Citation Nr: 19190860 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 15-19 457 DATE: December 3, 2019 ORDER The claim of entitlement to service connection for bilateral hearing loss is reconsidered. The claim of entitlement to service connection for diabetes mellitus, type II is reconsidered. Entitlement to service connection for diabetes mellitus, type II is denied. Entitlement to service connection for PTSD is denied. Entitlement to an initial evaluation higher than 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to an initial evaluation higher than 10 percent for left knee patellofemoral syndrome is denied. Entitlement to an initial compensable evaluation for right knee limited extension is denied. Entitlement to an initial compensable evaluation for left knee limited extension is denied. Entitlement to a 10 percent evaluation for residuals of a recurrent anal fissure prior to November 4, 2015 is granted. Entitlement to an evaluation higher than 10 percent for residuals of a recurrent anal fissure prior to January 25, 2018 is denied. Entitlement to an evaluation higher than 60 percent for residuals of a recurrent anal fissure on and after January 25, 2018 is denied. Entitlement to an evaluation higher than 50 percent for sarcoidosis with sleep apnea prior to April 26, 2019 is denied. Entitlement to a 60 percent evaluation for sarcoidosis with sleep apnea effective April 26, 2019 is granted. Entitlement to an evaluation higher than 10 percent for hypertension is denied. Entitlement to a compensable evaluation for hiatal hernia with gastroesophageal reflux disorder is denied. Entitlement to a compensable evaluation for a cyst removal scar is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. A February 2005 rating decision denied entitlement to service connection for bilateral hearing loss. Thereafter, new and relevant service department records were added to the record, and those records existed at the time of the prior denial. 2. A June 2013 rating decision denied entitlement to service connection for diabetes mellitus, type II. Thereafter, new and relevant service department records were added to the record, and those records existed at the time of the prior denial. 3. The evidence does not show that diabetes mellitus was diagnosed within service, that diabetes mellitus manifested to a compensable degree within one year of separation from service, and diabetes mellitus is not shown to otherwise be related to service. 4. The more probative evidence of record demonstrates that PTSD has not been clinically diagnosed during the appeal period. 5. At worst, right knee patellofemoral pain syndrome causes flexion limited to 120 with repeated use over time. 6. At worst, right knee extension is limited to 5 degrees. 7. At worst, left knee patellofemoral pain syndrome causes flexion limited to 120 with repeated use over time. 8. At worst, left knee extension is limited to 5 degrees. 9. Prior to November 4, 2015, service-connected anal fissure residuals caused mild fecal soiling. 10. Prior to January 25, 2018, service-connected anal fissure residuals caused mild fecal soiling akin to constant slight leakage, and occasional moderate leakage. 11. On and after January 25, 2018, there is no evidence of total loss of sphincter control 12. Prior to April 26, 2019, at worst pulmonary function testing showed FEV-1 to 74 percent. 13. On and after April 26, 2019, at worst pulmonary function testing showed FEV-1 to 49 percent. 14. The Veteran requires continuous medication to control hypertension. Diastolic pressure is not predominantly 110 or more, and systolic pressure is not predominantly 200 or more. 15. The hiatal hernia with gastroesophageal reflux disease causes symptoms of dysphagia, pyrosis, reflux, and substernal arm pain that is not productive of considerable or severe impairment of health. 16. The cyst removal scar measures 4 by 0.3 centimeters, and is not painful or unstable. Physical examination did not show any characteristics of disfigurement. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for bilateral hearing loss is reconsidered. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2018). 2. The claim of entitlement to service connection for diabetes mellitus is reconsidered. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for entitlement to service connection for diabetes mellitus, type II have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304(f), 4.125 (2018). 5. The criteria for an initial compensable evaluation for right knee limited extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5261 (2018). 6. The criteria for entitlement to an initial evaluation higher than 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, DC 5260 (2018). 7. The criteria for entitlement to an initial evaluation higher than 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, DC 5260 (2018). 8. The criteria for an initial compensable evaluation for left knee limited extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5261 (2018). 9. The criteria for a 10 percent evaluation for residuals of a recurrent anal fissure prior to November 4, 2015 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, DC 7332 (2018). 10. The criteria for an evaluation higher than 10 percent for residuals of a recurrent anal fissure prior to January 25, 2018 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, DC 7332 (2018). 11. On and after January 25, 2018 the criteria for an evaluation higher than 60 percent for residuals of a recurrent anal fissure are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, DC 7332 (2018). 12. Prior to April 26, 2019 the criteria for an evaluation higher than 50 percent for sarcoidosis with sleep apnea are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.96, 4.97, DCs 6600, 6846, 6847 (2018). 13. On and after April 26, 2019 the criteria for 60 percent evaluation for sarcoidosis with sleep apnea have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.96, 4.97, DCs 6600, 6846, 6847 (2018). 14. The criteria for a compensable evaluation for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104 DC 7101 (2018). 15. The criteria for a compensable evaluation for hiatal hernia with gastroesophageal reflux disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114 DC 7346 (2018). 16. The criteria for a compensable evaluation for a cyst removal scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7800 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Army from June 1972 until March 1975, and from December 1977 to June 1992. This matter comes to the Board of Veterans’ Appeal (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office. This matter was previously remanded in August 2018 and has since been returned for further appellate review. The Board finds that there has been compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). During the pendency of the appeal, a June 2019 rating decision granted entitlement to service connection for unspecified depressive disorder with unspecified anxiety disorder, and entitlement to service connection for sleep apnea. The Veteran originally claimed entitlement to service connection for PTSD, and entitlement to service connection for PTSD remains before the Board. The claim of entitlement to service connection for sleep apnea was fully granted in the June 2019 decision. In addition, a June 2018 rating decision increased the evaluation assigned for anal fissure residuals from noncompensable to 10 percent effective November 4, 2015; and to 60 percent effective January 25, 2018. The rating schedule provides higher evaluations for that condition throughout the appeal period, therefore the higher rating claim remains on appeal. New and Material Evidence - Reconsideration of Previously Denied Claims 1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for bilateral hearing loss. 2. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for diabetes mellitus In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 3.104, 20.1100, 20.1103 (2018). A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108 (2012). Alternatively, any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). A claim is not reconsidered, however, where VA could not have obtained the records when it initially decided the claim because the records did not exist at that time, or because the claimant failed to provide sufficient information to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or any other official source. 38 C.F.R. § 3.156(c)(2). A February 2005 rating decision denied service connection for bilateral hearing loss, and a June 2013 rating decision with notification letter denied entitlement to service connection for diabetes mellitus. The Veteran did not appeal those decisions nor submit new and material evidence within one year. The rating decisions are thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. The February 2005 rating decision reported review of the Veteran’s service treatment records (STRs) from March 1975 through July 1991. In March 2012, VA obtained additional STRs, including the Veteran’s April 1992 separation examination and report of medical history that included the Veteran’s report of ear trouble. Those STRs were available at the time of the 2005 rating decision and VA could have obtained them based on the Veteran’s reported period of service. Then, in March 2014 VA obtained the Veteran’s complete military personnel records that did not show any service in Vietnam, and that fact bears on the issue of presumptive service connection for diabetes mellitus. Those relevant service department records existed at the time of the prior denial in 2013 and could have been obtained by VA. In light of the receipt of relevant service department records following the 2005 and 2013 rating decisions, the claims of entitlement to service connection for bilateral hearing loss and diabetes mellitus are reconsidered. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, service connection for certain chronic diseases, including diabetes and hearing loss, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 3. Entitlement to service connection for diabetes mellitus, type II. The Veteran filed a claim of entitlement to service connection for diabetes mellitus, type II (originally claimed as borderline diabetes), but did not offer a specific theory of entitlement. See December 2011 claim; see October 2013 claim. First, service connection for diabetes mellitus may not be presumed. The Veteran’s DD 214 and service personnel records do not show service in the Republic of Vietnam, and the Veteran has not otherwise provided testimony regarding exposure to herbicides. Therefore, presumptive service connection for diabetes as a disease associated with herbicide exposure is not warranted. 38 C.F.R. §§ 3.307, 3.309. The evidence also shows that diabetes mellitus was not noted in service, and did not manifest to a compensable degree within one year of service. The STRs are silent for a diagnosis of diabetes mellitus. Treatment records from NMC Portsmouth show that in September 2008 the Veteran did not yet carry a diagnosis of diabetes mellitus, but his physician was monitoring his blood sugars. Next, an October 2010 Portsmouth record notes the Veteran was controlling his diabetes with diet. The available records show that diabetes was diagnosed sometime between 2008 and 2010, which is more than 1 year after the Veteran’s separation from service. Thus, service connection for the chronic disease of diabetes is not presumed. Second, service connection for diabetes mellitus is not warranted on a direct basis. Although the Veteran is currently diagnosed with diabetes mellitus, there is nothing in the record demonstrating onset in service, or some other nexus between the currently diagnosed diabetes mellitus and the Veteran’s period of service. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The available treatment records discuss the Veteran’s diagnosis and treatment, but do not discuss the etiology of the condition. The Veteran has not proffered a theory of entitlement or testimony regarding the claimed etiology of the condition. Overall, the record does not reflect any nexus between the currently diagnosed diabetes and the Veteran’s period of service and direct service connection is not warranted. VA did not obtain a medical opinion on the etiology of diabetes mellitus, but such development is not required in this case. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). An examination is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is no indication of an in-service event or nexus between the claimed disorder and the Veteran’s period of service and VA was not required to obtain a medical opinion. In sum, the claim is denied because service connection for diabetes mellitus may not be presumed and diabetes mellitus is not otherwise related to the Veteran’s service. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for PTSD. The Veteran filed a claim of entitlement to service connection for PTSD, but did not provide stressor information and did not otherwise provide a theory of entitlement. See October 2013 claim; see February 2014 notification letter requesting stressor details. Service connection for depressive disorder and anxiety disorder is in effect, but service connection for PTSD is not warranted because PTSD has not been diagnosed during the appeal period. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125. The Board notes that the Fifth Edition of the DSM (DSM-5) recently replaced the Fourth Edition of the DSM (DSM-IV). The evidence for the claim includes a March 2015 VA treatment record documenting a positive PTSD screen. When evaluated further by providers at VA and at other federal medical facilities, those providers diagnosed anxiety and/or depression. See April 2015 VA treatment note; see May 2016 VA treatment note; see November 2017 Ft. Eustis record. The Veteran underwent a VA examination in April 2019 with a psychiatrist. At that time, the Veteran reported coming upon the aftermath of a car accident when he was in the Army. The examiner found that the reported event met the stressor criteria for PTSD, but then explained there was no evidence of a diagnosis of PTSD because the Veteran denied suffering most symptoms compatible with PTSD and he did not meet the full diagnostic criteria under the DSM. The diagnoses advanced by the Veteran’s treatment providers and the April 2019 VA examiner are more probative than the positive PTSD screen as they are more thorough. See 38 C.F.R. §§ 3.304(f), 4.125. In sum, the most probative evidence of record demonstrates that PTSD has not been clinically diagnosed during the appeal period and service connection is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2017). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and 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). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 5. Entitlement to an initial compensable evaluation for right knee limited extension. 6. Entitlement to an initial evaluation higher than 10 percent for right knee patellofemoral pain syndrome The Veteran appeals the initial evaluations assigned for the service-connected right knee patellofemoral pain syndrome with limited extension. There are certain requirements specific to increased rating claims for musculoskeletal disabilities. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). 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; 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 criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran’s right knee disability is rated under 38 C.F.R. § 4.71a, DC 5260 for limitation of flexion of the leg and DC 5261 for limitation of extension. Although the Veteran does not meet the schedular requirements for a 10 percent evaluation under DC 5260, the 10 percent evaluation was assigned for an actually painful joint. See 38 C.F.R. § 4.59. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. The preponderance of the evidence is against the assignment of an evaluation higher than 10 percent under DC 5260 or to a compensable evaluation under DC 5261. The relevant evidence considered includes treatment records from VA and other Department of Defense medical facilities, along with VA examination reports. The available medical treatment records are largely silent for knee related complaints. A December 2015 Portsmouth treatment record does note the Veteran’s complaint of bilateral knee pain and buckling when climbing stairs. Knee x-rays showed minimal degenerative changes. Otherwise, the treatment records do not include complaints or treatment specific to the knees. The Veteran was afforded 3 VA examinations during the pendency of this appeal. At a January 2015 VA examination, initial range of motion of the right knee in flexion was limited to 135 degrees at which point there was objective evidence of painful motion. Extension was limited to 5 degrees at which point pain was noted. The Veteran performed 3 repetitions without additional loss of range of motion. The Veteran described flares of symptoms as pain with prolonged standing. Examination further showed normal muscle strength and normal stability. There was no history of patellar subluxation or dislocation, or any other right knee conditions or symptoms. In the remarks section, the examiner stated that pain, weakness, fatigability and/or incoordination were contributing factors of disability. The examiner went on to explain that those factors did not cause additional limitation of functional ability of the right knee joint during a flare or with repeated use over time. The testimony of pain with prolonged standing does show pain with weight bearing, but the examiner did not otherwise comment on pain in passive motion, or in weight bearing and nonweight bearing. The Veteran underwent another VA examination in January 2018. At that time the Veteran had normal range of motion of the right knee on initial range of motion testing. Pain was noted but did not cause functional loss. The Veteran was able to perform 3 repetitions without any additional loss of function or range of motion. There was pain in weight bearing and active range of motion, but no pain on passive range of motion or in nonweight bearing. The examination was consistent with the Veteran’s statements describing functional loss with repetitive use over time; and pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability with repeated use over a period of time. The Veteran described flares of symptoms in terms of chronic knee pain and limitation with sitting, standing, ambulating, climbing stairs, squatting, kneeling, and running. Disturbance of locomotion was an additional factor that contributed to disability and the Veteran regularly used a cane. There was no reduction in muscle strength, ankylosis, recurrent subluxation, lateral instability, recurrent effusion or patellar subluxation, or any other knee condition or symptom. The examiner reported that the Veteran had additional limitation of functional ability during a flare, but the examiner concluded they were unable to describe that loss in terms of range of motion because the Veteran was not experiencing a flare at the time of the examination. The 2018 examiner did not adequately address the Veteran’s reports of flares, as explained in the prior Board remand. Most recently, the Veteran was examined in April 2019. Initial range of motion of the right and left knee showed flexion to 135 and extension to 0. Pain was noted on examination in flexion and extension and caused functional loss. There was no evidence of pain with weight bearing or in non-weight bearing, or in passive motion. There was no crepitus, no localized pain or palpation. With observed repetitive use, there was additional loss of range of motion bilaterally in flexion to 130 degrees due to pain and weakness. Veteran did not report flares, but did report pain in both knees during but not limited to repeated use over time. The examiner opined that pain and weakness would significantly limit functional ability with repeated use over a period of time, and estimated that the functional loss would be to 120 degrees in flexion. Additional contributing factors of disability included disturbance of locomotion, and pain on prolonged standing or walking. There was some reduction in muscle strength but no muscle atrophy. There was no ankylosis, no instability, no recurrent subluxation or effusion, or any other identified knee symptoms or conditions. The April 2019 VA examination adequately addressed all findings necessary to rate the right knee disability. Based on the April 2019 VA examination report, and at worst, right knee flexion is limited to 120 degrees with repeated use over time. To warrant a higher evaluation under DC 5260, flexion must be limited to 30 degrees or less. Here, there is no evidence of record supporting a finding that right knee flexion has been limited to 30 degrees or less and an increase is not warranted under DC 5260. Additionally, at worst right knee extension was limited to 5 degrees. See January 2015 VA examination report. Thereafter, the evidence does not show a limitation on extension and the 2019 examiner found that there was no additional loss of extension with repeated use over time. To warrant a compensable evaluation under DC 5261, extension must be limited to 10 degrees or less, which is not shown in this case. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, disturbance of locomotion, and pain on prolonged standing or walking, and additional limitation with repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements are not shown to result in limitation of motion more nearly approximating extension limited to 10 degrees or flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991) (holding that the Board must consider all potentially applicable regulatory provisions). Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The December 2015 Portsmouth record notes the Veteran’s lay testimony of knee buckling when climbing stairs. The Veteran is competent to report his symptoms to include the feeling of instability, but the Board finds the objective stability testing to be more probative as to whether the Veteran has right knee instability. Notably, joint testing was not accomplished at the time of the December 2015 record although that testing was completed at the VA examinations and provided negative results throughout the appeal period. Thus, a separate evaluation under DC 5257 for other impairment of the knee is not warranted. Additionally, the evidence of record does not demonstrate ankylosis, semilunar cartilage issues, impairment of the tibia or fibula, or genu recurvatum. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5256, 5289, 5259, 5262, 5263 (2018). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an evaluation higher than 10 percent for right knee flexion, or to a compensable rating for right knee extension. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. Entitlement to an initial evaluation higher than 10 percent for left knee patellofemoral syndrome 8. Entitlement to an initial compensable evaluation for left knee limited extension The Veteran’s left knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg and DC 5261 for limitation of extension. The preponderance of the evidence is against the assignment of an evaluation higher than 10 percent under DC 5260 or to a compensable evaluation under DC 5261. The January 2015, January 2018, and April 2019 VA examination reports included left knee findings identical to those for the right knee; and the December 2015 Portsmouth record similarly mentioned left knee pain and buckling when climbing stairs. Again, based on the April 2019 VA examination report, and at worst, left knee flexion is limited to 120 degrees with repeated use over time. To warrant a higher evaluation under DC 5260, flexion must be limited to 30 degrees or less. Here, there is no evidence of record supporting a finding that left knee flexion has been limited to 30 degrees or less and an increase is not warranted under DC 6260. Additionally, at worst left knee extension was limited to 5 degrees. See January 2015 VA examination report. Thereafter, the evidence does not show a limitation on extension and the 2019 examiner found that there was no additional loss of extension with repeated use over time. To warrant a compensable evaluation under DC 5261, extension must be limited to 10 degrees or less, which is not shown in this case. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, disturbance of locomotion, and pain on prolonged standing or walking, and additional limitation with repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements are not shown to result in limitation of motion more nearly approximating extension limited to 10 degrees or flexion limited to 45 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. See Schafrath, 1 Vet. App. at 592-93. The December 2015 Portsmouth record notes the Veteran’s lay testimony of knee buckling when climbing stairs. The Veteran is competent to report his symptoms to include the feeling of instability, but the Board finds the objective stability testing to be more probative as to whether the Veteran has right knee instability. Notably, joint testing was not accomplished at the time of the December 2015 record although that testing was completed at the VA examinations and provided negative results throughout the appeal period. Thus, a separate evaluation under DC 5257 for other impairment of the knee is not warranted. Additionally, the evidence of record does not demonstrate ankylosis, semilunar cartilage issues, impairment of the tibia or fibula, or genu recurvatum. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5256, 5289, 5259, 5262, 5263. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an evaluation higher than 10 percent for left knee flexion, or to a compensable rating for left knee extension. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to a compensable evaluation for residuals of a recurrent anal fissure prior to November 4, 2015, in excess of 10 percent prior to January 25, 2018, and in excess of 60 percent after that date The Veteran seeks entitlement to higher evaluations for service-connected anal fissure residuals throughout the appeal period. That condition is rated under DC 7332 for impairment of sphincter control as that is the predominant residual. See C.F.R. § 4.114. Under DC 7332, a 0 percent evaluation is assigned for healed or slight impairment of sphincter control without leakage. A 10 percent evaluation is warranted for constant slight or occasional moderate leakage. A 30 percent evaluation is warranted for occasional involuntary bowel movements necessitating wearing of a pad. A 60 percent evaluation is warranted for extensive leakage and fairly frequent involuntary bowel movements. A maximum 100 percent evaluation is warranted for complete loss of sphincter control. Prior to November 4, 2015, the criteria for a 10 percent evaluation for impairment of sphincter control is warranted. An April 2013 Ft. Eustis medical record notes the Veteran had mild fecal soiling associated with residuals of an in-service anal fissure and surgical repair. A March 2014 Portsmouth records also documents symptoms of mild fecal soiling. The Veteran was scheduled for a VA examination in March 2014, and that examiner simply stated that there were no signs or symptoms attributable to the anal fissure. The examiner did not document the Veteran’s lay testimony in the report, and the examination findings are inconsistent with the available treatment records. A March 2015 Portsmouth record documents that the Veteran had to go to the restroom as soon as he felt the need to make a bowel movement. Based on the cited medical records, entitlement to a 10 percent evaluation prior to November 4, 2015 is warranted for mild fecal soiling. Mild fecal soiling more nearly approximates the symptoms of constant slight or occasional moderate leakage contemplated by the 10 percent rating criteria. Mild fecal soiling does not more nearly approximate an evaluation higher than 10 percent, because the evidence does not show occasional involuntary bowel movements and the Veteran did not use absorbent materials. Based on the preponderance of the evidence, the criteria for a 10 percent evaluation prior to November 4, 2015 are met. Prior to January 25, 2018, the criteria for an evaluation higher than 10 percent are not met. November 2015 Portsmouth records document the Veteran had fecal smearing due to rectal incontinence every time he passed gas and there was objective evidence of decreased sphincter tone on examination. At a January 2016 Ft. Eustis appointment, the Veteran reported worsening symptoms with increased fecal urgency and worsening fecal incontinence with daily underwear smearing. A March 2016 Ft. Eustis record also reports the Veteran had rectal incontinence every time he passed gas. An October 2016 Ft. Eustis record further clarified the Veteran had an episode of fecal incontinence 4 months prior, and continued with fecal urgency and incontinence. The assessment was mild fecal soiling. The available records continue to show the Veteran had constant slight leakage, described as daily underwear smearing and mild fecal soiling. The October 2016 treatment record is consistent with occasional moderate leakage also contemplated by the 10 percent rating criteria. For the period prior to January 2018, there is also no evidence that the Veteran’s impairment of sphincter control necessitated the wearing of a pad. Thus, for the period from November 4, 2015 and prior to January 25, 2018 the criteria for an evaluation higher than 10 percent is not established. On and after January 25, 2018, a 60 percent evaluation has been in effect and the evidence does not show that a higher evaluation of 100 percent is warranted. After January 24, 2018, there is no evidence indicating the Veteran has complete loss of sphincter control. The January 2018 VA examiner documented the Veteran had impairment of sphincter control with extensive leakage and fairly frequent involuntary bowel movements, but not complete loss of sphincter control. The other medical records from January 25, 2018 onward do not document complete loss of sphincter control. Thus, for the period on and after January 25, 2018 the criteria for an evaluation higher than 60 percent for residuals of an anal fissure is not warranted. 10. Entitlement to an evaluation higher than 50 percent for sarcoidosis with sleep apnea. The Veteran seeks entitlement to an evaluation higher than 50 percent for sarcoidosis with sleep apnea. Under 38 C.F.R. § 4.96(a), when rating coexisting respiratory conditions, DCs 6600 through 6817 and 6822 through 6847 are not to be combined. A single rating will be assigned under the DC that reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The AOJ rated the Veteran’s service-connected sleep apnea (DC 6847) at 50 percent, making sleep apnea the predominant disability. The issue before the Board is whether the sarcoidosis warrants an evaluation higher than 50 percent. To warrant a higher 60 percent evaluation under DC 6846 for sarcoidosis, the evidence must show pulmonary involvement requiring systemic high dose corticosteroids for control. A 100 percent evaluation under that DC requires evidence of cor pulmonale; cardiac involvement with congestive heart failure; or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. Alternatively, sarcoidosis residuals may be evaluated under DC 6600 analogous to chronic bronchitis. Under that DC, a 60 percent evaluation is warranted for FEV-1of 40 to 55 percent predicted; FEV-1/FVC of 40 to 55 percent; DLCO (SB) of 40 to 55 percent predicted; or maximum oxygen consumption of 15 to 20 ml/kg in (with cardiorespiratory limit). A 100 percent evaluation is assigned for FEV-1 less than 40 percent of predicted value; or the ratio of FEV-1/FVC less than 40 percent; or DLCO (SC) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg in oxygen consumption (with cardiac or respiratory limitation); cor pulmonale; right ventricular hypertrophy; pulmonary hypertension; episodes of acute respiratory failure; or when the disability requires outpatient oxygen therapy. When evaluating respiratory disabilities using pulmonary function testing, post-bronchodilator studies are required except when the results of the pre-bronchodilator studies are normal or when the examiner determines that post-bronchodilator studies cannot be accomplished and explains why. See 38 C.F.R. § 4.96(d)(4). When evaluating based on pulmonary function testing, post-bronchodilator results are used in applying the evaluation criteria unless the post-bronchodilators results were poorer than the prebronchodilator results. In those cases, the pre-bronchodilator results are used for rating purposes. See 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different pulmonary function tests (FEV-1, FVC, etc.) so that the level of evaluation would differ depending on which test result was used, the rater is to use the test result that the examiner states most accurately reflects the level of disability. See 38 C.F.R. § 4.96(d)(6). An April 2013 Ft. Eustis record includes chest x-ray findings showing low lung volumes without focal infiltrates, effusions, or hilar adenopathy. The impression was low volume chest x-ray without findings to suggest active cardiopulmonary disease or active sarcoid. Similarly, March 2014 VA chest x-rays showed no significant abnormality. The Veteran underwent a VA examination for this condition in January 2015. The examiner found that sarcoidosis did not require the use of oral or parenteral corticosteroids, inhaled medications, oral bronchodilators, antibiotics, or oxygen therapy. Pulmonary function testing was conducted, but the Veteran refused a post-bronchodilator test and those results were not obtained. The examiner stated that DLCO testing was not completed because it was not indicated for the Veteran’s condition. The pre-bronchodilator results were FEV-1 to 74 percent, FVC to 79 percent, and FEV-1/FVC to 94 percent. The examiner stated that the FEV-1 percentage was the most accurate reflection of the Veteran’s current pulmonary function. The examiner found the Veteran did not have any signs or symptoms attributable to sarcoidosis, but also stated that the current pulmonary function test results confirmed the diagnosis of sarcoidosis. The FEV-1 percentage of 74 percent applied to DC 6600 yields a 10 percent evaluation. October 2016 Ft. Eustis x-ray results showed no acute cardiopulmonary abnormality or airspace disease. A March 2017 Ft. Eustis record described the sarcoidosis as clinically quiescent, without any recent symptoms. Although the Veteran did have complaints and treatment of bronchitis and sinusitis, those were not attributed to sarcoidosis. Pulmonary function testing was conducted for a month-long history of bronchitis, and showed pre bronchodilator FEV-1 to 83 percent, and FEV-1/FVC to 104 percent. Post bronchodilator, FEV-1 was 86 (reported as plus 3 percent), and FEV 1/FVC was to 107 (reported as plus 3 percent). The assessment was mild restriction thought likely due to height and weight ratio. Application of the post bronchodilator FEV-1 and FEV-1/FVC percentages to DC 6600 does not meet the requirement for a 10 percent minimum evaluation. Overall, prior to April 26, 2019 the criteria for an evaluation higher than 50 percent for sarcoidosis with sleep apnea is not warranted. The evidence prior to April 26, 2019 does not show cor pulmonale or cardiac involvement; progressive pulmonary disease with fever, night sweats, and weight loss; or pulmonary involvement requiring systemic high dose corticosteroids for control. Thus, the criteria for an evaluation higher than 50 percent under DC 6846 are not met. The evidence also did not show FEV-1 or FEV-1/FVC of 55 percent predicted or less, right ventricular hypertrophy, pulmonary hypertension, or acute respiratory failure; and the Veteran did not require outpatient oxygen therapy. There is not evidence of maximum oxygen consumption of 20 or less, and the examiner explained that DLCO results were not appropriate for the Veteran’s condition. Thus, the criteria for an evaluation higher than 50 percent under DC 6600 is also not warranted prior to April 26, 2019. The Veteran was most recently examined on April 26, 2019. The examiner found that sarcoidosis did not require the use of oral or parenteral corticosteroids, inhaled medications, oral bronchodilators, antibiotics, or oxygen therapy. Pulmonary function testing as recorded in the examination report showed pre bronchodilator findings of FVC to 5 percent, FEV-1 to 3 percent, and FEV-1/FVC to 60 percent. Post bronchodilator values were FVC to 41 percent, FEV-1 to 49 percent, and FEV-1/FVC to 116 percent. The examiner stated that the pulmonary function testing reflected the Veteran’s current pulmonary function, and clarified the Veteran did not have any other respiratory disorders. The examiner also found that the Veteran did not have an findings, signs, or symptoms attributable to sarcoidosis, including any pulmonary involvement. The examiner stated FVC percent was the test result that most accurately reflected the Veteran’s level of disability. The Board observes that DC 6600 does not consider FVC percentage, but rather considers FEV-1 and FEV-1/FVC. In the test results accompanying the 2019 examination report, those findings were recorded as pre and post bronchodilator findings of FVC to 42 percent (rounded from 41.6), FEV-1 to 49 percent, and FEV-1/FVC to 81 percent (rounded from 81.14). The results were “severe restriction.” The Board is unclear why the 2019 examination report contains different findings. The Board will resolve any doubt stemming from the 2019 VA examination report in the Veteran’s favor and find that at worst, the Veteran’s sarcoidosis was manifest by FEV-1 to 49 percent. The 2015 examiner stated that FEV-1 was the most accurate reflection of the Veteran’s respiratory disability, and the Board will apply that finding to the 2019 examination report in order to rate the Veteran’s disability under DC 6600. Thus, from April 26, 2019 onward (the date of the VA examination) the criteria for a 60 percent evaluation under DC 6600 are met because pulmonary function testing shows FEV-1 between 40 to 55 percent. The criteria for an evaluation higher than 60 percent on and after that date is not warranted, however, as the evidence does not show cor pulmonale; cardiac involvement with congestive heart disease; or pulmonary disease with fever, night sweats, and weight loss despite treatment. Also, the evidence did not show FEV-1 or FEV-1/FVC less than 40 percent of predicted value; maximum exercise capacity less than 15, right ventricular hypertrophy, pulmonary hypertension, or episodes of acute respiratory failure. The Veteran did not require outpatient oxygen therapy. To summarize, prior to April 26, 2019 the criteria for an evaluation higher than 50 percent for sarcoidosis with sleep apnea is not warranted. On and after that date, and resolving reasonable doubt in the Veteran’s favor, the criteria for a 60 percent evaluation under DC 6600 for residuals of sarcoidosis are met. 11. Entitlement to a compensable evaluation for hypertension. The Veteran seeks entitlement to an evaluation higher than 10 percent for hypertension. Hypertension is rated at 38 C.F.R. § 4.104 DC 7101. Under DC 7101, a 10 percent evaluation is assigned when diastolic pressure is predominantly 100 or more. 10 percent is also the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is assigned when diastolic pressure is predominantly 110 or more, or when systolic pressure is predominantly 200 or more. A 40 percent evaluation is assigned for diastolic pressure predominantly 120 or more, and a maximum 60 percent evaluation is assigned for diastolic pressure predominantly 130 or more. Here, the evidence does not show that the Veteran’s diastolic pressure is predominantly 110 or higher, nor is systolic pressure predominantly 200 or more. The Veteran underwent VA examinations in March 2014 and April 2019. At the March 2014 examination, the Veteran’s blood pressure readings were 128, 130, and 128/80. The examiner found that diastolic was not predominantly 100 or more. The April 2019 VA examiner documented that the Veteran’s average blood pressure readings were 140/80 indicative of moderate hypertension. The Veteran did not have functional loss due to hypertension. Private treatment records reflect similar findings as those noted in the VA examinations. See April 2013 Ft. Eustis record (Veteran’s blood pressure was assessed as elevated at 142/89 and he had not been taking his medication); see November 2014 Ft. Eustis records (Veteran’s systolic blood pressure is in the low-normal range after a medication change, and Veteran’s hypertension was not at goal with a reading of 145/73); see March 2015 Ft. Eustis record (the Veteran’s blood pressure is doing very well); see September 2018 VA record (Veteran’s blood pressure is at 142/84 assessed as near his goal of less than 140/90). Overall, the available medical records do not show diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. In sum, the VA examinations and available medical records do not include findings that would warrant an evaluation higher than 10 percent because throughout the appeal period diastolic pressure has not been predominantly 110 or more and systolic pressure has not been predominantly 200 or more. 12. Entitlement to a compensable evaluation for hiatal hernia with gastroesophageal reflux disorder The Veteran seeks entitlement to an evaluation higher than 10 percent for service connected hiatal hernia with gastroesophageal reflux disorder. Hiatal hernia is rated at 38 C.F.R. § 4.114 DC 7356. Under that DC, a maximum 60 percent evaluation is assigned for symptoms of pain, vomiting, material weight loss and hematemesis of melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent evaluation is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain that is productive of considerable impairment of health. A 10 percent evaluation is assigned when there are 2 or more of the symptoms for the 30 percent criteria of less severity. The Veteran underwent a VA examination in March 2014. The Veteran had symptoms of dysphagia, pyrosis, and reflux for which he took medication. There was not evidence of substernal or arm or shoulder pain. The examiner did not comment on whether there was severe or considerable impairment of health. The Veteran attended another VA examination in April 2019. At that time, the examiner diagnosed gastroesophageal reflux disease as a progression of the hiatal hernia. The Veteran had symptoms of infrequent episodes of epigastric distress, reflux, and substernal arm pain. The examiner found the symptoms did not result in considerable or severe impairment of health. There were no other signs of symptoms, or other esophageal condition. Available medical treatment records show the Veteran tended to decline experiencing gastroesophageal symptoms. See October 2013 Ft. Eustis record (the Veteran denies gastrointestinal symptoms); see February 2014 Ft. Eustis record (the Veteran denies gastrointestinal symptoms and heartburn); see November 2014 Portsmouth record (no gastrointestinal symptoms); see May 2016 VA treatment record (the Veteran did not endorse any gastrointestinal symptoms); see June 2017 VA record (Veteran denies any gastrointestinal symptoms). Overall, the VA examination and medical records reflect the Veteran’s hiatal hernia with gastroesophageal reflux disorder manifests as symptoms of dysphagia, pyrosis, reflux, and substernal arm pain that is not productive of considerable or severe impairment of health. The 10 percent rating criteria fully contemplates the Veteran’s symptoms, and entitlement to an evaluation higher than 10 percent is not established. 13. Entitlement to a compensable evaluation for a cyst removal scar. The Veteran seeks entitlement to a compensable evaluation for a scar on the left side of his face. The Veteran’s scar is rated under Diagnostic Code 7800, for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. VA amended the criteria for rating skin disabilities effective from August 13, 2018, however DC 7800 was not changed by the amendments. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating under Diagnostic Code 7800 because the Veteran does not have at least one characteristic of disfigurement. The Veteran underwent two VA examinations in connection with this claim. A March 2014 VA examination report documents the Veteran’s scar measured 3 by 0.2 centimeters and was not painful or unstable. The scar is located anterior to the left ear. On physical examination there was no characteristic of disfigurement. An April 2019 VA examination report documents the Veteran’s scar measured 4 by 0.3 centimeters and was not painful or unstable. Again, physical examination did not show any characteristics of disfigurement and the scar did not result in any functional limitation. Color photographs are of record and have been viewed by the Board. Based on the foregoing, entitlement to a compensable evaluation for the service-connected scar is not warranted because there are no characteristics of disfigurement. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s scar is not deep and non-linear and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does do not cover an area or areas of 144 square inches or greater. Moreover, the Veteran’s scar is not unstable or painful. Therefore, Diagnostic Codes 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for the service-connected scar on the left side of the face. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. This issue is remanded to secure another VA examination. The Veteran last underwent a VA examination for this claim in January 2015, at which time he did not have a hearing loss disability for VA purposes. Since then, a November 2017 Portsmouth treatment record reports that the Veteran had decreased hearing in the right ear. The available evidence indicates the Veteran’s hearing may have worsened to the point that he now has a hearing loss disability for VA purposes. Thus, remand is required to obtain another examination and opinion. Last, on remand efforts must be made to identify and obtain outstanding and relevant VA or private treatment records. 38 C.F.R. § 3.159(c)(1)(2018); Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his claimed bilateral hearing loss. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) Determine whether the Veteran now has a hearing loss disability for VA purposes. (b.) If so, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that bilateral hearing loss had onset in, or is otherwise related to, active military service. (c.) The examiner is reminded that service connection is already in effect for tinnitus as due to the Veteran’s period of service. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Smith, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.