neoplasms of the genitourinary system during the appeal period. Therefore, a rating in excess of 60 percent is denied. As a final matter, the Board finds that the Veteran has not raised the matter of an extraschedular rating and that the evidence does not present exceptional or unusual circumstances. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either a veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). REMANDED Entitlement to an initial compensable rating for service connected onychocryptosis of the right hallux is remanded. Entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU). REASONS FOR REMAND 1. Entitlement to an initial compensable rating for service connected onychocryptosis of the right hallux. The Veteran asserts that his onychocryptosis of the right hallux is more severe than his noncompensable rating reflects. He alternatively asserts that he has a painful scar associated with his service connected onychocryptosis of the right hallux. He is currently rated under Diagnostic Code 7804, which is used to rate painful scars, as the Veteran’s right toenail predominate disability is scarring. See 38 C.F.R. § 4.20 (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization and symptomatology are closely analogous). The Board notes that the last VA examination afforded to the Veteran in April 2013 noted evidence of ingrown toenails with dystrophic changes, but did not record any scar measurements, scar severity, or percent of body affected. In light of the above considerations, the Board concludes that a medical examination and opinion is needed to fully and fairly evaluate the Veteran’s scar associated with his onychocryptosis of the right hallux. 2. Entitlement to a total rating based upon individual unemployability due to service connected disabilities (TDIU). At the Veteran’s July 2013 private examination for his service connected back, knee, and ankle disabilities, an inferred claim for entitlement to a TDIU was raised as the examiner opined the Veteran’s disabilities prevented him from maintaining his current employment as a truck driver. A claim for TDIU is considered part and parcel of an increased rating claim when such a claim is raised by the record. See Rice v. Shinseki, App. 447 (2009). As the record raises a question of whether the Veteran is unemployable due to his service connected disabilities, TDIU is properly before the Board. To date, the Veteran has not been provided with a formal TDIU application (VA Form 21-8940). As such, the Veteran should be provided notice of the elements necessary to substantiate a claim of entitlement to TDIU. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination to determine the nature and severity of his service connected onychocryptosis of the right hallux disability. All indicated evaluations, studies, and tests deemed to be necessary should be accomplished. All pertinent evidence of record should be made available to and reviewed by the examiner. All information required for rating purposes should be provided to the examiner. The examination must be conducted in accordance with the current disability benefits questionnaire or examination worksheet applicable to the disability. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All indicated testing must be conducted and all pertinent symptomatology and findings must be reported in detail. The examiner must measure the accurate size of the scar and indicate whether any scar is painful, unstable, deep or superficial, or linear or non-linear. The examiner is also asked to determine whether there is any disabling effect(s) caused by the Veteran’s service connected onychocryptosis of the right hallux disability. A complete rationale for any opinion offered should be provided. 2. Provide the Veteran with notice that is compliant with 38 U.S.C. § 5103 (a) as to the issue of entitlement to a TDIU, and take all necessary steps to develop a claim of entitlement to a TDIU, to include providing the Veteran with a VA Form 21-8940 and determining his current employment status. (Continued on the next page)   3. After completing the above action, to include any other development deemed warranted, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims continue to be denied or is not granted to the Veteran’s satisfaction, send him and his representative a Supplemental Statement of the Case (SSOC) and give him an opportunity to respond to it before returning the file to the Board for further appellate consideration of the claim. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Peden, Associate Counsel