Citation Nr: 1807424 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 12-22 003 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an initial disability rating (or evaluation) in excess of 10 percent for service-connected metatarsalgia and hallux valgus of the left foot. 2. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected metatarsalgia of the right foot. 3. Entitlement to an initial disability rating (or evaluation) in excess of 10 percent for service-connected migraine headaches. 4. Entitlement to an initial disability rating (or evaluation) in excess of 10 percent for service-connected gastroesophageal reflux disease (GERD) with hiatal hernia. 5. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected left wrist tendonitis. 6. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected right wrist tendonitis. 7. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected medial epicondylitis of the left elbow. 8. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected medial epicondylitis of the right elbow. 9. Entitlement to a higher (compensable) initial disability rating (or evaluation) for service-connected primary insomnia. 10. Entitlement to service connection for a disability manifesting in heart murmur. 11. Entitlement to service connection for a disability manifesting in joint pain of the left hand. 12. Entitlement to service connection for a disability manifesting in joint pain of the right hand. 13. Entitlement to service connection for a disability manifesting in problems overheating. 14. Entitlement to service connection for a disability manifesting in difficulty breathing. 15. Entitlement to service connection for an acquired psychiatric disability other than primary insomnia, to include anxiety. 16. Entitlement to service connection for a disability manifesting in aches of the left hip. 17. Entitlement to service connection for a disability manifesting in aches of the right hip. WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from June 1990 to June 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. Jurisdiction over this claim is currently with the RO in San Diego, California. In May 2017, the Veteran testified in a Videoconference Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the Veteran's file in the Veterans Benefits Management System (VBMS). The issue of service connection for erectile dysfunction has been raised by the record during the May 2017 Videoconference Board hearing, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). The issues of higher initial ratings for left and right wrist tendonitis, and left and right elbow medial epicondylitis are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to the promulgation of a decision by the Board, on the record during the May 2017 Videoconference Board hearing, the Veteran withdrew the appeal as to the issues of higher initial ratings for metatarsalgia and hallux valgus of the left foot, metatarsalgia of the right foot, and migraine headaches, and service connection for a disability manifesting in heart murmur, and a disability manifesting in difficulty breathing. 2. For the entire initial rating period from July 1, 2010, the Veteran's GERD has been manifested by vomiting, nausea, reflux, persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, not accompanied by substernal or arm or shoulder pain, and which are not productive of considerable impairment of health. 3. For the entire initial rating period from July 1, 2010, the Veteran's primary insomnia has been manifested by sleep disturbance with problems with sleep onset and frequent waking with associated daytime fatigue; the primary insomnia symptoms are not severe enough to interfere with occupational and social functioning, or to require continuous medication. 4. The Veteran does not have, nor has he had at any time proximate to, or during the course of this appeal, a current diagnosis of disabilities manifesting in left and right hand joint pain, left and right hip aches, or problems overheating, or an acquired psychiatric disorder other than primary insomnia, to include anxiety. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal regarding the issues of higher initial ratings for metatarsalgia and hallux valgus of the left foot, metatarsalgia of the right foot, and migraine headaches, and service connection for a disability manifesting in heart murmur, and a disability manifesting in difficulty breathing have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for an initial disability rating in excess of 10 percent for GERD with hiatal hernia have not been met or more nearly approximated at any time during the initial rating period from July 1, 2010. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7346 (2017). 3. The criteria for a compensable initial disability rating for primary insomnia have not been met or more nearly approximated at any time during the initial rating period from July 1, 2010. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9499-9400 (2017). 4. The criteria for service connection for a disability manifesting in joint pain of the left and right hand, aches of the left and right hip, and problems overheating, and an acquired psychiatric disorder other than primary insomnia, to include anxiety, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawn Issues The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by the appellant or by his or her authorized representative and must be in writing, except for appeals withdrawn on the record at a hearing. 38 C.F.R. § 20.204. At the outset of the May 2017 Videoconference Board hearing and before a final decision was promulgated by the Board, the Veteran withdrew the appeal on the record regarding the issues of higher initial ratings for metatarsalgia and hallux valgus of the left foot, metatarsalgia of the right foot, and migraine headaches, and service connection for a disability manifesting in heart murmur, and a disability manifesting in difficulty breathing. As the Veteran has withdrawn the appeal on these issues, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal, and it is dismissed without prejudice. 38 U.S.C. § 7104 (West 2012). Duties to Notify and Assist The Veteran has not 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 duty to assist argument). Disability Rating Legal Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Here, the Board will evaluate the issues as appeals for higher evaluations of the original awards. In such cases, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Id. The Board has thoroughly reviewed all the evidence in the Veteran's VA file. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the United States Court of Appeals for Veterans Claims (Court). 38 U.S.C.A. § 7104(d)(1); see Allday v. Brown, 7 Vet.App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, as to the issues on appeal. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. Initial Rating for GERD with Hiatal Hernia The Veteran is in receipt of a 10 percent disability rating from July 1, 2010, for GERD with hiatal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7346 (hernia hiatal). GERD is not among the listed conditions in the Rating Schedule. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017). The Board finds that GERD is most closely analogous to a hiatal hernia (Diagnostic Code 7346) in terms of symptomatology and resulting disability picture. Under Diagnostic Code 7346, a 10 percent disability rating is warranted for a hiatal hernia with two or more of the symptoms required for a 30 percent rating, which are of lesser severity than is required for a 30 percent rating. A 30 percent rating requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal, arm, or shoulder pain, which is productive of considerable impairment of health. A 60 percent rating requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. Instead, a single disability rating will be assigned under the diagnostic code which reflects the veteran's predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. Id. Throughout the course of this appeal, the Veteran has generally contended that the service-connected GERD with hiatal hernia has been manifested by more severe symptoms than that contemplated by the 10 percent initial disability rating assigned. The Veteran underwent a VA general examination in May 2010 shortly before discharge from active service in June 2010. At that time, he complained of severe heartburn, and he was assessed with GERD. The Veteran underwent another VA general examination in April 2013. There, he presented with symptoms of persistently recurrent epigastric distress, dysphagia, pyrosis (heartburn), reflux, nausea, and vomiting. After a review of all the evidence, lay and medical, the Board finds that, for the entire initial rating period from July 1, 2010, the Veteran's GERD has been manifested by vomiting, nausea, reflux, persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, not accompanied by substernal or arm or shoulder pain, which are not productive of considerable impairment of health, and more nearly approximate the criteria for a 10 percent disability rating under Diagnostic Code 7346. 38 C.F.R. §§ 4.3, 4.7, 4.114. Significantly, the Veteran's VA treatment records, including the May 2010 and April 2013 VA examinations, do not reveal that the Veteran's GERD resulted in weight loss, hematemesis or melena with moderate anemia, or considerable impairment of health due to the GERD symptoms. While the Veteran did demonstrate vomiting (one criterion for the 60 percent rating), the totality of the evidence does not more nearly approximate the criteria for even a 30 percent rating for the GERD with hiatal hernia. Based on the above, the Board finds that the weight of the lay and medical evidence of record demonstrates that the criteria for a disability rating in excess of 10 percent have not been met or nearly approximated for any part of the initial rating period from July 1, 2010. The weight of the evidence of record reflects that the symptoms of GERD with hiatal hernia have not been productive of considerable impairment of health. Nor has the Veteran contended otherwise. In the absence of any gastrointestinal symptomatology that is productive of considerable impairment of health associated with the GERD with hiatal hernia, a rating in excess of 10 percent is not warranted at any point during the initial rating period from July 1, 2010. The Board does not find evidence that the rating assigned for the GERD with hiatal hernia should be higher for any other separate period based on the facts found during the initial rating appeal period. Instead, the evidence of record supports the conclusion that the Veteran is not entitled to additional compensation during any time within the period on appeal. See Fenderson, 12 Vet. App. at 126. For these reasons, the Board finds that a preponderance of the evidence is against an initial rating in excess of 10 percent for GERD with hiatal hernia for the entire initial appeal period from July 1, 2010. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Insomnia 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. § 4.27 (2017). In this case, the Veteran's primary insomnia is rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Rating Formula for Mental Disorders, a zero (0) percent (noncompensable) rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent evaluation is warranted when the evidence demonstrates occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication. A 30 percent rating is warranted when the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent 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); inability to establish and maintain effective relationships. A 100 percent 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Global Assessment of Functioning (GAF) scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the Diagnostic and Statistical Manual of Mental Disorders at 32 (4th ed. 1994)). A GAF score between 71 through 80 is indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. With regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. The use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list and are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the United States Court of Appeals for the Federal Circuit (Federal Circuit) determined that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." Thus, the demonstrated symptomatology is the primary focus when deciding entitlement to a given disability rating and a veteran may be entitled to a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id. After review of the lay and medical evidence of record, the Board finds the weight of the evidence is against finding that the primary insomnia disability picture more closely approximates occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication, so that the criteria for a rating of 10 percent under the General Rating Formula for Mental Disorders are met for any period. Throughout the rating period, primary insomnia was manifested by symptoms of sleep disturbance with problems with sleep onset and frequent waking with associated daytime fatigue, which are not severe enough to interfere with occupational and social functioning, or to require continuous medication, which is contemplated in the noncompensable schedular rating criteria at 38 C.F.R. § 4.130. The Veteran underwent a VA mental disorders examination in July 2010, shortly after discharge from active service. At that time, the Veteran complained of sleep disturbance with problems with sleep onset and frequent waking with associated daytime fatigue. He was diagnosed with primary insomnia and assigned a current GAF score of 65, with a score of 70 for the past year, suggesting some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Ultimately, the VA examiner indicated that the Veteran's mental disorder (primary insomnia) symptoms were not severe enough to interfere with occupational and social functioning. In April 2013, the Veteran was afforded another VA mental disorders examination. There, although the Veteran was not diagnosed with an acquired psychiatric disability, he presented with chronic sleep impairment, and the VA examiner assigned a GAF of 80, suggesting symptoms that are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), and no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Considered together with the psychiatric symptoms associated with primary insomnia that are consistent with the 0 percent (noncompensable) rating, the Board finds that the weight of the evidence is against a finding that the level of occupational and social impairment due to the primary insomnia symptoms are of the frequency, severity, and duration contemplated by the schedular criteria for a compensable (10 percent) rating for any period. In short, the level of occupational and social impairment demonstrated by the evidence during the initial rating period is consistent with the criteria for a noncompensable rating so that the primary insomnia disability picture more closely approximates symptoms that are not severe enough to interfere with occupational and social functioning, and do not require continuous medication; thus, the weight of the evidence is against finding that a higher (compensable) initial disability rating for primary insomnia is warranted for any period from July 1, 2010. 38 C.F.R. §§ 4.3, 4.7. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the initial rating appeals for GERD with hiatal hernia, and insomnia. See Yancy v. McDonald, 27 Vet. App. 484 (2016); see also Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection for Joint Pain of the Left and Right Hand, Problems Overheating, an Acquired Psychiatric Disorder other than Insomnia, to Include Anxiety, and Aches of the Left and Right Hip Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran is not currently diagnosed with any bilateral hand or bilateral hip disability, disability manifesting in problems overheating, or acquired psychiatric disability other than primary insomnia, to include anxiety. Because the Veteran has no diagnosed bilateral hand or bilateral hip disability, disability manifesting in problems overheating, or acquired psychiatric disability other than primary insomnia, to include anxiety, it necessarily follows that there is no "chronic disease" under 38 C.F.R. § 3.309(a) for which the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service would be applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a) (West 2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When 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; 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 49. The Veteran generally contends that he has a bilateral hand and bilateral hip disability, a disability manifesting in problems overheating, and an acquired psychiatric disability other than primary insomnia, to include anxiety, as a result of active service. After review of the lay and medical evidence of record, the Board finds that the weight (preponderance) of the evidence is against a finding of a current bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety. In the May 2010 VA general examination report, after a comprehensive physical examination, the VA examiner concluded that the Veteran had normal examination results of the bilateral hands and bilateral hips. In addition, the VA examiner opined that the heat exhaustion (noted in service) had resolved with subjectively reported sensitivity to the heat for endurance/exertional activities, but with no otherwise diagnosable residual. As mentioned above, the Veteran underwent a VA mental disorders examination in July 2010 and April 2013. At those times, after a comprehensive psychiatric examination, the Veteran was not diagnosed with an acquired psychiatric disability other than primary insomnia for which he is already service connected (see initial disability rating analysis above). The Veteran underwent another VA general examination in April 2013. There, the VA examiner concluded that the Veteran did not have a diagnosed left or right hand, or left or right hip disability, manifested by pain and aches, respectively. In this regard, the Veteran is already service connected for status post fracture of the right ring finger, and painful scars of the left and right hand. Here, there is no other current left or right hand disability manifesting in left and right hand joint pain. VA treatment records are also absent for any diagnosis of a bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety. In this case, despite the Veteran's general complaints of bilateral hand pain, bilateral hip aches, problems overheating, and anxiety, there is no current bilateral hand or bilateral hip, overheating, or anxiety "disability." See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. West, 239 F.3d 1356, 1361-62 (Fed. Cir. 2001). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. §§ 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (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." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present. McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that that, when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). Although the Veteran has at least implicitly asserted that he experiences symptoms that are attributable to diagnoses of bilateral hand or bilateral hip disabilities, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, he is a lay person and, under the facts of this case, he does not have the requisite medical expertise to diagnose a bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, or render an opinion as to the etiology of such symptoms claimed to be a bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety. An opinion as to diagnoses and causation of bilateral hand or bilateral hip disabilities, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, involves making findings based on medical knowledge and clinical testing results, and the orthopedic and psychiatric systems are complex and often involve unseen systems processes and disease processes that are not observable by the five senses of a lay person. The Veteran has also not reported contemporaneous medical diagnoses by a competent source, and his implied symptoms have not later been supported by diagnoses rendered by a medical professional. See Jandreau, 492 F.3d at 1372. Consequently, the Veteran's purported opinion relating the reported symptoms to diagnoses of a bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, are of no probative value. In this case, the weight of the evidence is against finding a bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, at any point during the claim period, including prior to the filing of the claim for service connection. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a currently diagnosed bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Because a current bilateral hand or bilateral hip disability, a disability manifesting in problems overheating, or an acquired psychiatric disability other than primary insomnia, to include anxiety, has not been shown by competent evidence, the Board does not reach the additional question of the relationship (nexus) between any current bilateral hand and bilateral hip disability, disability manifesting in problems overheating, or acquired psychiatric disability other than primary insomnia, to include anxiety, and service. ORDER The appeal of an initial disability rating in excess of 10 percent for service-connected metatarsalgia and hallux valgus of the left foot, having been withdrawn, is dismissed. The appeal of a higher (compensable) initial disability rating for service-connected metatarsalgia of the right foot, having been withdrawn, is dismissed. The appeal of an initial disability rating in excess of 10 percent for service-connected migraine headaches, having been withdrawn, is dismissed. The appeal of service connection for a disability manifesting in heart murmur, having been withdrawn, is dismissed. The appeal of service connection for a disability manifesting in difficulty breathing, having been withdrawn, is dismissed. An initial disability rating in excess of 10 percent for service-connected GERD with hiatal hernia is denied. A higher (compensable) initial disability rating for service-connected primary insomnia is denied. Service connection for a disability manifesting in joint pain of the left hand is denied. Service connection for a disability manifesting in joint pain of the right hand is denied. Service connection for a disability manifesting in problems overheating is denied. Service connection for an acquired psychiatric disability other than primary insomnia, to include anxiety, is denied. Service connection for a disability manifesting in aches of the left hip is denied. Service connection for a disability manifesting in aches of the right hip is denied. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's appeal of higher initial ratings for left and right wrist tendonitis, and left and right elbow medial epicondylitis. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C. § 5103A(a) (West 2012); 38 C.F.R. § 3.159(c), (d) (2017). Initial Ratings for Bilateral Wrists and Bilateral Elbows The Veteran last underwent a VA examination of the service-connected left and right wrist tendonitis, and left and right elbow medial epicondylitis in an April 2013 VA examination. The fact that a VA examination is nearly five years old is not a valid basis, unto itself, to provide the Veteran with another VA examination of the service-connected disability. In this case, however, since the last VA examination in April 2013, the Veteran has asserted that the service-connected left and right wrist tendonitis, and left and right elbow medial epicondylitis has worsened. Specifically, during the May 2017 Videoconference Board hearing, the Veteran testified that he has developed a clicking in the wrists and elbows, which results in more pain. See Hearing Transcript at 13. In light of the specific assertion of worsening since the last VA examination (in April 2013), a VA examination should be obtained to assist in determining the severity of the service-connected left and right wrist tendonitis, and left and right elbow medial epicondylitis. See 38 C.F.R. § 3.159(c)(4); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (finding a veteran is entitled to a new examination where the veteran specifically alleged the disability had increased in severity since the last examination two years earlier); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the issues of left and right wrist tendonitis, and left and right elbow medial epicondylitis are REMANDED for the following actions: 1. Schedule the appropriate VA examination to assist in determining the current level of severity of the service-connected left and right wrist tendonitis, and left and right elbow medial epicondylitis. The relevant documents in the electronic file should be made available to, and be reviewed by, the examiner. A detailed history of relevant symptoms should be obtained from the Veteran. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. 2. After completion of the above and any additional development deemed necessary, readjudicate the issues of higher initial ratings for left and right wrist tendonitis, and left and right elbow medial epicondylitis in light of all the evidence of record. If the determinations remain adverse to the Veteran, he and the representative, if any, should be furnished with a Supplemental Statement of the Case. An appropriate period of time should then be allowed for a response before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ A. P. SIMPSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs