Citation Nr: 21002233 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 16-24 642 DATE: January 13, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to the Veteran’s service-connected posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for transitional cell carcinoma, claimed as bladder cancer, to include as due to herbicide exposure is granted. Entitlement to a compensable rating for allergic rhinitis is denied. Entitlement to a 50 percent rating for PTSD is granted. REMANDED Entitlement to a compensable rating for calculus, left ureter, for the time period prior to March 11, 2020, and a 20 percent rating thereafter, is remanded. Entitlement to service connection for prostate hypertrophy, to include as secondary to service-connected prostate cancer, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s sleep disorder had its onset in service, is related to service, or is proximately due to a service-connected condition. 2. The Veteran’s bladder cancer is presumptively due to herbicide exposure. 3. For the entire period on appeal, the Veteran’s rhinitis was not manifested with a 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 4. For the entire period on appeal, the Veteran’s PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to depressed mood, anxiety, chronic sleep impairment, mild memory loss, irritability, hypervigilance, difficulty concentrating and completing tasks, mildly exaggerated startle response, and suspiciousness. CONCLUSIONS OF LAW 1. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a bladder cancer, to include as secondary to herbicide exposure, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.309. 3. The criteria for a compensable rating for rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6522. 4. The criteria for a 50 percent disability rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 to September 1968. This appeal comes before the Board of Veterans’ Appeals (Board) from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Waco, Texas (hereinafter Agency of Original Jurisdiction (AOJ)). In May 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearings is of record. In October 2018, the Board sought a Veterans Health Administration (VHA) opinion to assist in its service connection analysis on the issue of whether the Veteran’s currently diagnosed bladder cancer is attributable to his military service, specifically to include exposure to herbicides chemicals while serving in Vietnam. In December 2018, the Board remanded the appeal to the AOJ for further development. Specifically, the Board directed the AOJ to obtain additional treatment records, to obtain an addendum opinion regarding the Veteran’s sleep apnea claim, and to schedule the Veteran for VA examinations. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” the so-called “nexus requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). For Veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases may be presumed to have been incurred in service if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2019). Bladder cancer is on the list of diseases presumed to have been incurred in-service and receive a one-year presumption. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). If there is no manifestation within one year of service, service connection for a recognized chronic disease can still be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Continuity of symptomatology requires that the chronic disease have manifested in service. 38 C.F.R. § 3.303(b). In-service manifestation means a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. Regarding exposure to a herbicide agent, to include Agent Orange, a Veteran, who during active military, naval or air service, served in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during his or her service to a herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Here the Veteran’s exposure has been conceded based on his combat service in Vietnam. The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin’s disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin’s lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson’s disease, and ischemic heart disease. 38 C.F.R. § 3.309(e). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Increased Rating Disability ratings are determined by applying the criteria established in VA’s Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.20. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found; this practice is known as staged ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence has been assembled, it is the Board’s responsibility to determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed.Cir.1996). The Board assesses both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Competent lay evidence means any evidence not requiring that the proponent 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); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to the Veteran’s service-connected PTSD. The Veteran is seeking service connection for a sleep disorder. He asserts that his obstructive sleep apnea is secondary to his service-connected PTSD. Direct Service Connection First, the evidence of record establishes that the Veteran has a current disability. Private treatment records indicate that the Veteran was diagnosed with sleep apnea in July 2005. VA treatment