Citation Nr: 18128695 Decision Date: 08/22/18 Archive Date: 08/22/18 DOCKET NO. 14-24 124 DATE: August 22, 2018 ORDER New and material evidence having not been submitted, the claim of entitlement to service connection for right leg varicose veins is not reopened. New and material evidence having been submitted, the claim of entitlement to service connection for hepatitis C is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection, is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for prostate cancer is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, is reopened. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for thyroid cancer, claimed as due to exposure to ionizing radiation, is denied. Entitlement to a rating in excess of 20 percent for lumbosacral strain with degenerative disc disease is denied. Entitlement to a rating in excess of 10 percent for left knee chondromalacia is denied. Entitlement to a rating in excess of 10 percent for right knee chondromalacia is denied. Entitlement to a rating in excess of 10 percent for hypertension is denied. REMANDED Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection, to include as secondary to treatment for prostate cancer is remanded. Entitlement to service connection for prostate cancer, to include as due to exposure to ionizing radiation, is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, is remanded. Entitlement to service connection for erectile dysfunction, claimed as secondary to prostate cancer, is remanded. Entitlement to special monthly compensation for loss of use of a creative organ, secondary to prostate cancer is remanded. FINDINGS OF FACT 1. In an October 2005 decision, the RO denied service connection for right leg varicose veins, hepatitis C, and prostate cancer; although notified of the decision and his appellate rights, the Veteran did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of notification of the decision. 2. Additional evidence received since the October 2005 decision is new to the record, but does not relate to an unestablished fact necessary to substantiate the merits of the claim of service connection for right leg varicose veins. 3. Additional evidence received since the October 2005 decision relates to unestablished facts necessary to substantiate the claims of entitlement to service connection for hepatitis C and prostate cancer and, if presumed credible, raises a reasonable possibility of substantiating the claims. 4. In a July 1994 decision, the RO denied service connection for chronic pathology causing hematuria; although notified of the decision and his appellate rights, the Veteran did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of notification of the decision. 5. Additional evidence received since the July 1994 decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection, and, if presumed credible, raises a reasonable possibility of substantiating the claim. 6. In a July 2009 decision, the RO denied service connection for posttraumatic stress disorder; although notified of the decision and his appellate rights, the Veteran did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of notification of the decision. 7. Additional evidence received since the July 2009 decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for an acquired psychiatric disability, to include depression and posttraumatic stress disorder, and, if presumed credible, raises a reasonable possibility of substantiating the claim. 8. A bilateral hearing loss disability was not manifested during active service, sensorineural hearing loss was not manifested to a compensable degree within one year after separation from service, and the most probative evidence indicates that the Veteran’s current bilateral hearing loss is not otherwise related to his active service, to include conceded noise exposure. 9. The Veteran is not a radiation-exposed veteran and thyroid cancer was not manifested in service or within one year of separation from service and there is no indication that his thyroid cancer, first shown in 2010, is otherwise related to his active service. 10. The Veteran’s lumbosacral strain with degenerative disc disease has been manifested at worst by forward flexion limited to 60 degrees with pain and a combined range of motion of the thoracolumbar of 105 degrees. 11. The Veteran’s left knee chondromalacia has been manifested at worst by flexion limited by pain to 90 degrees and full extension to 0 degrees with pain at the endpoint of motion. 12. The Veteran’s right knee chondromalacia has been manifested at worst by flexion limited by pain to 90 degrees and full extension to 0 degrees with pain at the endpoint of motion. 13. The Veteran’s hypertension has been manifested by a history of diastolic pressure predominantly 100 or more with continuous medication required for control and by diastolic pressure predominantly 100 or more at the time of the July 2012 VA examination. CONCLUSIONS OF LAW 1. The October 2005 RO decision that denied service connection for right leg varicose veins, hepatitis C, and prostate cancer is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.1103 (2017). 2. The criteria for reopening the claim of entitlement to service connection for right leg varicose veins have not been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156(a) (2017). 3. The criteria for reopening the claims of entitlement to service connection for hepatitis C and prostate cancer have been met. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 4. The July 1994 RO decision that denied service connection for chronic pathology causing hematuria is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.1103 (2017). 5. The criteria for reopening the claim of entitlement to service connection for chronic pathology causing hematuria have been met. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 6. The July 2009 RO decision that denied service connection for posttraumatic stress disorder is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.1103 (2017). 7. The criteria for reopening the claim of entitlement to service connection for an acquired psychiatric disorder, to include depression and posttraumatic stress disorder, have been met. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 8. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 9. The criteria for entitlement to service connection for thyroid cancer, claimed as due to exposure to ionizing radiation, have not been met. 38 U.S.C.A §§ 1110, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311 (2017). 10. The criteria for entitlement to a rating in excess of 20 percent for lumbosacral strain with degenerative disc disease have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2017). 11. The criteria for entitlement to a rating in excess of 10 percent for left knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 12. The criteria for entitlement to a rating in excess of 10 percent for right knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 13. The criteria for entitlement to a rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1974 to March 1994. This matter comes before the Board of Veterans’ Appeals (Board) from February 2013 and June 2013 rating decisions. In August 2017, the Veteran withdrew his request to testify at a hearing before a Veterans Law Judge. In December 2015 correspondence, VA notified the Veteran that the attorney he had appointed was no longer accredited to represent claimants before VA and provided him the opportunity to appoint a new representative. To date, he has not appointed a new representative and the Board recognizes he is proceeding pro se. Claims to Reopen The Veteran seeks to reopen previously denied claims of service connection for right leg varicose veins, hepatitis C, chronic pathology causing hematuria (also claimed as urinary tract infections), prostate cancer, and an acquired psychiatric disability to include posttraumatic stress disorder (PTSD). In general, decisions of the VA Regional Office (RO) that are not appealed in the prescribed time period are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. However, a finally disallowed claim will be reopened and the former disposition will be reviewed if new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed unless evidence is inherently incredible or beyond the competence of witness. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118. 1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for right leg varicose veins In October 2005, the RO denied the claim of entitlement to service connection for right leg varicose veins because the evidence of record showed there was no complaint, diagnosis, or treatment for right leg varicose vein problems in service and no evidence that current right leg varicose veins were related to service. The RO notified the Veteran of the decision the same month. He did not initiate an appeal by filing a notice of disagreement (NOD). In addition, new evidence received within the one-year appeal period following the notice of decision was not material to the claim because it did not relate to right leg varicose veins. Therefore, the October 2005 RO decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.1103 (2017). The evidence of record at the time of the October 2005 decision included service treatment records; VA examination reports pertinent to other claims; and post-service treatment records from the Philadelphia VA Medical Center (VAMC), which reflect the Veteran’s report of pain at the groin near his prostatectomy surgical site, intermittent pain in both knees and feet, and the assessment of right leg varicosities (varicose veins); and lay statements. The Veteran now seeks to reopen his claim of service connection for right leg varicose veins. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the disallowed claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence added to the claims file since the final October 2005 decision includes an August 2005 treatment summary from a private vascular surgeon, Dr. Grillo, which was addressed to the Veteran’s physician, S. Lizerbram, D.O. Dr. Grillo noted the Veteran’s complaint of pain in his right lower extremity from his groin to his calf for two to three years. Other new evidence added to the file includes service personnel records, additional VA treatment records, private treatment records from multiple sources, records associated with the Veteran’s claim for disability benefits from the Social Security Administration (SSA), VA examination reports pertinent to other claims, and lay statements. While the evidence added to the file since the October 2005 decision is new, the evidence is not material to the claim of service connection for right leg varicose veins. In this regard, none of the new evidence demonstrates or indicates that right leg varicosities began or were manifested during service or that they are otherwise related to military service or to a service-connected disability. Rather, the evidence shows that the Veteran began to experience symptoms of right leg varicose veins in 2002 at the earliest and does not include any competent medical or lay evidence linking them to a disease or injury in service or a service-connected disability. In other words, the new evidence is cumulative or redundant of the evidence previously of record because it merely documents a current diagnosis. However, because the additionally received evidence does not tend to establish any point not previously demonstrated, such as an in-service disease or injury or a medical nexus between the current right leg varicosities and military service or a service-connected disability, the Board concludes that new and material evidence has not been received sufficient to reopen the previously denied claim of service connection for right leg varicose veins. 2. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for hepatitis C In October 2005, the RO denied the claim of entitlement to service connection for hepatitis C because while treatment records from the Philadelphia VAMC noted a diagnosis of hepatitis C in 2001, service treatment records were silent for complaints, treatment, or diagnosis of hepatitis C and were silent for any evidence of known risk factors of hepatitis C infection such as exposure to blood products or transfusions. In addition, the RO explained that the Veteran did not complete and return a hepatitis C risk factor questionnaire mailed to him in July 2005 or identify or provide other medical evidence needed to substantiate his claim. The Veteran did not initiate an appeal of this decision and new and material evidence was not received within one year of the notice of the decision. Thus, the October 2005 decision denying service connection for hepatitis C became final and is not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.1103. The Veteran’s application to reopen the claim of service connection for hepatitis C was received in January 2012. Comparing the evidence of record at the time of the October 2005 decision with additional evidence received since that decision, the Board finds that new and material evidence has been received sufficient to reopen the claim of entitlement to service connection for hepatitis C. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Specifically, private treatment records received in March 2012 include a May 2001 consultation report by a private gastroenterologist, H. Freilich, M.D. The Veteran had complained of a one-and-a-half-year history of [unintentional] weight loss. He denied any history of transfusion or intravenous drug use, but admitted to sharing razors while in the military. Dr. Freilich indicated the Veteran did appear to have hepatitis C, most likely chronic, and believed he possibly contracted hepatitis C by sharing razors in the military. A June 2001 pathology report of a liver biopsy confirmed that findings were consistent with chronic hepatitis C. The May 2001 report by Dr. Freilich, which was received in March 2012, relates to unestablished facts necessary to establish the claim of service connection for hepatitis C. Presuming the credibility of the evidence, the record identifies an “injury” or hepatitis C risk factor in service involving sharing razors. Accordingly, this additional evidence is both new and material and warrants reopening the claim of service connection for hepatitis C. 38 C.F.R. § 3.156. 3. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection, to include as secondary to treatment for prostate cancer In July 1994, the RO denied the Veteran’s claim of entitlement to service connection for chronic pathology causing hematuria, claimed as “recurrent hematuria.” The RO decision acknowledged the Veteran’s complaints of lower back and abdomen pain accompanied by blood in the urine during service in August 1991 and February 1992, diagnosed as prostatitis and urethritis protozoan, respectively. The decision also noted his “complaints of pain in the urinary tract” and blood in the urine at retirement examination with no clinical findings shown and no diagnosis provided of a chronic pathology causing the symptoms. Consequently, the RO denied the claim because hematuria is “considered a symptom and is not a disability” for which service connection may be established. The Veteran did not initiate an appeal of this decision and new and material evidence was not received within one year of the notice of the decision. Thus, the July 1994 decision denying service connection for chronic pathology causing hematuria became final and is not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.1103. In January 2012, VA received the Veteran’s claim of entitlement to service connection for “urinary tract condition as a result of exposure to non-potable water while in Panama and secondary to prostate cancer treatment.” A February 2013 rating decision deferred a decision on the “issue of compensation for chronic pathology causing hematuria now claimed as urinary tract condition.” In a June 2013 rating decision, the RO denied the claim of entitlement to “service connection for chronic pathology causing hematuria.” The RO acknowledged the Veteran had been “seen in service for urinary tract infection” and he was “now claiming service connection for a current urinary tract condition.” The RO explained that a VA examiner determined in May 2013 that the Veteran’s current radiation cystitis was unrelated to his urinary tract infection in service and that urinary tract infection does not lead to prostate cancer. The examiner also opined that radiation treatment for the Veteran’s nonservice-connected prostate cancer was the likely cause of his radiation cystitis. Comparing the evidence of record at the time of the July 1994 decision with additional evidence received since that decision, the Board finds that new and material evidence has been received sufficient to reopen the claim of entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Specifically, the new evidence is material because it suggests a continuity of symptomatology related to nonspecific urethritis or chronic prostatitis since active duty service. Beginning in May 1990, the Veteran had chronic problems in service with hematuria and dysuria. Other than trichomoniasis found on urinalysis in February 1992, work-ups for sexually transmitted infections were consistently negative. Instead, the diagnosis included kidney infection, nongonococcal urethritis, and chronic prostatitis. He was treated with antibiotics. New evidence received since the July 1994 decision reflects that the Veteran was diagnosed with prostate cancer in 2004 and he underwent a radical prostatectomy in November 2004. He received radiation treatment from January to March 2005. Subsequently, he developed radiation cystitis. However, in May 2013, a VA physician reviewed the Veteran’s claims file, observing recurrent urinary tract infections in service designated as nonspecific urethritis that occurred twice yearly after service as well. The examiner explained that “[t]his can be a chronic condition and may have caused infection of the prostate, where it is notoriously difficulty to eradicate infection.” Based on the new and material evidence received since July 1994, the claim is reopened. 4. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for prostate cancer An October 2005 rating decision denied entitlement to service connection for prostate cancer, claimed as due to exposure to radiation. The RO denied the claim because there was no evidence of complaints, diagnosis, or treatment for prostate cancer in service; no evidence that prostate cancer manifested to a compensable degree within a year of separation from service; and no evidence showing a link between the prostate cancer diagnosed in 2004 and any radiation exposure. The RO notified the Veteran of the decision the same month. He did not initiate an appeal by filing an NOD. In addition, new evidence received within the one-year appeal period following the notice of decision was not material to the claim because while it showed diagnosis and treatment of prostate cancer, it did not identify any relationship between the disability and the Veteran’s military service. Therefore, the October 2005 RO decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.1103 (2017). The Veteran’s application to reopen the claim of service connection for prostate cancer was received in May 2011. Comparing the evidence of record at the time of the October 2005 decision with additional evidence received since that decision, the Board finds that new and material evidence has been received sufficient to reopen the claim of entitlement to service connection for prostate cancer. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Specifically, in a May 2013 VA medical opinion report related to recurrent urinary tract infections, the reviewing physician indicated that nonspecific urethritis, for which the Veteran was treated during and after service, “can be a chronic condition and may have caused infection of the prostate, where it is notoriously difficult to eradicate infection.” Because the reviewing examiner identified a possible cause of infection of the prostrate during service and the Veteran currently has residuals of prostate cancer, the claim is reopened. 5. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD In July 2009, the RO denied the claim of entitlement to service connection for PTSD because the Veteran did not identify an in-service stressor, post-service VA treatment records showed treatment for depression, and PTSD was not otherwise shown to have been incurred in or caused by service. The RO notified the Veteran of the decision the same month. He did not initiate an appeal by filing an NOD or submit new and material evidence within the one-year appeal period following the notice of decision. Therefore, the July 2009 RO decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.1103 (2017). The Veteran’s application to reopen the claim of service connection for PTSD was received in January 2012. Comparing the evidence of record at the time of the July 2009 decision with additional evidence received since that decision, the Board finds that new and material evidence has been received sufficient to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Specifically, private treatment records associated with the Veteran’s application for SSA disability benefits and VA treatment records suggest that his diagnosed depression is attributable in part to prostate cancer and residual disabilities of prostate cancer. In this case, the Veteran’s claim for PTSD is appropriately broadened to include the diagnosed depression disability noted in post-service treatment records. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009), (holding that although a claim identifies only a single diagnosed disorder, it must be considered a claim for any disability that may reasonably be encompassed by that claim). In addition, the Veteran is competent to describe depression symptoms related to his prostate cancer and residual disabilities. Finally, if presumed credible, this new and material evidence raises a reasonable possibility of substantiating the claim for service connection for an acquired psychiatric disability (depression) as secondary to the prostate cancer claim, which remains on appeal. Thus, the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). In addition, 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). To establish direct service connection, there must be: the existence of a present disability; in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including an organic disease of the nervous system (such as sensorineural hearing loss) or malignant tumors, may be established on a presumptive basis by showing that such a disease manifested to a compensable degree within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). 