Citation Nr: 21001572 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 13-24 875A DATE: January 11, 2021 ORDER Service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD), schizophrenia, and anxiety is denied. Service connection for diabetes mellitus is denied. Service connection for a neurocognitive disorder claimed as short-term memory loss is denied. Service connection for a gastrointestinal (GI) disorder is denied. Service connection for glaucoma is denied. A rating in excess of 10 percent prior to October 9, 2019, and in excess of 20 percent thereafter for chronic right ankle strain with distal achilles tendinopathy is denied. REMANDED Entitlement to service connection for a sleep disorder to include as secondary to a psychiatric disability is remanded. Entitlement to service connection for sleep apnea to include as secondary to a psychiatric disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence does not support a diagnosis of PTSD. 2. An acquired psychiatric disorder, to include PTSD, schizophrenia, and anxiety was not present during the Veteran’s active service, did not manifest to a compensable degree within one year of service separation, and is not otherwise causally related to his active service. 3. The preponderance of the evidence reflects that the Veteran does not have a current disability of a neurocognitive disorder resulting in short term memory loss. 4. A gastrointestinal (GI) disorder was not present during the Veteran’s active service, did not manifest to a compensable degree within one year of service separation, and is not otherwise causally related to his active service. 5. Diabetes mellitus was not present during the Veteran’s active service, did not manifest to a compensable degree within one year of service separation, and is not otherwise causally related to his active service. 6. The Veteran’s glaucoma was not present during the Veteran’s active service, did not manifest to a compensable degree within one year of service separation, and is not otherwise causally related to his active service. 7. Prior to October 9, 2019, the Veteran’s right ankle disability was not shown to be manifested by marked limitation of motion, and from that date his right ankle is not shown to have been ankylosed. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disability including PTSD, schizophrenia, and anxiety have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a neurocognitive disorder claimed as short - term memory loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a gastrointestinal (GI) disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for service connection for glaucoma have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for a rating in excess of 10 percent for a right ankle disability prior to October 9, 2019 and in excess of 20 percent thereafter are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4. 71a, Diagnostic Codes (DCs) 5003, 5024, 5270-5273. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1975 to January 1978. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2012 and June 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In December 2015, the Board denied the claims for service connection for diabetes mellitus, glaucoma, and headaches. The Veteran appealed the Board’s decision. In a March 2017 Memorandum Order, the United States Court of Appeals for Veterans Claims (Court) remanded the issues to the Board for further development. In May 2018 the Board remanded those claims as well as claims for service connection for a psychiatric disability, short term memory loss, a sleep disability, sleep apnea, a gastrointestinal disability, and a claim for a rating in excess of 10 percent for a right ankle disability. Of note, in a September 2020 rating decision, the RO granted the Veteran’s claim for service connection for headaches and that claim is no longer in appellate status. The September 2020 rating decision also granted a disability rating of 20 percent for the Veteran’s right ankle disability effective October 9, 2019. Since the Veteran has not expressed satisfaction with that decision, the claim remains on appeal before the Board. During the pendency of the appeal, the Veteran contended he is unemployable. See e.g., October 2019 PTSD Disability Questionnaire. Such contention raises the issue of whether the Veteran is entitled to a rating of total disability due to individual unemployability (TDIU). The Board acknowledges that the case of Rice v. Shinseki, 22 Vet. App. 447 (2009) determined entitlement to a TDIU is considered part and parcel of an increased rating claim. However, here the Veteran has asserted that the basis for unemployability is his psychiatric disability rather than his service – connected right ankle disability currently on appeal for an increased rating. Accordingly, the Board does not have jurisdiction to consider TDIU under Rice v. Shinseki. Service Connection The Board has reviewed all of the evidence in the Veteran’s claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303 (b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303 (b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption 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. Personality disorders are considered congenital or developmental defects and not diseases or injuries within the meaning of applicable legislation and, therefore do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303 (c), 4.9. Service connection, however, can be granted for additional disability resulting from a mental disorder that is superimposed upon the personality disorder. 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; see also VAOPGCPREC 82- 90, 55 Fed Reg. 45,711 (July 18, 1990); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the individual offering it have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2) This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD), schizophrenia, and anxiety. The Veteran seeks service connection for a psychiatric disability as a result of active duty service. See e.g., September 2013 Veteran Correspondence. In a December 2015 Board decision, the Veteran’s claim was broadened to include any acquired psychiatric disorder reasonably encompassed by the mental illness symptoms experienced by the Veteran. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran has made several contentions regarding his claim for service connection for a psychiatric disability. Initially, he asserted that throughout his tour of duty he experienced excessive neglect and abuse as the result of racism which impacted his mental health. See August 2013 Veteran’s Correspondence. However, subsequently through his attorney the Veteran contended that he had a diagnosis of paranoid schizophrenia which was recognized by VA and for which he received a nonservice–connected pension. The Veteran claimed that his paranoid schizophrenia disorder was related to active duty service because he witnessed and assisted at two plane crash sites during active duty causing psychological injury. See December 2015 Attorney Correspondence. In support of his claim, the Veteran submitted an article entitled Could Stress Cause Psychosis in Individuals Vulnerable to Schizophrenia, wherein the author, Dr. Cheryl Corcoran, opines that schizophrenia stems from postnatal psychosocial stress. Id. While the Board is sympathetic to the contentions of the Veteran, after a careful review of his claims file to include the article by Dr. Cheryl Corcoran and his lay statements, the Board finds that the preponderance of the evidence is against a finding that the Veteran has an acquired psychiatric disability that is etiologically related to any in-service incurrence. The Veteran’s service treatment records (STRs) are silent for any complaint or manifestation of a psychiatric disorder upon examination for separation from service. See February 1975 Separation Examination. Post–service treatment records indicate that the Veteran’s mental health disability has been assigned various psychiatric diagnoses to include depression, paranoid schizophrenia, anxiety and polysubstance abuse. See e.g., VA Medical Center Medical Records 2001-2019. The Veteran had a positive PTSD screen on January 2012 and a negative PTSD screen on February 2019, but no formal diagnosis of PTSD is contained within his claims file. As to the question of whether the Veteran has a psychiatric disability that is related to service, the Board notes that the Veteran was afforded a VA examination in May 2016. The examiner indicated that the Veteran did not have a mental disorder which conforms to the DSM-V criteria. The Veteran reported that he had no mental health treatment during the military and had some treatment when he got out of the military, in around 1979. The Veteran indicated that he may have seen someone at the Omaha VA in the 1990s and maybe saw someone in 2003 or 2004 for mental health issues. The examiner indicated that although the Veteran had in-service stressors and he met Criterion A (exposure to actual or threatened death or serious injury), the Veteran did not have reported symptoms which met Criterion B through H. VA afforded the Veteran an additional VA psychiatric disorders examination and obtained a new medical opinion in October 2019. As an initial matter, the Board finds that the October 2019 is adequate for adjudication purposes. The examiner is an appropriate medical professional to assess mental health disabilities and reviewed the entire claims file. After an in-person interview with the Veteran, the examiner assigned a diagnosis of paranoid personality disorder and concluded that the Veteran’s symptoms did not meet the criteria of any other mental health illness. Specifically, the examiner noted that while the Veteran’s stressor (described as witnessing the aftermath of an airplane crash) was adequate to support a diagnosis of PTSD and the Veteran demonstrated persistent avoidance of memories associated with the trauma, he did not report symptoms that rose to the level of clinical significance for 6 other areas of diagnostic criteria required for a PTSD diagnosis. The VA examiner confirmed that the Veteran’s medical records in the early 2000s documented a diagnosis of schizophrenia. However, a further review of those medical records indicated that the diagnosis was made while the Veteran was heavily using substances including drugs and alcohol. The examiner opined that it was more likely than not that the Veteran’s psychotic symptoms at that time of diagnosis were the result of substance use rather