records show that the Veteran has sleep apnea that is treated with a CPAP. See generally VA treatment records. Regarding the second requirement, the preponderance of the evidence is against finding that a sleep disorder began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran’s STRs do not show any notations related to a sleep disorder and the Veteran has not alleged any specific injury or event that took place during service related this claim. As such the evidence does not show the occurrence of an in-service event or injury. Additionally, in a 2020 examination, the VA examiner opined that the Veteran has a diagnosis of obstructive sleep apnea evident by an AHI of 17.3 in 2011. I am unable to locate his initial sleep study in 2005 with current available records, but his PCM annotates an AHI of 33 in 2005. Although the lay statement reports a witnessed account “stopped breathing,” there is no objective evidence to support Veteran had sleep apnea at this time. It is impossible to scientifically confirm a diagnosis of sleep apnea due to a witness of “stopped breathing.” Sleep studies reveal Veteran was diagnosed with sleep apnea after separation from service. I believe his sleep apnea is the result of his increased weight. His current BMI is 29.8 (overweight). It is well known in the medical community that the main causation factor for OSA is obesity and increased weight. Medical literature reports in adults, the most common cause of obstructive sleep apnea is excess weight and obesity, which is associated with soft tissue of the mouth and throat. During sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked. Therefore, the claimed obstructive sleep apnea is more likely related to his weight and unrelated to service. There is no objective evidence to support sleep apnea occurred while in service. A nexus has not been established. In her opinion that the Veteran’s sleep apnea was less likely related to his military service, the examiner noted that sleep apnea was a purely anatomical condition relating to collapse and obstruction of the airway during sleep, and was not related to his military service, but rather to an increase in weight. In rendering her opinion, the examiner reviewed the Veteran’s claims file, considered his lay statements, and provided a detailed rationale including an explanation that a lay statement describing an episode of “stopped breathing” was insufficient from a medical/scientific point of view to establish the onset of sleep apnea in service. Therefore, the Board assigns high probative weight to this opinion. As the preponderance of the evidence is against finding that a sleep disorder began during active service, or is otherwise related to an in-service injury, event, or disease, it follows that the nexus element of the claim is not established. The Board notes that neither the Veteran nor his witnesses are competent to diagnose the onset or etiology of sleep apnea, including identifying any specific symptom or set of symptoms as establishing the actual onset of sleep apnea. As such, service connection is not warranted for a sleep disorder based on the theory of direct service connection. Secondary Service Connection Next, the Board will address the question of whether the Veteran’s sleep disorder is secondary to his service-connected PTSD, to include whether the Veteran’s disorder is caused by or aggravated by his service-connected PTSD. A July 2005 private treatment note indicates that the Veteran underwent a sleep study and was diagnosed with “moderately severe obstructive sleep apnea.” He was noted to have a body mass index (BMI) of 27.1. A November 2011 private treatment note indicates that the Veteran underwent a sleep study and was diagnosed with “obstructive sleep apnea controlled with CPAP.” He was noted to have a body mass index (BMI) of 26.6. In a December 2015 VA examination, the examiner noted that Per Veteran statement he was having problems related to sleep apnea in approximately 2004. He reports having a sleep study and was diagnosed. In 2012 he applied for a service connection for PTSD and received a service connection. The examiner opined that There is no evidence that indicates his sleep apnea has worsened or his symptoms have returned. There is also no evidence that his c-pap machine chip has been checked to see if he is compliant with the use of c-pap. There is no literature or evidence that indicates PTSD causes sleep apnea. Current literature in UpToDate list the following for well-defined risk factors for OSA which include older age, male gender, obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities. Potential risk factors include smoking, nasal congestion, and family history. Some literature does mention a relationship between untreated sleep apnea and the worsening PTSD symptoms. There is no evidence that Veteran’s sleep apnea is aggravated by the service-connected PTSD. In her opinion that the Veteran’s sleep apnea was less likely as not caused by, or aggravated by, his service-connected PTSD (or any other service-connected disability), the examiner noted that sleep apnea was related to older age, male gender, obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities, many of which have been documented in the Veteran’s medical record. In rendering her opinion, the examiner reviewed the Veteran’s claims file, considered his lay statements, and provided a detailed rationale. Therefore, the Board assigns high probative weight to this opinion. In a February 2016, a VA examiner opined that There is no objective medical evidence showing veteran’s sleep apnea condition as greater than baseline currently. Sleep study on 11/16/2011 at Scott and White Sleep Institute, Temple, TX diagnosed Obstructive sleep apnea, controlled with CPAP. The veteran’s claimed sleep apnea was less likely than not aggravated beyond its natural progression by the veteran’s service-connected posttraumatic stress disorder. In her opinion that the Veteran’s sleep apnea was less likely as not caused by, or aggravated by, his service-connected PTSD (or any other service-connected disability), the examiner noted that there was no evidence that the Veteran’s sleep apnea was aggravated beyond normal baseline due to his PTSD. In rendering her opinion, the examiner reviewed the Veteran’s claims file, considered his lay statements, and provided a detailed rationale. Therefore, the Board assigns high probative weight to this opinion. In a March 2020 VA examination, the VA examiner opined that the Veteran’s medical records reveal the most recent sleep study in 2011. The 2011 sleep study reveals an AHI of 17. His AHI has decreased since the initial sleep study. Additionally, obstructive sleep apnea results from a mechanical obstruction and is not related to PTSD. It is well known in the medical community that the main causation factor for OSA is obesity and increased weight. Medical literature reports in adults, the most common cause of obstructive sleep apnea is excess weight and obesity, which is associated with soft tissue of the mouth and throat. His current BMI is 29.8 (overweight). During sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked. This mechanical airway obstruction is aggravated by weight gain and NOT aggravated by sleep problems interfering with his use of a C-PAP machine due to his Post traumatic stress disorder symptoms. A nexus has not been established. In his opinion that the Veteran’s sleep apnea was less likely as not caused by, or aggravated by, his service-connected PTSD (or any other service-connected disability), the examiner noted that sleep apnea was a purely anatomical condition relating to collapse and obstruction of the airway during sleep, and had nothing to do with mental illness. In rendering his opinion, the examiner reviewed the Veteran’s claims file, considered his lay statements, and provided a detailed rationale. Therefore, the Board assigns high probative weight to this opinion. The Board has also considered the Veteran’s presentation of case law from the Board in support of his claims. There is opinion in those cases that that particular Veterans’ obstructive sleep apnea was caused or aggravated by PTSD. The Board notes that Board decisions are not precedent. Notably, 38 C.F.R. § 20.1303 states, “Although the Board strives for consistency in issuing its decisions, previously issued Board decisions will be considered binding only with regard to the specific case decided.” Instead, “each case presented to the Board will be decided on the basis of the individual facts of the case in light of applicable procedure and substantive law.” Id. Moreover, the facts of the cases cited by the Veteran are not identical to the facts of his own case. The evidentiary records of other Veterans are in relevant respects quite different from the Veteran in the present case on appeal. Every Veteran’s case presents different facts which of necessity will tend to yield different outcomes. There has also been a recent and comprehensive evaluation of the Veteran’s medical records that considered his specific medical history and lay statements. The VA examiners directly addressed the medical reasons why the Veteran’s sleep apnea was not etiologically related to his PTSD. The Veteran has not raised any other issue of material fact to counter this medical conclusion. Consequently, the Board gives more probative weight to the combined December 2015, February 2016, and March 2020 VA opinions. The Board finds that taken together, these opinions are persuasive, as they rely on expert knowledge, medical literature, and the Veteran’s medical history. In addition, they are consistent with one another in noting that the Veteran’s sleep disorder is due to his body mass index, and there is no similar medical opinion of record weighing in favor secondary service connection. As such, service connection is not warranted for a sleep disorder as secondary to the Veteran's service-connected PTSD. Moreover, the Board also notes that the Veteran is already compensated for a chronic sleep impairment as a symptom of his service-connected PTSD. See December 2013 VA examination report at page 5. As such, service connection is not warranted for a sleep disorder as secondary to the Veteran’s service-connected PTSD. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for transitional cell carcinoma, claimed as bladder cancer, to include as due to herbicide exposure. The Veteran contends that his bladder cancer is due to exposure to Agent Orange (herbicide agents) while stationed in Vietnam. His military personnel records confirm that the Veteran was stationed in Vietnam for one year. As discussed above, it is conceded that the Veteran was exposed to herbicide agents while in-service. The more dispositive question is whether the Veteran’s exposure to herbicide agents while in-service caused or is related to the onset of his bladder cancer. On January 1, 2021, the National Defense Authorization Act for FY 2021 became law. One section of the law added three diseases to the list of those presumed service-connected in veterans exposed to herbicide agents. Specifically, the law adds to 38 U.S.C. § 1116(a)(2)(J), which lists bladder cancer. Thus, the criteria for establishing service connection for bladder cancer have now been met. 3. Entitlement to a compensable rating for allergic rhinitis. The Veteran asserts that he is entitled to a compensable rating for rhinitis as his symptoms are more severe than reflected by the rating currently assigned. Allergic rhinitis is rated under the criteria found at 38 C.F.R. § 4.97, Diagnostic Code 6522, for allergic or vasomotor rhinitis. While Diagnostic Code 6522 does not provide for a noncompensable disability evaluation, 38 C.F.R. § 4.31 provides for zero percent evaluations in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code and the requirements for a compensable evaluation are not met. Under Diagnostic Code 6522, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. At a January 2014 VA examination, the Veteran reported that he has suffered from allergies since 1968 and routinely used over the counter medications to treat the condition. Upon physical examination, the examiner found the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no complete obstruction on either side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The Veteran did not have any granulomatous conditions. The Veteran did not have any scars related to his rhinitis. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, nor other obvious disfigurement. There was not at least 50 percent obstruction of the nasal passage on both sides. The examiner noted the Veteran’s rhinitis did not impact his ability to work. At a December 2015 VA examination, the Veteran reported that he has had sinus allergies for a very long time. He believes he had this problem during active duty. Says his allergies give him bad headaches. Says he is on Zyrtec daily and also uses Flonase spray prior to bedtime. Says he has gotten worse over time and must use meds every day. No recent sinus infections. Upon physical examination, the examiner found the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no complete obstruction on either side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The Veteran did not have any granulomatous conditions. The Veteran did not have any scars related to his rhinitis. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, nor other obvious disfigurement. There was not at least 50 percent obstruction of the nasal passage on both sides. At a March 2020 VA examination, the Veteran reported that his rhinitis had stayed remained constant. He “states that he would struggle with itching eyes, runny nose, sneezing, coughing, and congestion. He states that this condition has remained the same with the symptoms being continuous and bothersome. Veteran is currently taking flonase and cetirizine daily.” Upon physical examination, the examiner found the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no complete obstruction on either side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The Veteran did not have any granulomatous conditions. The Veteran did not have any scars related to his rhinitis. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, nor other obvious disfigurement. There was not at least 50 percent obstruction of the nasal passage on both sides. The examiner noted the Veteran’s rhinitis would “result in difficulty with ability to work outside, near fumes, wet, humid condition, common allergies, dust, and pollen. All of these conditions exacerbate allergic rhinitis symptoms resulting in uncontrolled cough and at times shortness of breath. All which decrease occupational productivity and efficiency.” Further review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities, to include his rhinitis. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms that are worse than those noted in the VA examination reports of record. The Board finds that the Veteran is not entitled to a compensable rating for his rhinitis. A compensable rating would require evidence that the Veteran's allergic rhinitis was manifested by polyps; or, without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. In this case, the VA examiners specifically noted that the Veteran did not have obstruction of 50 percent or greater on both sides, or complete obstruction on one side. Further, it was specifically noted that he did not have polyps. Therefore, entitlement to a compensable rating for allergic rhinitis is not warranted at this time. 38 C.F.R. § 4.97, Diagnostic Code 6522. The Board has considered other potentially applicable rating criteria but finds that a higher rating is not warranted for the Veteran's rhinitis because the Veteran does not have 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side due to traumatic septum nasal deviation; nor did he have any loss of part of the nose or scars; permanent hypertrophy of turbinates and with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side; nor other types of granulomatous infection. 