6. Entitlement to service connection for bilateral hearing loss The Veteran contends he has a current bilateral hearing loss disability due to exposure to communications equipment during his 20 years of military service in the Army. His service personnel records identify his principal duties to include radio teletype operator, wire systems installer, tactical satellite microwave systems team chief or section sergeant, multichannel systems supervisor, supply specialist and instructor/writer. His DD Form 214 identifies his MOS as armorer/unit supply specialist. His service treatment records document some exposure to hazardous occupational noise exposure and his participation in the hearing conservation program. Accordingly, the Board finds the Veteran’s reports of military noise exposure credible and consistent with his military service and concedes such noise exposure. The question for the Board is whether the Veteran has a current disability that began during service, during the applicable presumptive period, or is at least as likely as not related to an in-service injury or disease. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The lack of any evidence that the Veteran exhibited hearing loss during service is not fatal to his claim. The laws and regulations do not require in-service complaints of or treatment for hearing loss in order to establish service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Veteran was afforded a VA examination in July 2012. Audiometry scores did not reveal a hearing loss disability for VA purposes. However, his speech recognition scores were reported as 92 percent in each ear and the audiologist diagnosed mild sensorineural hearing loss in each ear. Thus, the first criterion for establishing service connection–a current disability–is met. The Veteran’s service treatment records are silent for complaints, diagnosis, or treatment for hearing problems. As noted, he underwent audiometric testing throughout his active duty service, including as part of the hearing conservation program. The results of audiometric testing at enlistment and in October 1991, which is the last recorded date of such testing, are recorded as follows: HERTZ Date Ear 500 1000 2000 3000 4000 February 1974 (Enlistment) RIGHT 10 10 15 N/A 5 LEFT 25 15 20 N/A 10 October 1991 (Periodic Exam) RIGHT 0 0 0 5 20 LEFT 5 5 0 0 10 In a December 1993 retirement report of medical history, the Veteran denied currently or ever having hearing loss. He did endorse having ear trouble. A physician’s summary reflects the Veteran’s report of his ears ringing from time to time after being around power generators for periods of time. Post-service private and VA treatment records are silent for complaints, diagnosis, or treatment for hearing problems. During the July 2012 VA examination, the Veteran reported that his hearing loss began in 1995 or 1996 and had worsened since then. He described his military duties and noise exposure from loud radios, power generators, maneuvers with weapons, and being around a lot of tank noise while stationed in Germany. Regarding post-service occupational noise exposure, he indicated he worked as a long-haul truck driver from 1994 to 2000. He reported recreational noise exposure from target shooting with hearing protection between 1974 and 2007. Following a review of the claims file and examination, the audiologist opined it was less likely than not that the current hearing loss was due to military noise exposure. In support of the conclusion, the examiner noted the Veteran’s in-service audiograms were all normal and did not demonstrate significant threshold shift compared to a reference audiogram. In addition, the examiner explained that if the hearing loss was due to military noise exposure, it would be expected that the Veteran’s hearing loss would have progressed during active duty. The Board concludes that service connection for bilateral hearing loss is not warranted on any basis. First, the evidence of record demonstrates that a hearing loss disability was not incurred during active duty service and was not manifested to a compensable degree within one year of separation from active duty service. Notably, the Veteran’s statement to the July 2012 VA examiner that his bilateral hearing loss began in 1995 or 1996 is consistent with the finding that his hearing loss began more than one year after separation from service. Second, the Veteran is competent to report perceived hearing loss or diminished hearing. The evidence in this case reflects that despite his credible history of noise exposure during service, he consistently denied experiencing any change in his hearing acuity during this time. The Veteran’s subjective reports along with the audiometry findings weigh against a finding that the current bilateral hearing loss disability was either incurred in or caused by military service. In this regard, the Board notes that the audiometric testing data reflect that the Veteran had a 15 decibel upward shift in right ear hearing acuity at 4000 Hertz between entrance examination in February 1974 and October 1991. During the same period, however, his left ear hearing acuity at 4000 Hertz remained the same and his hearing at 500, 1000, and 2000 Hertz had a downward shift in hearing acuity ranging from 10 to 20 decibels bilaterally between entrance examination and October 1991. In other words, while the Veteran had a 15-decibel upward shift (worsening) at one level in his right ear, it did not reach the level of a hearing disability; at three other levels he had a 10- to 20-decibel downward shift (improvement) in both ears. Thus, the Veteran’s service treatment records support the conclusion that his hearing acuity generally improved since entrance examination in 1974. Finally, the Board finds the opinion of the July 2012 VA examiner persuasive because it was based on a review of the claims file and supported by an articulated medical explanation that is consistent with the remaining records. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). There is no medical opinion evidence to the contrary. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 7. Entitlement to service connection for thyroid cancer, claimed as due to exposure to ionizing radiation The Veteran contends that his thyroid cancer, which was diagnosed in 2010, is due to exposure to radiation during his military service. In correspondence received in June 2005 related to other claims, he asserted he was exposed to radiation during his military duties as a communications specialist and satellite technician. Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods. Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, specific to radiation-exposed veterans, there are certain types of cancer that are presumptively service connected, including cancer of the thyroid. 38 U.S.C. § 1112(c); 38 C.F.R. § 3.309(d)(2)(ii). Second, when a “radiogenic disease” first becomes manifest after service, and it is contended that the disease resulted from exposure to ionizing radiation during service, various development procedures must be undertaken in order to establish whether or not the disease developed as a result of exposure to ionizing radiation. 38 C.F.R. § 3.311(a)(1). “Radiogenic disease” means a disease that may be induced by ionizing radiation and includes thyroid cancer and “any other cancer.” 38 C.F.R. § 3.311(b)(2)(ii), (xxiv). Third, even if the claimed disability is not listed as a presumptive disease under 38 C.F.R. § 3.309(d) or as a radiogenic disease under 38 C.F.R. § 3.311, service connection must still be considered under 38 C.F.R. § 3.303(d) in order to determine whether the disease diagnosed after discharge was incurred during active service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A “radiation-exposed veteran” is defined as either a veteran who while serving on active duty, or an individual who while serving on active duty for training or inactive duty training, participated in a radiation-risk activity. 38 C.F.R. § 3.309(d)(3)(i). “Radiation-risk activity” is defined to include onsite participation in a test involving the atmospheric detonation of a nuclear device; other activities during periods that ended on July 1, 1946 or before January 1, 1974; and presence at certain locations in Kentucky, Ohio, or Tennessee if the service member was monitored through the use of dosimetry badges or served in a position that had exposures comparable to a job that is or was monitored through the use of dosimetry badges. 38 C.F.R. § 3.309(d)(3)(ii). The term “atmospheric detonation” includes underwater nuclear detonations. 38 C.F.R. § 3.309(d)(3)(iii). In December 2012, VA requested from the U.S. Army Ionizing Radiation Dosimetry Center a DD1141, Record of Exposure to Ionizing Radiation, or an equivalent record of occupational radiation exposure for the Veteran. The U.S. Army Dosimetry Center responded that it had researched the files for records of exposure to ionizing radiation for the Veteran, but was unable to locate any records for him. The Veteran’s service personnel records identify his principal duties to include radio teletype operator, wire systems installer, tactical satellite microwave systems team chief or section sergeant, multichannel systems supervisor, supply specialist and instructor/writer. His DD Form 214 identifies his MOS as armorer/unit supply specialist. His service treatment records do not reflect participation in any radiation-risk activity. The records are also silent for complaints, diagnosis, or treatment for thyroid cancer or thyroid problems. The Board finds that service connection for thyroid cancer is not warranted. First, the evidence of record reflects that the Veteran is not a radiation-exposed veteran, as defined in the applicable regulation. Therefore, service connection for thyroid cancer under the provisions of 38 C.F.R. §§ 3.309(d) and 3.311 must be denied. Similarly, the claim must be denied on a direct basis because the evidence shows that thyroid cancer was not incurred in service and there is no competent medical evidence otherwise linking his thyroid cancer to service. Finally, service connection for thyroid cancer on a presumptive basis under 38 C.F.R. § 3.309(a) must be denied because this disability did not manifest within one year of separation from service. Instead, thyroid cancer first manifested in 2010, more than 16 years after separation from service. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim for service connection for thyroid cancer, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating The Veteran contends that higher ratings than those currently assigned are warranted for service-connected low back, left knee, right knee, and hypertension disabilities. His claim for increased ratings was received in January 2012. Pertinent to these claims, the Board notes that the Veteran had also claimed entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. His claim for a TDIU was granted effective from the date VA received his claim on July 17, 2012. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). 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. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings should 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. 38 C.F.R. § 4.7. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Generally, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also for consideration in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. Pertinent to the low back and knee disabilities, in determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Disability of the musculoskeletal system is primarily 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. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on undertaking the motion. Id.; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 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. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Factors of joint disability reside in reductions of their normal excursion of movements in different planes and consideration will be given to less movement or more movement than normal, weakness, excess fatigability, incoordination, painful movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. Id. Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell, 25 Vet. App. at 43. Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). 8. Entitlement to a rating in excess of 20 percent for lumbosacral strain with degenerative disc disease The Veteran’s lumbosacral strain with degenerative disc disease is rated 20 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply to disability of the thoracolumbar spine. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, 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 body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 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. Note 2. Range of motion measurement is rounded to the nearest five degrees. Id. Note 4. Associated objective neurologic abnormalities are evaluated separately, under an appropriate diagnostic code. Id. Note 1. Separate disabilities ratings have been assigned for the Veteran’s radiculopathy affecting each lower extremity. The Veteran was afforded VA examinations in July 2012 and December 2015 to evaluate the severity of his lumbar spine disability. During the 2012 examination, the Veteran described having constant spasm and constant pain in his lumbar spine, with the pain going down both legs without numbness or tingling. He reported taking Percocet and baclofen for pain. He did not report any flare-ups affecting the function of his thoracolumbar spine. He indicated he used a cane constantly for locomotion. The examiner noted that prior x-ray studies revealed degenerative changes in the lumbar spine. Lumbar spine range-of-motion testing revealed forward flexion to 60 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees, and right and left lateral rotation to 10 degrees. He had pain at the endpoint of each plane of motion. Following repetitive-use testing, there were no further limitations in range of motion and no functional loss or impairment due to pain, fatigue, weakness, or lack of endurance. Other lumbar spine examination findings included the following: localized tenderness to palpation; spasm of the thoracolumbar spine; 4/5 muscle strength testing; no muscle atrophy; normal deep tendon reflexes and sensory function; radiculopathy of each lower extremity; and intervertebral disc syndrome with no incapacitating episodes over the last 12 months. The examiner described the effects of the Veteran’s lumbar spine disability on his usual occupation as a stocker and truck driver as limiting his ability to walk, stand, or sit for more than 20 minutes and limiting his ability to carry more than 10 pounds due to back pain. During the December 2015 VA examination, the Veteran described low back pain with intermittent tingling radiating down his buttocks and posterior legs to his feet associated with sitting 15 minutes, walking 10 minutes, forward bending, or lifting and/or carrying 10 pounds. Range-of-motion testing revealed forward flexion limited to 70 degrees, extension to 30 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 25 degrees with objective evidence of pain on forward flexion, right and left lateral rotation, and with weight-bearing. Following repetitive-use testing, there was no additional loss of function or range of motion, including due to pain, weakness, fatigability, or incoordination. Other examination findings of the thoracolumbar spine included no pain on palpation, no guarding or muscle spasm, normal muscle strength without atrophy, hypoactive reflexes, normal sensory function, mild radiculopathy of the bilateral lower extremities; no ankylosis of the spine; and intervertebral disc syndrome with no incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician in the past 12 months. VA and private treatment records associated with the claims file note the Veteran’s history of back pain, but do not include contemporaneous examination findings responsive to the applicable diagnostic criteria. Having considered the medical and lay evidence of record, the Board finds that a rating higher than 20 percent is not warranted for the Veteran’s lumbosacral strain with degenerative disc disease at any time during the appeal. His low back disability has been manifested at worst by forward flexion limited to 60 degrees with pain and a combined range of motion of the thoracolumbar of 105 degrees. These findings are consistent with the 20 percent rating assigned since the date VA received the Veteran’s claim for an increased rating. A higher, 40 percent rating is not warranted because at no time during the appeal has the Veteran’s low back disability been manifested by forward flexion of the thoracolumbar spine limited to 30 degrees or less or any ankylosis of the thoracolumbar spine. The Board observes that the December 2015 VA examination shows the Veteran’s low back disability was manifested at worst by forward flexion limited to 70 degrees with pain and a combined range of motion of the thoracolumbar spine of 200 degrees. These findings are consistent with a 10 percent rating under Diagnostic Code 5237. Despite the apparent improvement in the Veteran’s back, the Board will not disturb the more favorable, 20 percent rating currently assigned. The Board notes that the examination findings have shown that the Veteran’s service-connected low back disability has produced radiculopathy in both lower extremities. However, service connection is currently in effect for radiculopathy of the right and left lower extremities and 20 percent ratings have been assigned for each lower extremity under Diagnostic Code 8720. Those ratings are not currently at issue. Finally, the Board considered whether a higher rating is warranted based on the Veteran’s diagnosed intervertebral disc syndrome. However, the medical evidence of record reflects the Veteran has not experienced incapacitating episodes, defined as 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, having a total duration of at least 4 weeks but less than 6 weeks during any 12-month period. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. As a result, a rating in excess of 20 percent for the Veteran’s low back disability is not warranted on any basis. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim for a higher rating than that assigned for his lumbar spine disability, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 9. Entitlement to a rating in excess of 10 percent for left knee chondromalacia 10. Entitlement to a rating in excess of 10 percent for right knee chondromalacia The Veteran’s left and right knee chondromalacia disabilities are each rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260. For VA compensation purposes, normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Ratings for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees is 0 percent; flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Ratings for limitation of extension of the knee are assigned as follows: extension limited to 5 degrees is 0 percent; extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. Id., Diagnostic Code 5261. VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (Sept. 17, 2004). Because ratings may be separately assigned for limitation of flexion and limitation of extension, the Board will consider both Diagnostic Codes. Diagnostic Code 5257 pertains to other impairment of the knee involving recurrent subluxation or lateral instability and provides a 10 percent rating for slight impairment, a 20 percent rating for moderate impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA General Counsel has held that separate ratings may be assigned for arthritis and instability under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (July 1, 1997). The Veteran was afforded VA examinations of his knees in July 2012 and December 2015. During the former examination, he stated that treatment for his knees had been limited to Synvisc injections and Percocet for pain and that only the Percocet improved the pain. He did not report flare-ups affecting the function of his knees or lower extremities. He reported constant use of a cane for locomotion. Range-of-motion testing revealed bilateral knee flexion limited to 90 degrees and full bilateral knee extension to 0 degrees with pain occurring at the endpoint of each plane of motion bilaterally. Following three repetitions, there was no change in bilateral knee range-of-motion measurements and the knees were not further diminished by pain, fatigue, weakness, or lack of endurance. The examiner concluded the Veteran did not have functional loss of the bilateral knees and lower extremities. Other examination findings of the knees, bilaterally, included no tenderness or pain to palpation, 4/5 strength, no instability on testing, no history of patellar subluxation or dislocation, no meniscal condition, and no tibial or fibular impairment. The examiner reviewed x-ray studies of the bilateral knees, which showed fragmentation of the upper lateral aspect of the left patella, probably as a result of previous trauma or bipartite patellae; and no other abnormalities in the bones or joints. The examiner commented that the Veteran’s knee disabilities would interfere with sedentary or physical work due to being unable to walk, stand, or sit for more than 20 minutes and being unable to life more than 15 pounds due to knee pain. During the December 2015 VA examination, the Veteran reported occasional bilateral knee pain and/or popping associated with reclining 30 minutes, risking quickly from a sitting position, kneeling, squatting, walking 15 minutes, or climbing one flight of stairs. He did not report flare-ups of symptoms in either knee. He stated that he occasionally used a brace for his back and knee disabilities and occasionally used a cane due to occasional lightheadedness