than a typical psychotic episode. The rationale for the examiner’s opinion was the fact that during the October 2019 examination the Veteran refused to provide any information regarding psychotic symptoms and did not report sufficient criteria to warrant a schizophrenia diagnosis. Dr. Cheryl Corcoran’s article submitted by the Veteran in support of his claim, drew a conclusion consistent with that of the VA examiner’s findings. In particular, Dr. Corcoran noted that events that might trigger the onset of schizophrenia include “postnatal environmental insults such as psychosocial stress, TBI and perhaps even substance abuse”. See Could Stress Cause Psychosis in Individuals Vulnerable to Schizophrenia, 7 CNS Spectr 33, 40 (2002). Nevertheless, Dr. Corcoran opined that more prospective longitudinal studies of at - risk individuals were needed, to explore the neurobiological mechanisms underlying psychotic episodes. See Id. at 41. The Veteran denied any psychological hospitalizations, suicide attempts, therapy or psychotropic medications since his prior VA examination in May 2016. When asked about anxiety, the Veteran indicated that he had always been kind of “hyper” and “it’s been a long time I can’t put my hand on it.” The VA examiner noted that the while the Veteran reported vague symptoms of anxiety, he did not report sufficient symptomatology sufficient to meet the criteria for any current anxiety disorder. The Veteran reported symptoms of suspiciousness and difficulty in establishing and maintaining effective work and social relationships. He suspected without sufficient basis that others were exploiting, harming, or deceiving him. He was preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates, was reluctant to confide in others because he feared that the information would be used maliciously against him and read hidden, demeaning or threatening meanings into benign remarks or events. The VA examiner noted that the Veteran’s medical records reflected a history of paranoid personality traits and he reported sufficient symptoms during the October 2019 examination to warrant a diagnosis of paranoid personality disorder. Regarding the etiology of the Veteran’s diagnosed psychiatric disability, the October 2019 VA examiner opined that it was likely than not that it was incurred in or caused by service. The rationale for the examiner’s opinion was that the Veteran’s paranoid personality disorder was characterological in nature, with a long - standing pattern of interpersonal, emotional, and behavioral deficits less likely than not related to any service or any particular incident of service. Based upon the competent and credible evidence of record, the Board finds that the Veteran did not have an in-service incurrence of an acquired psychiatric disability. Nor does the evidence show that an acquired psychiatric disorder manifested within one year of service. The Board affords great weight to the findings and opinions of the October 2019 VA examiner who determined that the Veteran has a diagnosis of paranoid personality disorder but no diagnoses of PTSD, schizophrenia or anxiety and provided detailed explanations for those opinions. The Board finds that the article authored Dr. Cheryl Corcoran to be not highly probative on the issue of etiology of the Veteran’s psychiatric disability because he does not have schizophrenia. Specifically, the Board notes that while the Veteran had a previous diagnosis of schizophrenia in the 2000’s and did in fact receive a nonservice–connected pension under this diagnostic code, the October 2019 VA examiner determined that the Veteran did not meet the criteria for the condition. Nor is there any evidence suggesting that he was affirmatively diagnosed with the condition throughout the appeals period. Significantly, the October 2019 VA examiner opined that the Veteran more likely than not had drug induced psychotic episodes and not actual schizophrenia because the diagnosis was rendered during a time period when he was actively abusing substances. As stated above, personality disorders are not diseases or injuries subject to VA compensation but are considered congenital or developmental defects. As such, there is no issue of causation with a personality disorder, and the presumption of soundness does not apply. See Morris v. Shinseki, 678 F.3d 1346, 1354 (Fed. Cir. 2012). Accordingly, a paranoid personality disorder suffered by the Veteran in service or otherwise is inconsequential to his appeal. While service connection is available for benefits related to circumstances when a psychiatric disability is superimposed upon personality disorders under 38 C.F.R. § 4.127, this does not obviate the requirement that a psychiatric disorder be independently related to service. The rules underlying 38 C.F.R. § 4.127 do not permit service connection for a disability resulting from the personality disorder. 61 Fed. Reg. 52,695-02, 52698 (Oct. 8, 1996) (Final Rule). The rule explains that the existence of a psychiatric disability superimposed on a personality disorder could result in compensation for a disability resulting from both disorders if the superimposed disorder is service-connected and it is not possible to separate the effects of the conditions, and those effects can be attributed to the service-connected condition. Here, paranoid personality disorder is the only mental health condition that meets the diagnostic medical criteria for a disability. There is no identified psychiatric disorder that can be found to be superimposed on the Veteran’s personality disorder which is non – qualifying. In reaching this decision the Board acknowledges the appellant’s sincerely held belief that his current psychiatric pathology is related to his military service. As a lay person, however, who is untrained in the field of medicine, he is not competent to diagnose or offer an opinion that requires the expertise and training of a trained psychiatrist or psychologist. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for an acquired psychiatric disorder claimed as PTSD, schizophrenia, and anxiety, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a neurocognitive disorder claimed as short-term memory loss. The Veteran asserts that he is entitled to service connection for short term memory loss. See August 2013 VA Form 21- 4138 Veteran Statement in Support of Claim. Nevertheless, after a thorough review of the evidence of record, the Board finds that the claim for service connection for short term memory loss must be denied, as the preponderance of the evidence is against a finding that the Veteran has a current disability to support his claim. A necessary element for establishing any service connection claim is the existence of a current disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). While the Board acknowledges that the Veteran complained about memory issues, Veteran’s post - service treatment records are silent for any diagnosis of a neurocognitive disorder. The Board notes that the Veteran sought medical attention for polysubstance abuse of both ethanol and street drugs which impaired his judgement and insight. See e.g., September 2000 Omaha VA Psychiatry Admitting Consultation Note. A June 2001 VA examination found that the Veteran’s memory both recent and remote was grossly intact. The Veteran was afforded a VA Examination in October 2019. When asked about his memory the Veteran responded, “I don’t think it’s hard, sometimes I don’t want to remember.” He stated that he sometimes misplaces items such as his phone or glasses but could not identify when those issues began. The October 2019 VA examiner found that the Veteran did not meet the criteria for any DSM -5 Neurocognitive Disorder. In sum, the Board finds that there is no competent or persuasive medical evidence establishing that the Veteran has a current diagnosis of a neurocognitive disorder. Accordingly, as there is no current diagnosis of a neurocognitive disorder resulting in short term memory loss, the first element for service connection is not satisfied and the claim must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 3. Entitlement to service connection for a gastrointestinal (GI) disorder, to include as secondary to a psychiatric disability. The Veteran seeks service connection for a GI disorder although he offered no specific contention explaining why he believes his GI disability is related to active duty service. See August 2013 VA 21-4138 Statement in Support of Claim. The Veteran also asserted that his GI disorder was possibly related to his psychiatric disability. Id. As an initial matter the Board notes that service connection for an acquired psychiatric disorder has been denied and the Veteran has no service-connected psychiatric disabilities. Thus, without a service-connected psychiatric disability there cannot be service connection for his GI disability on a secondary basis. As it pertains to the claim of service connection for a GI disability on a direct basis, review of the STRs showed that the Veteran was examined on one occasion for complaints of abdominal pain associated with a sore throat which resolved with antibiotic treatment. See June 1977 STR. The Veteran’s separation examination was silent for complaints on his medical history form of gastrointestinal conditions and clinical evaluation of the abdomen was normal. Review of post-service VA treatment records showed that the Veteran first complained of gastrointestinal distress in October 2000 as the result of prescription psychotropic medications. However, at a General Medical examination by VA in June 2001, no gastrointestinal complaints were reported. On VA examination in October 2019, diagnoses assigned to the Veteran’s GI disability were gastroesophageal reflux disease (GERD)and stricture of the esophagus. Following the examination, the examiner opined that it was less likely than not that the Veteran’s GI disabilities were related to service. The rationale was that there was no evidence showing that any gastrointestinal condition was incurred in or the result of an in – service incident. The October 2019 VA examiner is a medical professional who is competent to render medical opinions in this matter. The opinion offered was based upon an in – person examination of the Veteran as well as a review of his claims file. The Board finds it to be highly probative on the issue of nexus. Significantly, it is uncontradicted. The Veteran’s lay statements have been considered in evaluating his claim. Significantly, consistent the competent and credible evidence of record, the Veteran has not identified any relationship between his active duty service and his GI disabilities. While the Veteran may be competent to report what he has experienced, he is not competent to ascertain the etiology of any current disorder, as the causative factors for such are not subject to lay observation. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). In light of the foregoing, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for a GI disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for diabetes mellitus. The Veteran seeks service connection for diabetes mellitus but offers no specific contentions regarding why he believes it is related to active duty. See August 2013 VA 21-4138 Statement in Support of Claim. As an initial matter, the Board finds there was substantial compliance with the May 2018 Board remand directives pertaining to the claim of service connection for diabetes mellitus. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran’s service treatment records (STRs) are silent for any evidence of or treatment for diabetes mellitus. Post-service treatment records indicated that the Veteran’s diabetes mellitus type II was first diagnosed in April 2013, nearly 35 years after service. See April 2013 Emergency Medicine Note, UNMC, Omaha, Nebraska. Based on the foregoing information, there is no evidence that the Veteran’s current diabetes mellitus type II had its onset in service or that it became manifest to a compensable degree in the first year following his separation from active duty service. Consequently, service connection for diabetes mellitus on the basis that it became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. As for the question of whether the Veteran’s diabetes mellitus is otherwise related to his active duty service, VA afforded the Veteran an in-person examination in November 2019. The Veteran reported that the condition started in 2013. The November 2019 VA examiner gave a positive nexus opinion based upon an erroneous belief that the Veteran’s diabetes mellitus was service - connected by a June 2014 rating decision. VA obtained an addendum medical opinion in August 2020. The examiner opined that the Veteran’s diabetes mellitus was less likely than not incurred in or caused by active duty. The rationale for the negative nexus opinion was the fact that the Veteran’s diabetes began in 2013, well after the Veteran separated from service. The Board finds that the August 2020 examiner is competent and credible to offer a medical opinion in this matter. The examiner is a licensed physician who based his opinion upon a review of the pertinent medical evidence as identified in the opinion, The Board accords great weight to the examiner’s medical opinion. Significantly, it is uncontroverted. In this case, although the Veteran has a current diagnosis of diabetes mellitus type II, the evidence does not demonstrate that the disability had its onset during service or is the result of an incident during service. As noted above, the Veteran has not offered any explanation as to why he believes his diabetes mellitus is related to his active duty service. He has also not submitted any competent evidence indicating that his diabetes mellitus may be related to his active duty service. To the extent the Veteran believes his diabetes mellitus is related to his active duty service, the Board finds he is competent to testify as to symptoms he experiences, including those related to his current diabetes. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, while the Veteran may describe the symptoms of his diabetes, the question of whether his illness had its onset during service or is otherwise related to service is not something that can be determined by mere observation. Nor is this question simple, as it requires clinical testing and training to make the appropriate interpretations and conclusions about what the findings demonstrate in conjunction with the symptoms reported. The Veteran lacks the medical training or qualifications to diagnose diabetes or opine as to the causation of that disability. Id. His belief therefore cannot provide the requisite nexus opinion required to establish service connection. Accordingly, the criteria for service connection have not been met for diabetes mellitus type II. The evidence does not show that disability was diagnosed in service or within a year of service and the weight of the evidence is against a finding that the Veteran’s diabetes mellitus type II has existed continuously since service or is otherwise related to his active duty service. Therefore, the claim is denied. 5. Entitlement to service connection for glaucoma, to include as secondary to diabetes mellitus type II. The Veteran seeks service connection for glaucoma to include as secondary to his diabetes mellitus. See August 2013 VA 21-4138 Statement in Support of Claim. As an initial matter, the Board finds there was substantial compliance with the May 2018 Board remand directives pertaining to the claim of service connection for glaucoma. Stegall v. West, 11 Vet. App. 268 (1998). To the extent that the Veteran maintains that his glaucoma is related to his diabetes, since diabetes mellitus is not a service-connected disability, there is no basis for a secondary claim. Further, after reviewing the evidence of record, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of glaucoma began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § § 3.303 (a), (d), 3.310. In this regard, the medical evidence shows current evidence of primary open angle glaucoma in both eyes. See October 2019 Eye Conditions Disability Benefits Questionnaire. Service treatment records (STRs) are negative for complaints or findings related to glaucoma. Further, regarding direct service connection, the medical evidence does not show that the Veteran’s current glaucoma, diagnosed in 2000, is related to his active duty service, nor has the Veteran submitted any explanation as to why he believes it is. In October 2019, the Veteran was provided a VA examination. The examiner concluded that no nexus existed between the Veteran’s bilateral open angle glaucoma and his active duty service. The examiner opined that based upon the appearance of the optic nerve the Veteran would have been diagnosed with glaucoma regardless of whether he served in the military. The VA examiner’s opinion is probative, because it is based on examination of the Veteran and a review of the claims file, including the Veteran’s contentions, and includes an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Significantly, there is no competent opinion to the contrary. To the extent the Veteran believes his glaucoma is related to his active duty service, he is not competent to provide a nexus opinion regarding this issue. The questions addressed in this case are medical in nature and require knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner’s opinion. Increased Rating Claims Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where entitlement to compensation has already 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 (1994). In addition, the United States Court of Appeals for Veterans Claims (Court) has determined that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 6. Entitlement to a rating in excess of 10 percent for a right ankle disability prior to October 9, 2019 and in excess of 20 percent thereafter. The Veteran’s contends his right ankle disability is more severe than reflected by the current evaluations. See January 2012 VA 21-526b Supplemental Claim. By history the Board notes that service connection for a right ankle injury; distal Achilles’ tendinopathy was awarded in an April 2003 rating decision. An initial 10 percent evaluation was assigned effective January 24, 2002, by a June 2003 rating decision. The June 2012 rating decision on appeal continued a 10 percent evaluation for the right ankle disability, re-characterized the Veteran’s disability as chronic right ankle strain with distal Achilles’ tendinopathy. A September 2020 rating decision increased the rating to 20 percent pursuant to DC 5271 effective October 9, 2019, which was the date of the VA examination that documented the worsening symptoms. As an initial matter, the Board finds there was substantial compliance with the May 2018 Board remand directives pertaining to the claim of an increased rating for an ankle condition. Stegall v. West, 11 Vet. App. 268 (1998). Prior to October 9, 2019, the Veteran’s right ankle disability was rated as 10 percent disabling under DCs 5099-5024 for limitation of motion of the ankle. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 5024 pertains to tenosynovitis and provides for rating the service-connected disability based on limitation of motion of the affected body part, which in this case is the Veteran’s right ankle, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Degenerative arthritis is evaluated under DC 5003 and provides a rating of 10 percent for noncompensable limitation of motion of an involved joint confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. Since October 9, 2019, the Veteran’s right ankle disability has been rated at 20 percent under DC 5271, which assigns a 10 percent rating is assigned for moderate limited motion of the ankle. A 20 percent rating is assigned for marked limited motion of the ankle. 38 C.F.R. § 4.71a. The terms moderate and marked are not defined in the rating schedule and, rather than applying a mechanical formula, VA must evaluate all the evidence in order to ensure that its decisions are equitable and just. 38 C.F.R. § 4.6. The Schedule provides that the normal range of motion for the ankle is 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. In May 2012, the Veteran underwent a VA examination to evaluate his right ankle disability. The diagnosis was chronic right ankle strain. The Veteran reported persistent right ankle pain, weakness and stiffness. He regularly required an ankle brace and used over the counter medications for pain relief. He endorsed the use of a cane for stability. The Veteran routinely walked up to 6 blocks and stood without any functional limitations. Flareups resulted in increased pain, decreased range of motion and difficulty with weight bearing. Range of motion testing of his right ankle showed dorsiflexion to 20 degrees with objective evidence of pain at 5 degrees and plantar flexion to 45 degrees with objective evidence of pain at 30 degrees. The Veteran was able to complete repetitive use testing with right ankle showed dorsiflexion to 15 degrees and plantar flexion to 40 degrees. The decreased range of motion was noted to contribute to functional loss because of pain and reduced range of motion with movement. In January 2017, the Veteran’s right ankle was again evaluated by VA during an in-person examination. VA treatment records were reviewed. The diagnosis was right ankle strain with degenerative joint disease and right Achilles’ tendinopathy. The Veteran reported pain, stiffness, decreased range of motion. He also experienced clicking, popping, and snapping as well as intermittent swelling of the right ankle. The Veteran reported flare-ups from cold weather or prolonged weightbearing which resulted in increased pain, decreased range of motion, stiffness, and difficulty with weightbearing. Flareups were alleviated with over the counter medications, rest, elevation, stretching and soaking in hot water. The Veteran endorsed the constant use of an ankle brace and occasional use of a cane. Range of motion testing showed dorsiflexion to 15 degrees and plantar flexion to 40. Abnormal range of motion and pain on examination resulted in functional loss because it resulted in a slight limp. Pain was noted on examination including tenderness to the Achilles’ tendon and to the lateral and anterior of the Veteran’s ankle. There was no evidence of pain with weight bearing and no evidence of crepitus. There was no additional loss of range of motion on repetitive use testing, no joint instability, and no ankylosis. The Veteran had no loss of muscle strength and muscle atrophy was not present. An occasional use of an ankle brace was noted. Mild degenerative joint disease of the right ankle was noted on imaging. The Veteran was afforded another VA ankle examination in October 2019. The diagnoses were lateral collateral ligament sprain of the right ankle, old fracture of the right lateral malleolus, right calcaneal spur, and right Achilles’ tendinopathy. The Veteran reported moderate flare-ups of the right ankle which became severe if the he stepped down or onto uneven ground. Right ankle flareups were also precipitated by cold or wet weather. The Veteran indicated that he cannot stand or walk long distances without support. When his ankle is swollen, he cannot walk on it. Range of motion testing of his right ankle showed dorsiflexion to 10 degrees and plantar flexion to 30 degrees. Pain noted on examination caused functional loss. There was evidence of localized tenderness of moderate severity to the lateral area of the right ankle joint and associated tissue. No crepitus was noted. There was additional loss of range of motion on repetitive use testing with dorsiflexion to 5 degrees and plantar flexion to 20 degrees. Pain, fatigue, and lack of endurance contributed to limiting the Veteran’s functional ability with repeated use over time. Pain also contributed to limited functional ability with flareups which the examiner opined would result in limited range of motion equivalent to dorsiflexion to less than 5 degrees and plantar flexion to 15 degrees. Additional factors contributing to the Veteran’s disability were pain and ankle in the foot and a drop foot. The Veteran did not have any muscle atrophy. There was no ankylosis or joint instability. The Veteran required the occasional use of a cane for knee. The VA examiner opined that the impact of the Veteran’s right ankle on his ability to perform an occupational task would likely be difficulty with prolonged standing and walking. Considering the rating for the Veteran’s right ankle disability prior to October 9, 2019 the Board finds that at no time prior to that date, was the Veteran’s right ankle disability shown to have been manifested by marked limitation of motion. Specifically, on January 2017 VA examination, dorsiflexion of the right ankle was to 15 degrees and plantar flexion was to 40 degrees. Although abnormal range of motion resulting in a slight limp and pain described as tenderness to the Achilles’ tendon and to the lateral and anterior of the Veteran’s ankle was noted on examination, it did not result in functional loss. There was no evidence of pain with weight bearing and the Veteran was able to perform repetitive use testing with no additional limitation of motion. While there was localized pain, strength and stability testing was normal. Consequently, the Board finds that a 20 percent rating under Code 5271 was not warranted prior to October 9, 2019. From October 9, 2019, the Veteran’s right ankle disability has been assigned a 20 percent rating. The October 9, 2019 date was assigned based on findings of increased limitation range of motion, evidence of additional loss of range of motion with repetitive testing and functional loss including increased pain and difficulty with standing and walking. These finding are consistent with the Veteran’s complaints of symptoms of increased pain, swelling, and limited flexibility. The October 2019 VA examination objectively confirmed his report of worsening. The Board notes that the 20 percent rating under DC 5271 (for limitation of ankle motion) currently assigned for the Veteran’s right ankle disability is the maximum schedular rating under that code and reflects marked limitation. The Board has considered other potentially applicable diagnostic codes. DC 5270 provides for a higher rating based on ankylosis of the ankle. However, there is no medical diagnosis or indication of ankylosis during this period. The evidence of record indicates that the Veteran continues to maintain some motion of his right ankle. DC 5272 for ankylosis of the subastragalar or tarsal joint, DC 5273 malunion of os calcis or astragalus, and DC 5274 for astragalectomy were also considered. The Veteran has not contended, nor has the objective evidence indicated, that the Veteran has been diagnosed or treated for these conditions. Therefore, DC 5270, 5272, 5273, and 5274 are not applicable. Accordingly, a schedular rating is excess of 20 percent for the Veteran’s right ankle disability is not warranted. The Board notes the Veteran reports he is limited in activities such as standing, and walking, because of his right ankle disability. The Veteran’s statements regarding his physical restrictions pertain to functional limitations that are contemplated by the governing diagnostic code criteria and corresponding regulations. Neither the Veteran nor his representative have alleged any symptoms of, or impairment due to, the right ankle disability not encompassed by the schedular criteria, and the record does not suggest there are any such symptoms or impairment. The Board acknowledges that a right drop foot was identified by the October 2019 VA examiner. However, a drop foot is considered a separate disability and not a symptom of an ankle condition under the diagnostic code. See 38 C.F.R. § 4.124a, DCs 8520-8725. While the Veteran’s drop foot may have arisen secondarily to his right ankle disability, there is no mechanism under the law for the Board to assume jurisdiction of this condition until and unless the Veteran chooses to raise it. The preponderance of the evidence is against the claim for an increased rating for the Veteran’s right ankle disability. Accordingly, the appeal in the matter must be denied. REMANDED 1. Entitlement to service connection for a sleep disorder to include as due to a psychiatric disability is remanded. 2. Entitlement to service connection for sleep apnea to include as secondary to a psychiatric disability is remanded. The Veteran contends he has a sleep disorder that began in active service and has caused continuous sleep problems. See September 2013 VA 21-4138 Statement in Support of Claim. On his January 1978 separation examination report of medical history, the Veteran noted that he had frequent trouble sleeping. The Veteran was referred by VA for a sleep study in October 2019 which confirmed a diagnosis of sleep apnea. The Veteran was afforded two separate VA examinations in October 2019 for sleep disorders and sleep apnea. Relevant to the sleep disorders opinion for direct service connection, the VA examiner opined that that the Veteran’s claimed condition was less likely than not incurred in or caused by service since the Veteran did not meet the criteria for any DSM-5 sleep disorder diagnosis. Relevant to the sleep apnea medical opinion for direct service connection, the VA examiner opined that that the Veteran’s claimed condition was less likely than not incurred in or caused by service because there was no evidence that sleep apnea was incurred in or caused by any in-service incident. As it pertains to both examinations, neither examiner acknowledged nor discussed the significance, if any, of the Veteran’s sleep issues during active duty noted in his STRs. The Board finds that the October 2019 VA examinations are inadequate because the rationale for the opinions is based on incorrect factual premises and neglect to fully address evidence of in–service incurrence. Remand is warranted for an opinion regarding whether the Veteran’s sleep disorder and/or sleep apnea was caused by or aggravated by his active duty service. The matters are REMANDED for the following action: 1. With any required assistance from the Veteran, obtain any outstanding VA and/or private treatment records relevant to the Veteran’s claimed sleep disorder or sleep apnea. 2. Schedule the Veteran for a new VA examination for his obstructive sleep apnea. The Veteran’s claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. Based on the examination results and a review of the pertinent medical history, the examiner should provide opinions responding to the following: (a.) Identify all diagnosed sleep disorders. (b.) For any sleep disorder diagnosed including sleep apnea the examiner is asked to offer an opinion as to whether it is at least as likely as not (50 percent or better probability) etiologically related to the Veteran’s active service and explain why or why not. (c.) For any sleep disorder diagnosed including sleep apnea the examiner is asked to offer an opinion as to whether it is at least as likely as not (50 percent or better probability) caused by a psychiatric disability and explain why or why not. (d.) For any sleep disorder diagnosed including sleep apnea the examiner is asked to offer an opinion as to whether it is at least as likely as not (50 percent or better probability) aggravated by a psychiatric disability and explain why or why not. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Alexander 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.