38 C.F.R. § 4.97, Diagnostic Codes 6502, 6504, 6523, 6524. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability has been provided by VA medical professionals who have examined him. The medical findings adequately address the criteria under which the disability is evaluated and clearly demonstrate that the degree of impairment attributable to the service-connected disability. The Board accords these findings records greater weight than the Veteran's complaints as to symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Accordingly, the Veteran’s belief that he is entitled to higher ratings for his rhinitis is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination report and treatment records that were recorded following examinations of the Veteran, than to the Veteran’s general belief that he is entitled to a higher rating. In sum, the Board finds that the available evidence does not support a higher disability rating at any point during the appeal period. Accordingly, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and entitlement to a compensable rating for rhinitis is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a rating, in excess of 30 percent disabling, for PTSD. The Veteran contends that he is entitled to an increased rating due to an increase in the severity of his PTSD disability. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Furthermore, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In December 2013, the Veteran underwent a VA mental disorders examination, wherein, the examiner diagnosed the Veteran with PTSD. The examiner opined that the Veteran had a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. Symptoms noted for this diagnosis and assessment include depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, impaired judgement, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work-like setting. In a statement received in February 2014, the Veteran described memory loss to the extent of losing track of conversations and instructions. He forgot names of people almost immediately. He did not travel due to distrust being in public spaces, and he had no social relationships. He generally desired to be alone. In a statement received in May 2016, the Veteran described leaving his job in 2010 due to difficulty remembering things with concentration difficulties. He did not socialize with colleagues, and had trouble remembering names. He described having panic attacks with taking long periods of time to complete simple tasks. At a hearing in May 2018, the Veteran described bouts of anxiety which interfered with his sleep. The Veteran underwent a VA examination for his PTSD in April 2020. The examiner noted a diagnosis of PTSD from previous VA treatment. The examiner noted occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. Symptoms noted for this diagnosis and assessment include anxiety, mild memory loss, intrusive memories, nightmares, occasional dissociation, flattened affect, memory and concentration problems, and irritability. The examiner noted that the Veteran was pleasant and cooperative during the exam and was oriented in all major spheres. His speech was unremarkable, and his thought process was logical and goal oriented. His mood was euthymic, and his affect varied depending upon the subjects discussed. He denied any suicidal or homicidal thoughts, his judgment was intact, and he demonstrated adequate insight into his current symptoms. PTSD symptoms include intrusive memories, nightmares, occasional dissociation, flattened affect, memory and concentration problems, and irritability. His symptoms have persisted since at least 2012. His PTSD will contribute to difficulties learning new vocational information because of both intrusive memories as well as his problems with concentration and memory. In addition, his problems with irritability will contribute to difficulties interacting with supervisors and co-workers in vocational settings. The VA examinations, which cover the period in question, were extensive in time and scope and each VA provider or examiner specifically noted an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). The symptomatology listed by each VA provider more closely approximated the symptoms associated with a 30 percent rating for a psychiatric disability. Mauerhan, 16 Vet. App. at 442. The Veteran has described episodes of memory loss to the extent of losing track of conversations and instructions, and taking long periods of time to complete simple tasks which is consistent with examples for the 50 percent rating. He describes panic attacks which affected him while working, but not to the extent of being near continuous and affecting ability to function independently. For example, the Veteran drives his 12-year-old grandson to school daily, and conducts routine household chores, which indicates that he not only cares for himself but others. VA treatment records are consistent with the findings of the VA examiners. VA treatment records regularly documented that the Veteran had appropriate speech, was well oriented, and demonstrated normal judgment, thinking and mood. Such findings and symptoms are evidence against findings that the Veteran had psychological symptoms, such as circumstantial, circumlocutory, or stereotyped speech; impaired judgment; or impaired abstract thinking, which are symptoms contemplated under a 50 percent rating for the appeal period. In considering the Diagnostic Code, the Board finds that a 50 percent rating most accurately reflects the Veteran’s most consistent symptoms. A 30 percent rating is warranted with occupational and social impairment with occasional and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although general functioning satisfactorily) due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. The Veteran has asserted his PTSD symptoms are more severe than noted in VA records. VA treatment records, the December 2013 and April 2020 VA examinations, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 30 percent rating, including anxiety and chronic sleep impairment, and symptoms associated with a 50 percent rating, including disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including occasional dissociation and irritability. See Mauerhan, supra. Given the above, the Board finds that the overall disability level more nearly approximates the criteria for a 50 percent rating with reduced reliability and productivity. In sum, the Board finds that the available evidence does not support a higher disability rating at any point during the appeal period. The preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 70 percent or 100 percent rating. In this respect, the Veteran does describe examples of memory loss has been clinically described as mild and does not rise to the level of significant spatial disorientation or memory loss to the extent of not remembering names of close relatives or self. The Veteran has demonstrated the ability to establish and maintain effective relationships, as well as take care of himself, with his with daily school transportation of his grandchild. Accordingly, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and entitlement to a disability rating in excess of 50 percent disabling for PTSD is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for prostate hypertrophy, to include as secondary to service-connected prostate cancer, is remanded. By a December 2020 rating action, the AOJ proposed to sever the Veteran’s entitlement to the award of service connection for prostate cancer. There is no indication that the AOJ has rendered a final decision on the proposed severance of the award of service connection for prostate cancer. Thus, the Board finds that the claim of entitlement must be deferred until the AOJ completes action on its proposed severance of the award of service connection for prostate cancer. Hence, the Board does not have jurisdiction over these issues, and the AOJ is requested to take appropriate action to complete this issue. The Board notes that whether the AOJ determines whether to sever its award of service connection for prostate cancer will affect the outcome of the Board’s adjudication of the Veteran’s claim for entitlement to service connection for prostate hypertrophy, to include as secondary to service-connected prostate cancer. Therefore, the issues are inextricably intertwined. A remand of the claim of entitlement to service connection for prostate hypertrophy, to include as secondary to service-connected prostate cancer is required. 2. Entitlement to a compensable rating for calculus, left ureter, for the time period prior to March 11, 2020, and a 20 percent rating thereafter, is remanded. As noted above, the Board has awarded service connection for bladder cancer and his award of service connection for prostate cancer is proposed to be severed. In addition, the Veteran is service-connected for calculus of the left ureter. For diseases involving the genitourinary system, the predominant area of dysfunction shall be considered for rating purposes. DC 7515 (bladder calculus), DC 7527 (prostate gland injuries) and DC 7517 (bladder injury) all include potential ratings for voiding dysfunction. The Board must defer this issue pending the initial rating assigned for bladder cancer residuals. However, on remand, the AOJ should provide a more specific explanation for the basis for the staged rating for left ureter calculus residuals during the appeal period. The matters are REMANDED for the following action: 1. Complete the adjudication of the proposed severance (either severing or declining to sever) of the award of service connection for prostate cancer, and award an initial rating and effective date of award for residuals of bladder cancer. (continued on the next page) 2. The AOJ should then review the record and readjudicate the claims. If a staged rating for left urethral calculi remains in effect, the AOJ should specifically explain the basis for the staged rating given the Veteran’s similar report of urinary frequency prior to March 2020 (reported as daytime void between 2 to 3 hours and nocturia times 2 (VA examination dated January 2014), nocturia 3 to 4 times a night (January 2014 Notice of Disagreement), urinary frequency of 5 to 6 episodes per day (May 2015 private treatment records), and daytime voiding 1 to 2 hours and nocturia times 2 (VA examination dated December 2015). If the claim remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his attorney opportunity to respond, and return the case to the Board. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael J. O’Connor 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.