of undetermined etiology. On examination, the Veteran had full knee extension to 0 degrees bilaterally and flexion to 130 degrees bilaterally. There was no objective evidence of pain with motion, pain with weight-bearing, or pain on palpation of the joints of associated soft tissues. Following repetitive-use testing, there was no additional loss of motion or functional loss, including due to pain, weakness, fatigability, or incoordination. Other reported examination findings included the following: normal muscle strength bilaterally; no muscle atrophy; no ankylosis; no history of recurrent subluxation or lateral instability and normal stability testing bilaterally; no meniscal conditions; and no impairment of the tibia and fibula. VA and private treatment records associated with the claims file note the Veteran’s history of bilateral knee pain, but do not include contemporaneous examination findings responsive to the applicable diagnostic criteria. Having considered the medical and lay evidence of record, the Board finds that a rating higher than 10 percent is not warranted for either knee. The Veteran’s knee disabilities have been manifested at worst by flexion limited by pain to 90 degrees bilaterally and full extension to 0 degrees with pain at the endpoint of motion bilaterally. These findings are consistent with the 10 percent rating currently assigned for each knee based on objective evidence of painful motion. 38 C.F.R. §§ 4.45, 4.59. A higher rating is not warranted for either knee at any time during the appeal because the evidence documents the Veteran does not have knee flexion limited to 30 degrees or knee extension limited to 15 degrees. The Board has considered other potentially applicable rating criteria, but finds that a higher rating is not warranted because the Veteran does not have any impairment of the femur manifested by malunion with knee disability, ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, or tibia and fibula impairment. 38 C.F.R. § 4.71a, Diagnostic Codes 5255, 5256, 5257, 5258, 5262. Therefore, the claim for a rating in excess of 10 percent for the left or right knee disability must be denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim for higher or separate ratings than those assigned for the left and right knee disabilities, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 11. Entitlement to a rating in excess of 10 percent for hypertension The February 2013 rating decision increased the assigned rating for the Veteran’s hypertension disability, effective January 17, 2012, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101. He believes a higher rating is warranted. Diagnostic code 7101 provides a 10 percent rating when diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is assigned where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. Higher ratings are available for predominantly higher blood diastolic blood pressure readings. 38 C.F.R. § 4.104. The Veteran’s service treatment records reflect he was diagnosed with hypertension and began taking lisinopril in June 1991 when his blood pressure was recorded as 152/102, 148/100, and 142/94. Other contemporaneous service treatment records document his diastolic blood pressure was recorded as 156/102 (August 1991); 128/70 (February 1992); 130/84 (July 1992); 122/118 (July 1992); 112/116 (September 1992); 148/108 (November 1993); right arm 144/98 and 134/84 and left arm 146/114 and 146/100 (November 1993); and right arm 134/96 and left arm 134/88 (December 1993). The Board finds the Veteran has a history of diastolic blood pressure predominantly 100 or more and required continuous medication for control. The Veteran was afforded VA examinations in July 2012 and December 2015 to evaluate his hypertension disability. In July 2012, he reported taking one tablet of Bystolic daily for hypertension with good control of blood pressure. Blood pressure readings were recorded as follows: left arm 144/101, right arm 134/104, repeat on left arm 147/98. At the December 2015 VA examination, he reported he continued to take medications to control his hypertension disability. His blood pressure was recorded as 134/90, 133/88, and 118/75. Private treatment records received in support of the claim for an increased rating reflect systolic blood pressure readings lower than 160 and diastolic blood pressure readings predominantly less than 100 with continued use of medications for control. Based on the foregoing, the Veteran’s hypertension has been manifested throughout the appeal by a history of diastolic pressure predominantly 100 or more with continuous medication required for control and by diastolic pressure predominantly 100 or more at the time of the July 2012 VA examination. These findings are consistent with the 10 percent rating currently assigned for hypertension. A higher, 20 percent rating is not warranted because the medical evidence of record reflects the Veteran’s blood pressure is not manifested by diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim for a higher rating than that assigned for hypertension, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for hepatitis C is remanded. The Veteran contends his current hepatitis C disability is related to military service. He believes he was exposed to hepatitis C virus while stationed in Panama and during temporary duty assignments (TDYs) to Ecuador, Honduras, and other countries. Private treatment records from S. Lizerbram, M.D., reflect that the Veteran established care in May 1999 with complaints of a six-month history of feeling tired and having muscle aches and unexplained weight loss. Subsequent records reflect he was diagnosed with hepatitis C in April 2001. During a May 2001 private gastroenterology consultation, the Veteran admitted sharing razors during military service; he denied any history of transfusion or intravenous drug use. At his military retirement examination in December 1993, the Veteran denied a history of jaundice or hepatitis or any recent weight loss. However, a treatment record two days later indicated the Veteran returned because he was found to have elevated liver enzymes. He reported feeling well and having had one drink since he was last seen at the clinic. The assessment included rule out hepatitis and the plan included a hepatitis A and B test panel. The Board has been unable to locate a record of subsequent hepatitis testing among his service treatment records. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for hepatitis C because no VA examiner has opined whether the Veteran’s current hepatitis C that was diagnosed in 2001 is related to any hepatitis C exposure during his military service from 1974 to 1994, including his report in May 2001 that he shared razors during service. The AOJ should give the Veteran another opportunity to complete and return a Hepatitis C Risk Factors Questionnaire and should arrange to obtain a VA medical opinion regarding the etiology of his hepatitis C based on all identified risk factors. 