Citation Nr: 21001287 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 11-28 691 DATE: January 7, 2021 ORDER Service connection for diabetes mellitus, type II (hereinafter diabetes), to include as secondary to hypertension and contaminated water at Camp Lejeune is denied. Service connection for a dental disability for compensation purposes is denied. Service connection for a dental disability for dental treatment purposes is denied. Service connection for a bilateral upper extremity and bilateral lower extremity poor circulation condition, to include as secondary to a service-connected disability is denied. Service connection for a gastric ulcer is granted. Entitlement to an initial disability rating greater than 30 percent for hypertensive heart disease is denied. Entitlement to an initial evaluation of hypertension in excess of 10 percent is denied. Entitlement to an initial compensable evaluation for tension headaches is denied. Entitlement to an initial compensable evaluation for erectile dysfunction is denied. REMANDED Entitlement to an initial compensable disability evaluation for scars, status-post left hand navicular surgery and removal of right scrotum cystocele prior to July 2, 2019, and in excess of 30 percent from July 2, 2019 under the criteria for unstable or painful scars under Diagnostic Code 7804 is remanded. Entitlement to an initial compensable evaluation for scarring, status-post left hand navicular surgery, scars not associated with underlying soft tissue damage and other effects criteria, currently 0 percent under Diagnostic Code 7802 is remanded. Entitlement to an initial compensable evaluation for scar, status-post removal of right scrotum cystocele, scars not associated with underlying soft tissue damage and other effects criteria, currently 0 percent under Diagnostic Code 7338-7802 is remanded. Entitlement to an initial evaluation of chorioretinal scar on right eye and left eye, with decreased vision, in excess of 20 percent is remanded. FINDINGS OF FACT 1. The Veteran’s diabetes mellitus, type II did not manifest during active duty service, is not related to any incurrence of active duty, to include any exposure to contaminated water at Camp Lejeune and is not caused or aggravated by hypertension. 2. The Veteran did not have a dental trauma with loss of substance of the body of maxilla or mandible while on active duty. 3. The Veteran does not have a service-connected dental disability (compensable or noncompensable); is not homeless or a designated prisoner of war; does not have an aggravating dental condition; does not have a schedular 100 percent evaluation and is not entitled to a 100 percent rating by reason of individual unemployability; has not been a participant in VA’s vocational rehabilitation program under 38 U.S.C. Chapter 31; and has not been scheduled for admission or otherwise received care and services under 38 U.S.C. Chapter 17, during any part of the appeal period. 4. The Veteran does not have a current diagnosis of a vascular/poor circulation condition pertaining to the left upper extremity, right upper extremity, right lower extremity, or left lower extremity. 5. The Veteran has a currently diagnosed gastric ulcer disability which has manifested with chronicity since active duty. 6. The Veteran’s hypertensive heart disease and atrioventricular block are manifested by a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 7. Throughout the appeal period, the Veteran’s service-connected hypertension has been manifested by diastolic pressure predominately 100 or more, but less than 110. 8. The Veteran’s tension headaches are not shown to be manifested by prostrating or incapacitating attacks. 9. The Veteran’s service-connected erectile dysfunction is productive of loss of erectile power, but not deformity of the penis. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type II (hereinafter diabetes), to include as secondary to hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for dental disability for compensation purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.381, 4.150. 3. The criteria for service connection for a dental disability for treatment purposes only have not been met. 38 U.S.C. §§ 1712, 5107; 38 C.F.R. § 17.161. 4. The criteria for service connection for a bilateral upper extremity and bilateral lower extremity poor circulation condition, to include as secondary to a service-connected disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for service connection for gastric ulcer have been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for a disability rating greater than 30 percent for hypertensive heart disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7007. 7. The criteria a disability rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1. 4.3, 4.7, 4.104, Diagnostic Code 7101. 8. The criteria for a compensable evaluation for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8199-8100. 9. The criteria for a compensable evaluation for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.115b, Diagnostic Code 7599-7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1977 to September 1999, during which time had primary specialties of Intermediate Automotive Mechanic, Motor Transport Maintenance Chief, and Recruiter; during his service, the Veteran received, among others, the Marine Corps Good Conduct Medal, a Certificate of Achievement, Meritorious Mast (7), and numerous letters and certificates of commendations. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a May 2016 decision, the Board, in pertinent part, denied entitlement to service connection for diabetes. The Veteran timely appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In October 2017, the Court granted a Joint Motion for Partial Remand, setting aside the Board’s decision on this issue and remanding it for additional development. In February 2018 and April 2020, the Board remanded this claim for further development. The matters previously remanded to the Agency of Original Jurisdiction (AOJ) have been returned. With regards to the claims adjudicated herein, the development previously ordered has been conducted; those for which the development was inadequate are remanded in this order. The dockets have been merged by the Board. It is noted that efforts to procure outstanding medical records were made, but the October 1996 blood tests were noted to be unavailable, and the Veteran was apprised that such were unable to be obtained. The Veteran does not contend he is rendered unemployable by his service-connected disabilities, and the Board does not find the record to implicate unemployability. The Veteran was represented by counsel at the time of the prior Board decision; counsel subsequently withdrew from representation in September 2016, and the record does not reflect the Veteran is currently represented in this appeal. The record reflects that the Veteran received a letter indicating that he could request a virtual tele-hearing instead of waiting for a travel board hearing. Upon further review, the Veteran does not have a pending hearing request. As noted above, he provided testimony in a hearing with the undersigned Veterans Law Judge in April 2015. A transcript of that hearing is of record and has been considered as evidence in this decision. Service Connection To establish direct service connection, there must be competent evidence showing: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the in-service injury incurred or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. 38 C.F.R. § 3.310. Certain chronic diseases, such as diabetes, cardiovascular disorders and peptic ulcers, may be presumed to have been incurred in or aggravated by service if manifested to a compensable degree within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307(d), 3.309(a). 1. Service connection for diabetes, to include as secondary to hypertension and/or related to contaminated water at Camp Lejeune The Veteran seeks service connection for diabetes, contending that such is related to his service-connected hypertension and/or contaminated water at Camp Lejeune. See April 2009, September 2010, and September 2014 statements. Additionally, he contends the disability was diagnosed during service, or otherwise had an in-service onset. See Hearing Transcript. The Veteran’s service treatment records are silent for any treatment for, diagnosis of, or symptoms related to diabetes. The June 2020 VA examination noted that the available records were reviewed, and that relevant medical research was reviewed. The examiner opined that the Veteran’s diabetes was less likely than not related to service, to include the fasting glucose level of 107 in March 1994 and his exposure to contaminated water at Camp Lejeune. The examiner noted that the criteria to diagnosis diabetes included fasting plasma glucose greater or equal to 126, HGALC test greater or equal to 6.5, or non-fasting glucose level greater than or equal to 200 in the presence of symptoms. The examiner also noted that the tests must be replicated to diagnose diabetes, and as the Veteran did not meet any of the criteria on any recorded tests, the negative opinion on in-service onset is warranted. The examiner noted the initial diagnosis of diabetes was from April 2010. The examiner noted review of the literature regarding contaminated water exposure at Camp Lejeune and noted there were no links shown between exposure to contaminated water at Camp Lejeune and diabetes. The examiner also addressed whether diabetes mellitus was related to his hypertension and discussed the Veteran’s statements regarding poor eating habits and stress. The examiner noted that the cause of diabetes mellitus is complex and includes a genetic link. The examiner noted risk factors of obesity, sedentary lifestyle, age over 45, family history, race, and the self-reported history of stress and poor eating. The examiner opined that the condition was less likely than not proximately due to the Veteran’s hypertension. The examiner noted further that hypertension and diabetes mellitus type II are aspects of metabolic syndrome, which includes both obesity and cardiovascular disease, and while the conditions have been noted to coexist, there is no causation between the conditions. The examiner noted that the Veteran’s diabetes was not as likely as not worsened beyond its natural progression due to service-connected hypertension. The examiner further noted that there was insufficient medical evidence to determine a baseline level of severity, and that while hypertension can damage the same organs, sugar levels are not affected by hypertension. The also examiner noted specific blood pressure and glucose readings and noted there was no correlation between such readings. The examiner considered the evidence of record, including the Veteran’s statements, prior to forming the opinion. The examiner supported their opinion with a sufficient rationale and cited to medical literature in support of the conclusions drawn. There is no contradictory competent medical opinion of record, and the VA examiner’s opinions are entitled to great probative weight. The Board acknowledges the Veteran testified that he received a phone call from a doctor during active duty that diagnosed him with diabetes, which he thought was a wrong number at the time. This contention is uncorroborated by any credible or competent record, and per the Veteran’s testimony, he never sought any treatment for diabetes until after service. Even if the Board found such a phone call occurred as testified (the Board does not so find, given the vague and uncorroborated nature of this claim), such would be mere hearsay from an unidentified speaker with an unidentified foundation for a diagnosis, and would not be a credible and competent basis for a retrospective diagnosis. The Veteran also testified that he recognized the symptoms of diabetes mellitus during active service: specifically, dry mouth, headaches, and frequent urination. While this testimony is acknowledged, the record does not reflect that the Veteran possesses the requisite expertise to provide any retrospective medical diagnosis or opinion on etiology, and his lay assertions, insofar as they are intended as such, are given no weight. See Jandreau v. Nicholson, 492 F.3d at 1374 (affirming that lay evidence is generally not competent to establish medical diagnosis or etiology). The Board finds the opinion of the VA examiner to be significantly more probative than the Veteran’s assertions. The Veteran’s contention that his personal copies of service treatment records were lost is noted; however, there is no evidence of record that the service treatment records associated with the file are incomplete. In sum, applying the findings and evidence to the appropriate legal standards, service connection for diabetes mellitus type II is not warranted under any theory. First, the condition is not shown to have manifested during active service or within the one-year presumptive period, as presumptive service connection for a chronic disease is not warranted under 38 C.F.R. §§ 3.307 and 3.309. The competent evidence of record does not show that the recorded 107 glucose level or the reported symptoms of dry mouth, headache, or frequent urination could be a basis for a retrospective diagnosis, and the VA examiner’s explanation of the criteria to diagnose diabetes mellitus is given more weight. Also, direct service connection to Camp Lejeune contaminated water is not warranted because, even assuming such exposure, there is no medical nexus shown to such in the competent evidence of record. 38 C.F.R. § 3.303. The VA examiner’s opinion was against the claimed connection and was proffered after review of the file and consideration of the medical research on the subject. This opinion is given dispositive weight on this point. Finally, secondary service connection for diabetes as related to hypertension is not warranted as there is no medical nexus shown. 38 C.F.R. § 3.310. The VA examiner’s opinion, proffered after review of the file and consideration of the medical research on the subject, was against the claimed connection, and is given dispositive weight on this point. As such, service connection is not warranted; as there is no doubt to resolve, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for a dental disability for compensation purposes The Veteran seeks service connection for loss of teeth for compensation purposes. He contends he had a root canal in service and the tooth that was worked on had a hole in the back that was not filled back in, and the tooth broke while he was eating chicken fewer than six months after he was separated. He contends this caused him to lose additional teeth. The Veteran does not contend he experienced any trauma during service to cause the loss of teeth, such as being punched in the face or being in a car accident. See Hearing Testimony. The dental conditions for which service-connected compensation benefits are available are set forth under 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. The regulations governing dental claims make a fundamental distinction between “replaceable missing teeth” (see 38 C.F.R. § 3.381(a)), and teeth lost as a result of loss of substance of body of maxilla or mandible due to trauma or disease such as osteomyelitis, and not loss of the alveolar process as a result of periodontal disease. See 38 C.F.R. § 4.150; Simington v. West, 11 Vet. App. 41, 44 (1998). For loss of teeth, bone loss through trauma or disease, such as due to osteomyelitis, must be shown for purposes of compensability. Absent a demonstration of dental trauma, service connection may be considered solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. See Woodson v. Brown, 8 Vet. App. 352, 254 (1995). Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities. 38 C.F.R. § 3.381(a). In the August 2019 VA examination, the examiner noted the Veteran did not have loss of any portion of mandible, maxilla, or teeth for reasons other than periodontal disease or edentulous atrophy. The examiner noted that the Veteran’s entrance exam was positive for severe tooth and gum trouble, and that the Veteran noted his gums bled at times and that he had tooth problems. The examiner noted the Veteran had lost some teeth that were endo treated during service and lost several teeth since his exit from the military. He was noted to be discharged before completion of the repairs. He was noted not to be homeless. The separation examination of June 1999 noted issues with tooth numbers 3, 6, 9, 13, 18, 19, 30, and 31; tooth #14 crown gone, with only roots remaining, and generalized gingivitis. The examination also noted caries defective restorations and fractured teeth: specifically, #3, 6, 9,13, 18, 19, 30, 31. Oral surgery was performed to extract #14, and root canals on #9 and #30 were performed in June 1999. Routine care was needed for #18 and 19, and all other treatment was performed at the same time. On examination (in June 2019), the Veteran was noted to have the loss of multiple teeth, with broken teeth at #5, 6, 7, 8, 9, 10, and 30. The Veteran was noted to have a long history of periodontal disease and to be a high risk for caries. The examiner opined that adequate dental treatment was provided during military service, and the examiner noted that records were silent for any follow up care after his treatment upon separation in 1999. The examiner noted that military records are silent for dental trauma, event, injury or illness other that periodontal disease and high risk of caries, which is not considered disabling, and opined that a nexus cannot be established. On review, the findings of the VA examination are accepted as credible and competent. The examiner considered the evidence of record, including the Veteran’s statements, prior to forming this opinion. The examiner supported their opinion with an adequate rationale. As noted on examination, the Veteran’s service treatment records confirm that he received dental care. However, the service records and the VA examination are negative for dental trauma resulting in the loss of substance of the body of the maxilla or mandible causing loss of teeth. The Board finds that the most probative evidence of record is the VA examination, which does not show dental trauma with loss of substance of the body of the maxilla or mandible. The Veteran does not allege trauma or disease-causing disability. In these circumstances, a basis upon which to establish service connection has not been presented and the Board finds that the claim of service connection for a dental disability for compensation purposes is denied. While the Veteran’s statement’s alleging inadequate or improper treatment is acknowledged, there is inadequate evidence of any treatment-related trauma causing a loss of substance of the body of the maxilla or mandible. Moreover, the Veteran’s testimony regarding the etiology of a hole or a cracked tooth appears speculative and not supported by competent evidence such as a medical opinion or any contemporaneous treatment records. On this point, it is noted that the Veteran is noted to have numerous cracked teeth, and further development on this theory (especially given the lack of any relevant dental records) does not appear likely to have any reasonable possibility of substantiating the claim. Service connection for compensation purposes remains denied. There is no doubt to resolve. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Service connection for dental disability for dental treatment purposes is denied. The Veteran requests service connection for dental treatment purposes. Class I VA outpatient treatment is available for veterans with an adjudicated compensable service-connected dental condition. In this case, the evidence does not show that the Veteran has an adjudicated service-connected compensable dental condition; therefore, entitlement to Class I dental treatment is not warranted. 38 C.F.R. § 17.161(a). Class II eligibility may be authorized for any treatment indicated as reasonably necessary for the one-time correction of the service-connected noncompensable condition for veterans having a service-connected noncompensable dental condition or disability shown to have been in existence at time of discharge or release from active service, which took place after September 30, 1981, but only if, among other requirements, the application for treatment is made within 180 days after such discharge or release. The Veteran filed his claim in 2009 and did not make an application within 180 days from discharge. Additionally, he does not have a service-connected noncompensable dental disability. He is not eligible for Class II treatment. 38 C.F.R. § 17.161 (b)(1)(i)(B). The Board has also determined that the Veteran is not eligible for any of the additional classes of outpatient VA dental treatment. The Veteran does not have a service-connected noncompensable dental condition determined to be the result of combat wounds or other service trauma (Class II(a)); he is not shown to be homeless or otherwise eligible pursuant to 38 U.S.C. § 2062 (Class II(b)); he was not a former prisoner of war (Class II(c)); there is no evidence that the Veteran previously applied for dental treatment, was denied, and made an application for retroactive benefits on or before April 5, 1983 (Class IIR); he does not have a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability (Class III); he does not have a 100 percent disability rating by either schedular rating or by reason of individual unemployability (Class IV); he is not participating in a rehabilitation program under 38 U.S.C. chapter 31, where dental services have been professionally determined to be necessary (Class V); and he is not scheduled for admission or otherwise receiving care and services under 38 U.S.C. chapter 17 for a dental condition that has been clinically determined to be complicating a medical condition currently under treatment (Class VI). 38 C.F.R. § 17.161. The Board finds that the preponderance of the evidence of record is against a finding that the Veteran has demonstrated an entitlement to VA outpatient dental treatment. Given the above, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claim seeking entitlement to service connection for VA dental treatment purposes only remains denied. 4. Service connection for a bilateral upper extremity and bilateral lower extremity poor circulation condition, to include as secondary to a service-connected disability The Veteran seeks service connection for poor circulation of the upper and lower extremities. The Veteran is service connected for hypertension and hypertensive heart disease. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Previously, this claim was remanded for a VA examination as an April 2011 VA treatment record noted that the Veteran had peripheral edema, which could stem, at least partially, from his prescribed amlodipine. The July 2019 VA examination of the arteries and veins conducted an in-person examination and noted the Veteran did not now have and did not ever have a vascular disease. In the medical opinion, the examiner noted that there was insufficient objective evidence to support the Veteran’s claim of poor circulation of the bilateral upper extremities and bilateral lower extremities. The examiner conducted an in-person examination and considered the evidence of record, including the Veteran’s statements, prior to forming this opinion. Additionally, during the July 2019 VA examination for heart conditions, the Veteran’s peripheral pulses were noted to be normal, with no edema. On review, the Board concludes that the competent evidence of record, the VA examination, shows that the Veteran does not have a current vascular disease or poor circulation of the bilateral upper extremities and bilateral lower extremities, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. While the Veteran may believe he has poor circulation, he is not competent to provide a diagnosis in this case. Diagnosis of a vascular disability requires some level of medical expertise that the Veteran is not shown in the record to possess. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence. A current disability is required for service connection to be granted under any theory. Service connection for a poor circulation condition affecting the bilateral upper extremities and bilateral lower extremities remains denied for lack of a diagnosis. Although the Veteran provided testimony suggestive of cervical spine radiculopathy and referenced a diagnosis of such, as previously noted, the Board does not find that this condition is reasonably encompassed by the claim on appeal. Accordingly, the Board declines to broaden the claim to encompass radiculopathy symptoms or a cervical spine condition. See c.f. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). If the Veteran wishes to file a claim for a cervical spine condition and any associated symptomatology, he may do so under separate cover. 5. Service connection for a gastric ulcer is granted. The Veteran seeks service connection for an ulcer condition. He testified that he was diagnosed with an ulcer during active service which resolved, experienced residuals at separation from active duty, and continues to have symptoms. The service treatment records show treatment for an ulcer in October 1996. On separation examination in June 1999, the Veteran reported stomach trouble. An April 2011 VA examination noted a diagnosis of residuals of stomach ulcer, resolved with medical treatment. The Veteran was initially denied due to lack of a current disability. Pursuant to the prior remand directive, a VA examination was conducted. During the July 2019 VA examination, the examiner noted there was a current gastric ulcer confirmed on examination. The examiner noted a gastric ulcer diagnosed in 1999, with the Veteran reporting an onset in 1996. The Veteran was noted to report intermittent right upper quadrant pain two to three times per month with diarrhea. He was noted to have recurring symptoms. Previously, the Veteran reported similar symptoms in the April 2011 VA examination. Gastric ulcers are chronic diseases subject to presumptive service connection if they manifest during active service. See 38 C.F.R. § 3.309(a). Resolving doubt in favor of the Veteran, the Veteran’s testimony of recurrent and chronic symptoms since his initial diagnosis is accepted as credible. The Veteran credibly testified to mild continuous symptoms for which he uses over-the-counter remedies, and as his reported symptoms were adequate to support a diagnosis, they are considered adequate to establish chronicity of this condition, negative nexus opinion on VA examination notwithstanding. Accordingly, service connection is warranted and hereby granted for a gastric ulcer. 38 C.F.R. §§ 3.307, 3.309(a). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Hyphenated codes are intended to show that the Veteran’s service-connected disability is rated by analogy. See 38 C.F.R. § 4.20 (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous). 6. Entitlement to an initial evaluation greater than 30 percent for hypertensive heart disease The Veteran’s hypertensive heart disease is rated 30 percent disabling under Diagnostic Code 7007. Under Diagnostic Code 7007, a 30 percent rating is assigned if the hypertensive heart disease is manifested by a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A rating of 60 percent is assigned for more than one episode of congestive heart failure within the past year, or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent is assigned for chronic congestive heart failure, or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory decision of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) resulting in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. On VA examination in April 2011, an enlarged heart was shown on chest x-ray. Hypertension examination indicated the Veteran did not have hypertensive heart disease; however, heart examination diagnosed hypertensive heart disease. Ejection fraction was shown to be 62 percent and estimated METs were 10. Diagnosis showed hypertensive heart disease, asymptomatic. The examiner stated it was at least as likely as not that the Veteran’s left ventricular hypertrophy (LVH) was due to military service and his hypertension caused left ventricular hypertrophy. After testifying to worsening, the issue was remanded, and Veteran was given a new VA examination for heart conditions in July 2019. The examiner noted the Veteran’s EKG showed left ventricular hypertrophy in March 1994. The Veteran reported chest tightness with more frequency, occurring over the last three years. He reported past episodes of pain of 6/10 that lasted between 5 to 15 minutes and reported drinking water when it occurred. He was noted to take Amlodipine 10 mg daily and Lisinopril 40 mg daily (both for hypertension), as well as aspirin (for the heart disease). The Veteran did not report any chest pain during the examination. The Veteran did not have any hospitalizations noted; his rhythm was normal; heart sounds were normal, and peripheral pulses were normal, with no peripheral edema. During the examination the Veteran’s EKG showed an AV block. The Veteran was noted not to have had any episodes of congestive heart failure (CHF), cardiac arrythmias, infectious cardiac conditions or pericarditis lesions, or cardiac valve issues. His blood pressure was 153/94, with normal peripheral pulses, normal lung sounds and negative jugular venous distension (JVD). The examiner determined that the Veteran was not a suitable candidate for a stress test, and through an interview, the Veteran’s METs were estimated to be greater than five but not more than seven. A METs of five to seven has been found to be consistent with activities such as walking one flight of stairs, golfing (without cart), mowing lawn (push mower) or heavy yard work (digging). The estimated METs level was due solely to the Veteran’s cardiac condition. The Veteran was noted to have an inability to lift heavy objects due to the heart condition. There was a new diagnosis noted of a heart block, which was a progression of the hypertensive heart disease. Other relevant evidence includes a treatment record from Bon Secours Memorial Regional Medical Center dated November 11, 2004, which showed treatment for acute chest pain secondary to chest wall strain and hypertension. An estimated ejection fraction is noted to be 62 percent in an August 2010 VA treatment record. Based upon the preceding evidence, the Board finds no basis to assign a rating greater than 30 percent for the Veteran’s hypertensive heart disease. The competent evidence of record shows a METs of greater than 5 but less than 7, and that he has only reported the symptoms of angina and dizziness (see Hearing Testimony), which is contemplated in a 30 percent rating. A higher 60 percent rating is not warranted because the Veteran’s does not have a left ventricular ejection fraction of 30 to 50 percent. Additionally, there is no evidence or allegation of even a single episode of congestive heart failure. Although the Veteran’s testimony is noted, the Board does not find the record to reflect any competent evidence that his claimed swelling of the feet and hands are symptoms related to the heart condition. Consideration was afforded to the possibility of a separate rating for an Atrioventricular Block, under Diagnostic Code 7015. The rating criteria under Diagnostic Code 7007 is extremely similar to the rating criteria of Diagnostic Code 7015, in that it is based on METS testing, cardiac symptoms such as dyspnea, fatigue, angina, dizziness, syncope, hypertrophy, dilation, and ejection fraction; or evidence of cardiac hypertrophy or dilation on an electrocardiogram, echocardiogram, or x-ray. The evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Rating an AV block and hypertensive heart disease based on METS testing and such symptoms would violate the rule against pyramiding, as the schedule recognizes that disability from distinct injuries or diseases may overlap, and separate disability ratings may only be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). As such, a separate rating is not warranted. Rating under Diagnostic Code 7015 would not result in additional benefit to the Veteran. Accordingly, the criteria for a 60 percent disability rating are not met or more closely approximated. The preponderance of the evidence is against the claim for a rating greater than 30 percent for hypertensive heart disease. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to an initial evaluation for hypertension in excess of 10 percent The Veteran seeks an initial rating for hypertension in excess of 10 percent; such was assigned effective March 4, 2009, pursuant to the criteria set forth in 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertension is rated pursuant to Diagnostic Code 7101. Under this Code, a 10 percent rating is warranted for hypertensive vascular disease with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A maximum 60 percent rating is warranted for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Upon review of the record, the Board finds that a rating in excess of 10 percent is not warranted at any point during the period under review. The record indicates that on examination, the Veteran had readings of 158/95, 163/93, and 153/94. The examiner noted that on review of the medical record, a majority of the Veteran’s recorded diastolic pressure were less than 110 diastolic and the majority of his recorded systolic pressures were less than 200. See VA Treatment Records; July 2019 VA examination. The VA examination noted having reviewed the medical records and pressure readings and concluded the Veteran’s diastolic pressures were predominantly less than 110 diastolic and his recorded systolic pressures were less than 200. He was noted to take medication to control his blood pressure, including amlodipine besylate and lisinopril. Id. On review by the Board, the findings in the VA examination are consonant with the record and appear based on a thorough examination. These findings are adopted as factual. The Veteran does not specifically allege, nor does review of the competent evidence of record show (to include the VA examination findings) diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. Accordingly, a rating in excess of 10 percent is not warranted. See 38 C.F.R. § 4.104, Diagnostic Code 7101. There are no other symptoms shown in the competent evidence of record. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against assigning the Veteran’s hypertension a rating in excess of 10 percent, the doctrine is inapplicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Entitlement to an initial compensable evaluation of tension headaches The Veteran seeks an initial compensable evaluation for his service-connected headache condition. The Veteran’s headaches are currently rated under Diagnostic Code 8199-8100, by analogy to Diagnostic Code 8100, which provides a noncompensable rating for characteristic prostrating attacks averaging less than one in two months over the last several months; a 10 percent rating for characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating for characteristic prostrating attacks occurring on an average of once a month; and 50 percent for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a. The rating criteria do not define “prostrating.” “Prostration” is a medical term defined, for example, as “extreme exhaustion or powerlessness.” Dorland’s Illustrated Medical Dictionary (32d ed. 2012). The July 2019 VA examination confirmed a diagnosis of tension headaches, and noted the Veteran reported his headache was the same over the last two years, with constant pressure on both sides of his head, rated between 6 to 9 out of 10 every day, and causing lightheadedness. He reported waking with a headache every day and taking 4 tablets of over the counter pain medications with minimal relief. The examiner noted constant head pain on the bilateral sides of the head, with lightheadedness, and noted the Veteran did not have characteristic prostrating attacks of migraine or non-migraine headache pain. The functional impact was noted to cause disturbance of attention and interference with concentration due to pain. The findings in the examination are consonant with review of the medical records and the Veteran’s testimony and are adopted as representative of the period on review. The evidence does not support a finding of any prostrating attacks. While the Veteran reported sitting down, leaning, or laying down when not at work, he also testified to working through his headaches, which he has described as constant. The constant nature of the reported head pain and the fact that activities are tolerated as needed is not suggestive of “extreme exhaustion or powerlessness.” As noted above, the Board acknowledges that the Veteran testified at the Board hearing that he experiences headache pain frequently. Unfortunately, however, without credible evidence of prostrating types of attacks occurring, the criteria for a compensable rating cannot be met. Headache pain and fogginess is not compensable. Therefore, the Board concludes that entitlement to a compensable rating for tension headaches is not warranted; as a preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to a compensable evaluation for erectile dysfunction The Veteran’s erectile dysfunction has been evaluated as noncompensable and rated by analogy under 38 C.F.R. § 4115b, Diagnostic Codes 7599-7522 for penis, deformity, with loss of erectile power. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. Under Diagnostic Code 7522, for the Veteran to receive a higher 20 percent rating for erectile dysfunction, a physical deformity of the penis with loss of erectile power is required. 38 C.F.R. § 4.115b. A footnote to Diagnostic Code 7522 also indicates the disability is to be reviewed for entitlement to special monthly compensation (SMC) for loss of use of a creative organ under 38 C.F.R. § 3.350(a). In this case, the Veteran is already in receipt of SMC for loss of use of a creative organ, and thus the Board cannot offer any relief in this regard. Upon review of the evidence, the Veteran does not meet the criteria for a 20 percent rating under Diagnostic Codes 7599-7522. In January 2020, the Veteran underwent a VA examination of the male reproductive organs. The VA examiner indicated that the Veteran had erectile dysfunction that was treated with medication. His condition had stayed the same since it was diagnosed in the 2000s. Previously, during the hearing, the Veteran had also testified to taking additional supplements to treat the condition. In this case, the Veteran’s loss of erectile power is documented, and is accepted as factual. However, the evidence of record does not reveal any physical deformity of the Veteran’s penis. The requirement under Diagnostic Code 7522 of deformity of the penis ‘with’ loss of erectile power means that both factors are required for a compensable evaluation. The Veteran’s VA and private treatment records do not document that the Veteran has any penile deformity. Furthermore, the Veteran has not asserted that he has any penile deformity. Accordingly, there is no lay or medical support for a compensable evaluation for the Veteran’s erectile dysfunction under Diagnostic Code 7522, and the increased evaluation claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to an initial compensable disability evaluation for scars, status-post left hand navicular surgery and removal of right scrotum cystocele prior to July 2, 2019, and in excess of 30 percent from July 2, 2019 under the criteria for unstable or painful scars under Diagnostic Code 7804 2. Entitlement to an initial compensable evaluation for scarring, status-post left hand navicular surgery, scars not associated with underlying soft tissue damage and other effects criteria, currently 0 percent under Diagnostic Code 7802 3. Entitlement to an initial compensable evaluation for scar, status-post removal of right scrotum cystocele, scars not associated with underlying soft tissue damage and other effects criteria, currently 0 percent under Diagnostic Code 7338-7802 The Veteran seeks an increased rating for his service-connected left hand scars and removal of the right scrotum cystocele. The Veteran has been assigned a compensable evaluation under Diagnostic Code 7804 for the period after July 2, 2019; prior periods were noncompensable. Previously, the Board remanded these claims for a new VA examination. Remand of these claims is again required for the reasons discussed below. As an initial matter, it is noted that the Veteran’s claim for residuals of in-service left hand surgery was not limited to scarring, nor does the Veteran so limit his contentions on appeal: he testified his left-hand scar did not cause pain, but that it created a decrease in strength. He also reported that his hand would lock up during driving. The Veteran has also reported that he had to be careful with his movements due to the tenderness related to the scar in the groin area. Review of this evidence shows that VA examinations performed post-remand do not necessarily address the nature and extent of the claimed hand symptomatology. It is unclear from review whether such symptoms are attributable to tender hand scar(s) or other residuals of surgery. As the Veteran has multiple ratings for scars, and there is a single scar rating encompassing both the left hand scar and the right scrotum cystocele scar, the Board will defer action on the remaining scar increase rating claims so that they can be decided at the same time. Accordingly, remand for a VA examination for all residuals of the Veteran’s left hand surgery is warranted. 4. Entitlement to an initial evaluation of chorioretinal scar on right eye and left eye, with decreased vision, in excess of 20 percent is remanded. In pertinent part, the May 2016 remand directed that the Veteran be afforded a VA eye examination to address his contention of worsening. While a July 2019 Miscellaneous C&P Correspondence note indicates that the Veteran failed to report for his scheduled eye examination, the Board notes that the Veteran did report to the other scheduled VA examinations for which notification letters are associated with the record. There is no specific description of what efforts to provide the ordered eye examination were taken. Moreover, it is possible that the scheduler did not have the correct address when trying to schedule the examination, given the June 17, 2019 Subsequent Development Letter indicating that the Veteran needed to separately confirm his address on a hotline. As the record fails to show that the Veteran was provided notice of the examination, there has not been substantial compliance with the prior remand directive. Accordingly, another remand is required to afford the Veteran an opportunity to report for a VA examination to address his claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for a hand examination to determine whether the Veteran has (and the current severity of) any non-scarring residuals of service-connected left hand surgery. The examiner should review the contentions of record regarding functional limitation of the left hand and provide a full description of the disability and report all signs and symptoms. 2. Schedule the Veteran for an eye examination to determine the severity of his service-connected eye disability for the period on review. Document any unsuccessful efforts to schedule the examination. 3. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. C. KING 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.