2. Entitlement to service connection for chronic pathology causing hematuria, also claimed as urinary tract infection. In January 2012, VA received a claim of entitlement to service connection for a urinary tract disorder claimed as incurred in service due to drinking non-potable water while stationed in Panama and as secondary to his treatment for prostate cancer, which is not service-connected but is also on appeal. In May 2013, a VA physician reviewed the Veteran’s claims file and opined that the Veteran’s current radiation cystitis was secondary to radiation treatment for prostate cancer and was unrelated to his urinary tract disorder in service. However, the physician added that “nonspecific urethritis is a difficult condition to diagnosis [sic] and cure at times so that it is also at least as likely as not that there may be a component consisting through this.” The Board requires an addendum opinion to clarify whether any current disability manifested by recurrent, chronic dysuria and hematuria is medically related to the Veteran’s chronic dysuria and hematuria symptoms in service (diagnosed as kidney infection, nongonococcal urethritis, and chronic prostatitis). This issue is remanded to obtain the necessary medical opinion evidence. 3. Entitlement to service connection for prostate cancer is remanded. Beginning in May 1990, the Veteran’s service treatment records reflect recurrent complaints of blood in his urine (hematuria), painful urination (dysuria), and urinary frequency often with low back pain and flu-like symptoms. The diagnosis included urinary tract infections, which were also characterized as kidney infection, nongonococcal urethritis, and chronic prostatitis. He was treated with antibiotics (Septra) and followed by urology specialists. In May 2013, a VA physician reviewed the Veteran’s claims file and provided an opinion regarding the claimed disability manifested by hematuria, dysuria, and urinary tract infections. The reviewing physician indicated that nonspecific urethritis, for which the Veteran was treated during and after service, “can be a chronic condition and may have caused infection of the prostate, where it is notoriously difficult to eradicate infection.” The examiner remarked that urinary tract infection does not lead to prostate cancer. However, the examiner did not provide an opinion as to whether the chronic prostatitis diagnosed and treated in service caused the Veteran’s prostate cancer or could have been an initial manifestation of undiagnosed prostate cancer. Therefore, remand for a supplemental VA opinion is required to address the etiology of the Veteran’s prostate cancer because the Board is prohibited from exercising its own independent judgment to resolve medical questions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 4. Entitlement to service connection for an acquired psychiatric disability, to include PTSD is remanded. 5. Entitlement to service connection for erectile dysfunction, claimed as secondary to prostate cancer is remanded. 6. Entitlement to special monthly compensation for loss of use of a creative organ, secondary to prostate cancer is remanded. The Veteran does not contend and the evidence of record does not reflect that his erectile dysfunction began in service or is otherwise related to service. Rather, he seeks entitlement to service connection for erectile dysfunction as secondary to prostate cancer and contends he is entitled to special monthly compensation for loss of use of a creative organ based on erectile dysfunction. Post-service treatment records reflect that the Veteran underwent a radical prostatectomy in November 2004 followed by pelvic radiotherapy treatment with Lupron. Records from his private urologist, B. Garber, M.D., indicate the Veteran developed organic impotence as a result of treatment for prostate cancer. In a December 2005 sexual function questionnaire, the Veteran indicated he had seen a psychologist or psychiatrist in the past “due to prostate cancer, high blood pressure, and divorce.” Here, he has attributed psychiatric impairment, in part, to his claimed prostate cancer disability, and VA treatment records reflect a current diagnosis of depression. Because the issues of entitlement to service connection for a psychiatric disorder, erectile dysfunction, and special monthly compensation for loss of use of a creative organ are dependent on the outcome of the service connection claim for prostate cancer, they are inextricably intertwined with that issue being remanded and must also be remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Ask the Veteran to complete and return a Hepatitis C Risk Factors Questionnaire. 2. Provide the Veteran’s electronic claims file to an appropriate clinician to determine the nature and etiology of the Veteran’s hepatitis C disability, which was diagnosed in 2001 after complaining of tiredness, muscle aches, and unexplained weight loss since approximately December 1998. The reviewing examiner must opine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hepatitis C was incurred in service or is related to any identified risk factor(s) during his military service from March 1974 to March 1994. In providing the requested opinion, the examiner should consider and discuss the December 1993 service treatment record documenting elevated liver enzymes, the general length of time between exposure to hepatitis C and initial onset of symptoms, and all risk factors the Veteran identifies, including his admission during a private gastroenterology consultation in May 2001 that he shared razors during military service. 3. Provide the Veteran’s electronic claims file to an appropriate clinician to obtain a supplemental medical opinion regarding the Veteran’s hematuria and dysuria symptoms, also claimed as recurrent urinary tract infections. Following a review of the claims file, the reviewing clinician should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any current disability manifested by chronic, recurrent dysuria and hematuria other than radiation cystitis, which has been attributed to the Veteran’s radiation treatment for prostate cancer, is related to the Veteran’s treatment in service since May 1990 for kidney infection, nongonococcal urethritis, and chronic prostatitis. A complete medical rationale must be provided for all opinions expressed. 4. Provide the Veteran’s electronic claims file to an appropriate clinician to obtain a supplemental medical opinion as to the etiology of his prostate cancer. Following a review of the claims file, the reviewing clinician should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the chronic prostatitis for which the Veteran was treated in service was an initial manifestation of prostate cancer or otherwise caused his prostate cancer, which was diagnosed in 2004. A complete medical rationale must be provided for all opinions expressed. (Continued on the next page)   5. If service connection is established for prostate cancer, then the Veteran should be afforded a VA examination by a psychiatrist or psychologist to determine the nature and etiology of any current acquired psychiatric disability. Following a review of the claims file, the examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any current psychiatric disability, to include depression or PTSD, (a) had its onset during service or is medically related to service; or, if not (b) whether any current psychiatric disability, to include depression, was caused OR is or has been aggravated by service-connected prostate cancer and/or related residual disabilities. A medical analysis and rationale are to be included with all opinions expressed. 6. After completing the requested actions, readjudicate the intertwined claims of entitlement to service connection for erectile dysfunction and entitlement to special monthly compensation for loss of use of a creative organ. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel