Citation Nr: 21061264 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 15-31 507A DATE: October 1, 2021 ORDER Service connection for right ear hearing loss is denied. A compensable initial rating for left ear hearing loss is denied. A compensable initial rating for hypertension is denied. A compensable initial rating for gastroesophageal reflux disease (GERD), prior to February 14, 2020, is denied. An initial rating in excess of 10 percent for GERD, since February 14, 2020, is denied. An initial rating in excess of 20 percent for cervical spine degenerative joints with herniated nucleus pulposus is denied. An initial rating in excess of 10 percent for lumbar spine herniated nucleus pulpous with radiculitis down posterior leg is denied. An initial rating in excess of 10 percent for right knee effusion/degenerative changes is denied. An initial rating in excess of 10 percent for left knee degenerative changes is denied. An initial rating in excess of 50 percent for obstructive sleep apnea (OSA) is denied. An effective date prior to September 25, 2012, for the grant of a 50 percent rating for OSA is denied. An effective date prior to September 25, 2012, for the grant of a 10 percent rating for left knee degenerative changes is denied. REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder not otherwise specified (NOS), prior to September 1, 2015. Entitlement to an initial rating in excess of 70 percent for PTSD with depressive disorder, not otherwise specified (NOS) since September 1, 2015. Entitlement to an effective date prior to September 1, 2015, for the grant of a 70 percent rating for PTSD with depressive disorder NOS. Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU). FINDINGS OF FACT 1. The Veteran served on active duty from December 1994 to November 1997, January 2003 to February 2004, December 2005 to June 2006, June 2006 to October 2007, and from October 2007 to September 2012; he has been rated 100 percent disabled since February 2020. 2. Hearing loss in the right ear is not shown. 3. Left ear hearing loss has been manifested by, at worse, a pure tone threshold average of 36.25 with speech recognition of 88 percent. 4. Hypertension requires continuous medication for control, but diastolic pressures are not predominantly 100 or more, either presently or by history, and systolic pressures are not predominantly 160 or more. 5. Prior to February 14, 2020, GERD was stable and well-controlled with no more than acid reflux occurring when symptomatic. 6. Since February 14, 2020, GERD has been manifested by symptoms of acid reflux, regurgitation, and substernal pain with nausea and vomiting four or more times per year without evidence of considerable impairment of health. 7. A cervical spine disability has been manifested by forward flexion ranging from 35 degrees to 45 degrees with painful movement and without ankylosis or intervertebral disc syndrome (IVDS) warranting physician-prescribed bedrest. 8. A lumbar spine disability has been manifested by painful motion to no less than 70 degrees forward flexion and tenderness to palpation that did not alter gait or spinal contour. 9. A right knee disability has been manifested by painful motion with limitation of flexion to no less than 95 degrees and extension to 0 degrees without instability or subluxation, or a meniscal disorder causing locking, pain, and/or effusion. Ankylosis, impairment of the tibia or fibula, repaired or unrepaired ligament tear, or shin splints have not been shown. 10. A left knee disability has been manifested by painful movement with limitation of flexion to no less than 80 degrees, extension to 0 degrees, and fatigue, weakness, incoordination, and lack of endurance that did not result in further functional loss. Instability or subluxation, a current meniscal disorder, ankylosis, impairment of the tibia or fibula, repaired or unrepaired ligament tear, and shin splints have not been shown. 11. Veteran's OSA requires nightly use of a CPAP machine and causes daytime somnolence. OSA does not result in chronic respiratory failure, carbon dioxide retention, or cor pulmonale, and has not required a tracheostomy. 12. The only claim filed for service connection for OSA and left knee degenerative changes was received in February 2012. Service connection has been in effect \for OSA and left knee degenerative changes since September 25, 2012, the day after the Veteran's discharge from service. CONCLUSIONS OF LAW 1. Right ear hearing loss was not incurred during service. 38 U.S.C. §§ 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2021). 2. The criteria for a compensable initial rating for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code (DC) 6100, and Tables VI, VII (2021). 3. The criteria for a compensable initial rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.104, DC 7101 (2021). 4. Prior to February 14, 2020, the criteria for a compensable initial rating for GERD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Codes (DCs) 7399-7346 (2021). 5. Since February 14, 2020, the criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.114, DCs 7399-7346 (2021). 6. The criteria for an initial rating in excess of 20 percent for cervical spine degenerative joints with herniated nucleus pulposus have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.71a, DCs 5242-5237 (2021); 85 Fed. Reg. 230 (Nov. 30, 2020). 7. The criteria for an initial rating in excess of 10 percent for lumbar spine herniated nucleus pulpous with radiculitis down posterior leg have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.71a, DCs 5243-5237 (2021); 85 Fed. Reg. 230 (Nov. 30, 2020). 8. The criteria for an initial rating in excess of 10 percent for right knee effusion/degenerative changes have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.71a, DCs 5260-5003 (2021); 85 Fed. Reg. 230 (Nov. 30, 2020). 9. The criteria for an initial rating in excess of 10 percent for left knee degenerative changes have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.71a, DCs 5003-5260 (2021); 85 Fed. Reg. 230 (Nov. 30, 2020). 10. The criteria for an initial rating in excess of 50 percent for OSA have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 4.97, DC 6847 (2021). 11. The criteria for an effective date prior to September 25, 2012, for the grant of a 50 percent rating for OSA have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2021). 12. The criteria for an effective date prior to September 25, 2012, for the grant of a 10 percent rating for left knee degenerative changes have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board on appeal of rating decisions issued in October 2012 and March 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was previously before the Board in March 2019, at which time the cervical spine, lumbar spine, left and right knee, hearing loss, hypertension, GERD, and TDIU issues were remanded for further development. The PTSD and OSA rating claims, and the effective date issues, had not yet been certified to the Board at that time. A February 2021 Report of Contact indicated that the Agency of Original Jurisdiction (AOJ) called the Veteran and that during the conversation, he indicated that he wished to withdraw the appeal remanded in March 2019. However, he was advised that he needed to submit the withdrawal request in writing, and no such submission has been received. Therefore, the issues remanded in March 2019 remain on appeal. Service Connection for Right Ear Hearing Loss Service connection may be granted directly as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Hearing loss is recognized by VA as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). Turning to the evidence, a current hearing loss disability in the right ear has not been documented. The March 2012 VA audiological examiner stated that there was no diagnosis for the right ear. While a sensorineural hearing loss in the right ear was diagnosed in September 2014 and January 2015 VA examinations, the test results at those examinations did not meet the criteria for a hearing loss disability under VA regulations. In this respect, hearing loss is considered a disability for VA purposes when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz (Hz) is 40 decibels or greater; when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores, using the Maryland CNC test, are less than 94 percent. 38 C.F.R. § 3.385. Testing results in September 2014 were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 35 25 In the January 2015 VA examination, the pure tone thresholds, in decibels, were reported as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 15 30 30 Speech audiometry revealed speech recognition ability of 96 percent in the right ear in September 2014 and January 2015. A review of treatment notes does not reflect a hearing loss in the right ear more severe than that documented above. A March 2021 audiological evaluation note reported hearing within normal limits in the right ear through 2000 Hz and a mild to moderate sensorineural hearing loss from 3000 to 8000 Hz. Speech discrimination was 100 percent in the right ear, which the audiologist found was consistent with pure tone thresholds. Thus, a hearing loss disability as defined by VA regulations was not clinically found at any time during the appeal period. While the examiners in 2014 and 2015 diagnosed sensorineural hearing loss, the pure tone thresholds and speech discrimination scores at those examinations show that the hearing loss did not rise to the level of a disability for VA rating purposes. Therefore, hearing loss is not currently shown in the right ear. Absent a current diagnosis or functional impairment, there is no disorder for which service connection may be granted. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the medical evidence does not support the claim as there is no present disability. The appeal for service connection for right ear hearing loss is denied. Increased Rating Claims Turning to the applicable laws and regulations, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Left Ear Hearing Loss Service connection in the left ear was granted effective in September 2012, and as discussed above, a hearing loss disability was not present in the right ear at the time, and service connection is not in effect for the right ear. A 0 percent rating was assigned to the left ear disability. Ratings of hearing loss range from 0 percent to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. If impaired hearing is service-connected in only one ear, in order to determine the percentage rating from Table VII, the nonservice-connected ear will be assigned a Roman Numeral designation for hearing impairment of Level I, subject to the provisions of 38 C.F.R. § 3.383, 4.85(f). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, Table VIA, in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. Ratings for hearing loss disability are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level, in decibels (dB) as measured by pure tone audiometric tests in frequencies 1000, 2000, 3000, and 4000 Hertz (Hz). 38 C.F.R. § 4.85, DC 6100. An examination for hearing impairment for VA purposes must include a controlled speech discrimination test (Maryland CNC). To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. At the March 2012 audiological examination, pure tone thresholds in the left ear, in decibels, were as follows: HERTZ 1000 2000 3000 4000 LEFT 15 35 40 55 The average pure tone threshold was 36.25 in the left ear, and speech audiometry revealed speech recognition ability of 88 percent in the left ear at the worst and 96 percent at the best. The September 2014 VA audiological examination revealed pure tone thresholds as below: HERTZ 1000 2000 3000 4000 LEFT 15 25 35 40 The average pure tone threshold was 29 in the left ear, and speech audiometry revealed speech recognition ability of 96 percent in the left ear. In the January 2015 VA audiological examination, the pure tone thresholds in the left ear were as follows: HERTZ 1000 2000 3000 4000 LEFT 10 25 40 45 The average pure tone threshold was 30 in the left ear, and speech audiometry revealed speech recognition ability of 96 percent in the left ear. As the Veteran's right ear has consistently not reflected a hearing loss disability and remains nonservice-connected, the right ear had Level I hearing acuity for rating purposes. For the left ear, the most severe hearing loss was documented in the March 2012 VA examination. Using Table VI, the audiometric test results show hearing acuity of Level II in the left ear. Level I hearing acuity in the right ear combined with Level II hearing acuity in the left ear warrants a 0 percent rating. The Veteran has not submitted any medical evidence indicating that his left ear hearing loss disability is more severe than exhibited at the audiological evaluations of record. The medical evidence indicates that he has been prescribed hearing aids, but there are no audiological test results reflecting a more severe hearing loss disability. A March 2021 VA audiology note shows speech discrimination of 96 percent with pure tone thresholds reported to be consistent with that finding. Therefore, the level of hearing impairment does not support an increased rating. The Board acknowledges the Veteran's assertions with respect to this claim. He can attest to factual matters of which he has first-hand knowledge, such as perceived hearing difficulty; however, a determination of whether his perceived hearing difficulty is an actual loss of hearing acuity due to loss of sensorineural functionality requires appropriate medical testing and is not subject to lay evidence. He has not submitted any competent evidence in support of the claim that reflects a higher rating. Detailed arguments were provided by his attorney during the appeal but were relevant to the impact of the disabilities on the Veteran's employability, rather than to any specific manifestations of the disabilities not documented in medical records and VA examinations. Relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In this regard, the March 2012 VA examination noted the Veteran's hearing loss disability resulted in difficulty hearing. In the September 2014 VA examination, the Veteran described having increased difficulty understanding his wife, even with his hearing aids. The January 2015 VA examiner indicated that the Veteran had difficulty understanding speech, especially in noise. Therefore, there is no prejudice to in that the functional effects of his hearing loss disability were adequately addressed by the examiner. Hypertension Hypertension is rated as noncompensable pursuant to DC 7101, which provides a 10 percent rating where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure of predominantly 100 or more requires continuous medication for control. A March 2012 VA General Medical examination noted mild hypertensive blood pressure. Blood pressure readings were 136/78, 132/75, and 139/80. In a January 2015 VA examination, it was noted that the Veteran began taking medication in 2012 and that there had been no change in medication. There was no history of diastolic blood pressure to predominantly 100 or more. Blood pressure readings at the examination were 124/82, 132/70, and 122/64. In a February 2020 VA examination, the Veteran's hypertension was noted to be well-controlled on lisinopril. The blood pressure readings were 132/68, 132/68, and 134/71. A review of treatment notes does not reveal diastolic readings of 100 or more, or systolic readings of 160 or more. Further, while the Veteran has taken medication continuously since being diagnosed with hypertension in 2012, his medical history does not reflect a diastolic pressure of predominantly 100 or more. Therefore, the medical evidence does not support a higher rating at any time during the appeal period. GERD Prior to February 14, 2020, GERD was rated at 0 percent under DCs 7399-7346 for acid reflux associated with hiatal hernia. Effective February 14, 2020, the rating assigned was increased to 10 percent. The Board will consider all relevant diagnostic codes. Under the relevant regulations, a higher rating will be warranted when the objective medical evidence shows the following: Two or more of the below symptoms (10 percent under DC 7346); persistently recurrent epigastric distress that is productive of considerable impairment of health, with symptoms to include: dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. (30 percent under DC 7346). Prior to February 14, 2020. In a March 2012 General Medical VA examination, the Veteran reported his only symptom was acid reflux, which was precipitated by lying down after eating, eating late in the day, and not taking his medication. He denied flare-ups. A review of treatment notes revealed no additional symptoms of GERD, which was reported as stable. Accordingly, a compensable rating is not warranted for GERD prior to February 14, 2020. In a January 2015 VA examination, the Veteran reported that his symptoms were controlled with omeprazole and that the disability would flare, causing reflux and heartburn, only when he did not take his medication. There was no esophageal stricture or spasm, and no diverticulum. A compensable rating requires at least two of the following: dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. However, during this period, the only symptom documented was acid reflux, even during flare-ups when he didn't take his medication. Accordingly, a compensable rating is not warranted for GERD for the period prior to February 14, 2020. Since February 14, 2020. In a February 2020 VA examination, the examiner noted symptoms of regurgitation and substernal pain. The Veteran also reported four or more episodes of nausea and four or more episodes of vomiting per year that each lasted less than one day. He continued to take omeprazole. The treatment notes of record do not reflect more severe symptoms. There is no indication that the GERD resulted in considerable impairment of health. The 10 percent rating assigned for this period contemplates the regurgitation and substernal pain reported in February 2020. While the nausea and vomiting are not explicitly listed within the rating criteria, the record does not show that the symptoms cause considerable impairment of health. Accordingly, the medical evidence does not support a higher rating since February 14, 2020. Spine and Knee Disabilities While this appeal was pending, the rating criteria for musculoskeletal disabilities was amended effective February 7, 2021. See 85 Fed. Reg. 230 (Nov. 30, 2020). If the amended criteria are more favorable, the implementation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of the change. If the pre-amended criteria are more favorable, VA can apply the pre-amended criteria for the period prior to and from the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's appeals under the pre-amended criteria prior to February 7, 2021, and both the pre-amended and amended criteria since February 7, 2021. The criteria that is more favorable will be applied. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Cervical and Lumbar Spine. Cervical and lumbar spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (Spine Formula). 38 C.F.R. § 4.71a, DCs 5237-5243. IVDS is rated under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The amended regulations clarify that DC 5243 is to be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. No other changes were made to the rating criteria for the spine. The Veteran's cervical spine disability has been assigned an initial 20 percent rating under DCs 5242-5237, and his lumbar spine disability has been assigned an initial 10 percent rating under DCs 5243-5237. The Board will consider all relevant diagnostic codes. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following: forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent under DC 5237); combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent under DC 5237); muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent under DC 5237); incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent under DC 5243); or in the absence of limitation of motion, degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent under DC 5003). A rating in excess of 20 percent will be warranted when the objective medical evidence shows the following: forward flexion of the cervical spine to 15 degrees or less (30 percent under DC 5237); favorable ankylosis of the entire cervical spine (30 percent under DC 5237); forward flexion of the thoracolumbar spine to 30 degrees or less (40 percent under DC 5237); favorable ankylosis of the entire thoracolumbar spine (40 percent under DC 5237); or incapacitating episodes of IVDS having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent under DC 5243). Cervical Spine In the March 2012 VA General Medical examination, the Veteran had subjective complaints of decreased mobility, severe neck pain, and cramping, without radiation to the arms or hands. Aggravating factors included turning his head to the left, excessive driving/sitting, and lifting excessive weight. He denied flare-ups. Range of motion of the cervical spine was to 45 degrees flexion, 45 degrees extension, 45 degrees left lateral flexion, 35 degrees right lateral flexion, 80 degrees left rotation, and 50 degrees right rotation. The examiner noted objective signs of pain but no muscle spasm. There was no ankylosis. Strength was normal. In a January 2015 VA examination, the examiner diagnosed degenerative arthritis with herniated nucleus pulposus. The Veteran reported tenderness of the left shoulder and left side of the neck. Range of motion testing revealed flexion to 35 degrees, extension to 30 degrees, left and right lateral flexion to 40 degrees each, and left and right rotation to 50 degrees each. There was pain with forward flexion, extension, and left lateral rotation. The examiner found no ankylosis, no guarding, and no muscle spasm. While there was tenderness to palpation, the examiner stated that it did not cause abnormal gait or abnormal spinal contour. Vertebral fracture with loss of height was not present. Strength testing was normal, as were reflexes in the upper extremities. There was normal sensation, and signs of radiculopathy were absent. The examiner indicated that IVDS was present but there was no history of prescribed bedrest. A scar of the neck was well-healed and did not exhibit tenderness or pain. A February 2020 VA examiner documented subjective reports of flare-ups one to three times per month, but the Veteran indicated that they were not debilitating or prostrating. Range of motion testing was to 40 degrees flexion, 25 degrees extension, 45 degrees bilateral flexion, and 80 degrees bilateral rotation. Pain was exhibited with forward flexion and extension. The examiner indicated that range of motion was reduced to 20 degrees flexion, 15 degrees extension, 20 degrees bilateral flexion, and 40 degrees bilateral rotation with flare-ups. There was tenderness to palpation over the cervical region and shoulders, and the examiner observed muscle spasm that did not cause abnormal gait or abnormal spinal contour. Ankylosis and vertebral fracture of the neck were absent. A review of the treatment notes of record does not reveal more severe cervical spine manifestations than those documented in VA examinations. Therefore, the medical evidence does not support an initial rating in excess of 20 percent at any time during the appeal period. The 20 percent rating contemplates the Veteran's forward flexion ranging from 35 degrees to 45 degrees with painful movement. A rating in excess of 20 percent requires forward flexion to less than 15 degrees or ankylosis, neither of which was present. Further, a rating under the Formula for IVDS is not warranted as bedrest for his symptoms was not prescribed by a physician. The Board considered ratings under other applicable diagnostic codes. In this regard, there were no signs of upper extremity radiculopathy to warrant a separate rating for neurological manifestations. See 38 C.F.R. § 4.71a, Spine Formula, Note 1. Moreover, the cervical spine scar was well-healed and not tender or painful. Thus, a separate compensable rating for the scar is not warranted. Accordingly, the medical evidence does not support an initial rating in excess of 20 percent for the cervical spine disability. Lumbar Spine The March 2012 VA General Medical examiner documented reports of severe central back pain that radiated down the left leg. The pain was precipitated by excessive walking, driving, carrying a heavy load, repetitive bending, squatting, and lifting with his legs. The Veteran denied flare-ups. Range of motion of the lumbar spine was to 70 degrees flexion, to 20 degrees extension, and to 40 degrees each bilateral flexion and rotation. Objective pain was noted, but muscle spasm was absent. Strength was normal, and there was no ankylosis. In a January 2015 VA examination, the Veteran described back pain that occasionally radiated down the left leg and that was worse with repetitive or strenuous lifting and bending. He further reported that he experienced flare-ups at least monthly for which he put himself on bedrest. IVDS was noted by the examiner, but no history of physician-prescribed bedrest was documented. Range of motion testing revealed flexion to 70 degrees, extension to 20 degrees, and bilateral flexion and rotation each to 30 degrees. No additional loss of function occurred with repetition. The examiner found no ankylosis, no guarding, and no muscle spasm. While there was tenderness to palpation of the paralumbar region, the examiner stated that it did not cause abnormal gait or abnormal spinal contour. Vertebral fracture with loss of height was not present. Strength testing and reflexes were normal. Sensation was intact, and the straight leg raise was negative. There was mild paresthesias/dysesthesias on the left side. A February 2020 VA examiner documented subjective reports of flare-ups associated with the left leg and increased pain with prolonged standing in excess of 30 to 60 minutes. Range of motion testing revealed flexion to 75 degrees, extension to 15 degrees, and bilateral flexion and rotation to 30 degrees each. There was pain observed with forward flexion and extension, and tenderness to palpation of the lumbar region. Muscle spasm and guarding were not present. Strength, reflexes, and sensory testing were all normal. Straight leg raise was positive on the left only. The examiner noted mild left radiculopathy. IVDS did not require physician-prescribed bedrest. There was no ankylosis or loss of vertebral height in the lumbar spine. The treatment notes of record do not reflect subjective symptoms or objective findings indicative of a more severe lumbar spine disability than described at VA examination. Thus, an initial rating in excess of 10 percent is not warranted. The 10 percent rating contemplates the Veteran's painful motion to no less than 70 degrees forward flexion and tenderness to palpation that did not affect gait or spinal contour. A higher rating is not warranted unless forward flexion is limited to 30 degrees, there is abnormal gait or spinal contour, or the combined range of motion of the lumbar spine was not greater than 120 degrees. None of these manifestations were present at any time during the appeal period. Further, while the Veteran reported putting himself on bedrest to relieve his symptoms, physician-prescribed bedrest is required for a rating under the General Formula for IVDS. Accordingly, a higher rating for IVDS with incapacitating episodes is not applicable. Next, the Board has considered other applicable diagnostic codes. Here, the record reflects that the Veteran has had left leg symptoms throughout the appeal period; however, a separate rating for left lower extremity radiculopathy was granted in an October 2020 rating decision, effective in September 2012. The Veteran did not appeal this rating and further review by the Board is not warranted. Accordingly, the medical evidence does not support an initial rating in excess of 10 percent for the lumbar spine disability. Right and Left Knee Disabilities Throughout the appeal period, the right knee disability was rated at 10 percent under DCs 5260-5003. The left knee disability was rated at 10 percent under DCs 5003-5260. The Board will consider all potentially relevant diagnostic codes. In addition, the Board must contemplate whether separate ratings are warranted for distinct manifestations of the right or left knee disabilities, to the extent allowable by law. Words such as "slight," "moderate," and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Under the pre-amended regulations, a 20 percent rating is warranted when the objective medical evidence shows: moderate recurrent subluxation or lateral instability; dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; flexion of the leg limited to 30 degrees; extension of the leg limited to 15 degrees; or malunion of the tibia or fibula with moderate knee or ankle disability. Under the revised criteria, a 20 percent rating is warranted when the objective medical evidence shows: a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; one of the following: - sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or - unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation flexion of the leg limited to 30 degrees; extension of the leg limited to 15 degrees; or MTSS, or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. Right Knee. Turning to the evidence, in the March 2012 VA General Medical examination, the Veteran had subjective complaints of moderate pain in the right knee with crunching/grinding when bending, and a locking sensation. He indicated that his symptoms were aggravated by climbing stairs and walking long distances. He denied flare-ups of the right knee symptoms. Range of motion was from 0 degrees extension to 120 degrees flexion. Testing for instability and meniscal disorders was negative. Repetition yielded no additional functional loss from pain, weakness, fatigue, or lack of endurance. There was no effusion, edema, instability, redness, heat, abnormal movement, guarding, deformity, malalignment, drainage, or weakness present. A January 2012 right knee X-ray was unremarkable, but a February 2012 MRI showed mild joint effusion with preserved ligaments and menisci. In January 2015, the examiner diagnosed right knee effusion and degenerative changes. Range of motion was from 0 degrees extension to 130 degrees flexion with pain in each direction. No additional loss of function was found with repetition. The Veteran complained of intermittent pain in the right knee with intermittent periods of giving out, more on the left than on the right. He indicated that repetitive bending and stair-climbing caused pain. Muscle strength was normal. There was no ankylosis or instability observed. A September 2019 VA examiner overall documented no deficits of function in the right knee. Range of motion testing revealed extension to 0 degrees and flexion to 140 degrees without pain on movement or weight-bearing. There was no loss of function with repetition. The examiner indicated that the right knee would have no additional symptoms or functional loss with either repeated use over time or flare-ups. No loss of strength was noted, and instability testing was normal. In a February 2020 VA examination, the Veteran described dull pain in the right knee with prolonged use. The disability precluded bending, squatting, and kneeling, and the Veteran related that the right knee had become worse over time and was worse than the left knee. Range of motion in the right knee was from 0 degrees extension to 95 degrees flexion. No additional loss of function was documented for repetition or repeated use over time. Joint instability and strength testing were normal. McMurray's test for meniscal disorders was negative. A review of treatment notes does not reveal symptoms more severe than those found at VA examinations during the appeal period. Accordingly, the Board determines that an initial rating in excess of 10 percent is not warranted for the right knee disability at any time during the appeal period. The 10 percent rating contemplates the Veteran's painful motion with limitation of flexion to no less than 95 degrees. A higher rating for limitation of flexion requires flexion to 30 degrees or less. The Veteran's right knee range of motion far exceeded that measurement throughout the appeal period, even with consideration of painful movement. As noted, while he experienced pain with flexion and extension of the right knee, the pain did not cause additional functional loss. Further, extension was normal and there was no instability or subluxation, and no findings of a meniscal disorder that resulted in locking, pain, and/or effusion. Additionally, ankylosis and impairment of the tibia or fibula were absent. Therefore, a rating in excess of 10 percent for the right knee disability under the pre-revision criteria is not supported by the evidence at any time during the appeal period. The revised criteria effective in February 2021 apply to symptoms and disorder of the ligaments, and symptoms of instability, and shin splints. The medical evidence does not show instability, a repaired or unrepaired ligament tear, or shin splints. Accordingly, a rating in excess of 10 percent under the revised criteria is also not supported by the evidence. Left Knee. In the March 2012 General Medical examination, the Veteran reported moderate pain in the left knee and indicated that the knee gave out while walking. Aggravating factors included riding in the car, excessive walking, and climbing stairs. He had arthroscopic surgery in 2010 and described one flare-up lasting one week. Range of motion was from 0 degrees extension to 140 degrees flexion. Testing for instability and meniscal disorders was negative. Repetition yielded no additional functional loss from pain, weakness, fatigue, or lack of endurance. There was no effusion, edema, instability, redness, heat, abnormal movement, guarding, deformity, malalignment, drainage, or weakness present. A March 2012 left knee X-ray was unremarkable. In the January 2015 VA examination, the Veteran endorsed constant pain in the left knee without swelling or locking. He described intermittent periods of giving out. Range of motion was from 0 degrees extension to 120 degrees flexion. There was pain with flexion and extension, but the examiner indicated that the pain did not result in functional loss. There was no additional functional loss with repetition. Repetitive bending and stair climbing caused pain. Muscle strength was normal. There was no ankylosis and no instability observed. A September 2019 VA examiner documented the Veteran's history of arthroscopy in 2010 with residual pain in the left knee. Range of motion testing revealed extension to 0 degrees and flexion to 90 degrees, causing functional loss with prolonged standing and walking. The examiner noted that both flexion and extension exhibited pain and that there was tenderness to palpation and pain with weight-bearing. There was no additional loss of function with repetition. The examiner indicated that the left knee would have pain, fatigue, weakness, lack of endurance, and incoordination with repeated use over time and flare-ups, but that range of motion would remain 0 to 90 degrees. No loss of strength was noted, and instability testing was normal. In a February 2020 VA examination, the Veteran described instability, poor tracking, and dull pain in the left knee, both intermittent and constant in frequency. Functional loss included the inability to bend, squat, or kneel. He denied flare-ups. Left knee range of motion was from 0 degrees extension to 80 degrees flexion. Pain was noted with flexion. The examiner documented no additional loss with repetition or with repeated use over time. There were no flare-ups described. Strength was normal, and the examiner indicated that there was no joint instability. McMurray's test for meniscal disorders was negative. A left knee scar was well-healed, linear, and non-tender. A review of treatment notes does not reveal symptoms more severe than those documented during the appeal period. Accordingly, the Board determines that am initial rating in excess of 10 percent is not warranted at any time during the appeal period. The 10 percent rating contemplates the Veteran's arthritis which results in painful motion with limitation of flexion to no less than 80 degrees. A higher rating for limitation of flexion requires flexion to 30 degrees or less. The left knee range of motion far exceeded that measurement throughout the appeal period, even with consideration of painful movement. As noted, while he experienced pain, as well as fatigue, weakness, incoordination, and lack of endurance, such manifestations did not result in further functional loss. Further, extension was normal and there was no instability or subluxation, and no findings of a meniscal disorder that resulted in locking, pain, and/or effusion. While the Veteran had a history of a meniscal tear, meniscal testing during the appeal period was negative for any current such disorder. Additionally, ankylosis and impairment of the tibia or fibula were not present. Therefore, an initial rating in excess of 10 percent for the left knee disability under the pre-revision criteria was not supported by the evidence at any time during the appeal period. The revised criteria effective in February 2021 apply to symptoms and disorders of the ligaments, symptoms of instability, and shin splints. While the August 2019 VA examiner noted occasional use of a left knee brace, the medical evidence does not show instability, a repaired or unrepaired ligament tear, or shin splints on the left. Accordingly, the medical evidence does not support a rating in excess of 10 percent under the revised criteria. OSA Service connection for OSA was granted in an October 2012 rating decision, and an initial 0 percent rating was assigned. The Veteran appealed the initially assigned rating, and a 30 percent rating was assigned for the entire appeal period in a January 2013 rating decision with an increase to 50 percent for the entire appeal period being assigned in a March 2016 rating decision. OSA is rated pursuant to DC 6847 which provides for a 50 percent rating when the sleep apnea requires the use of a breathing assistance device such as a CPAP machine. A 100 percent rating is assigned for sleep apnea that causes chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy. The evidence shows that, throughout the rating period, OSA required the use of a CPAP machine every night and caused persistent daytime somnolence. Neither VA examinations nor treatment notes reflect that the sleep apnea resulted in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or that it required a tracheostomy. He has also not alleged any such increased symptomatology. Therefore, the medical evidence does not support a rating in excess of 50 percent. As to all increased rating claims, the Board has considered the Veteran's lay statements that his disabilities are worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's hearing loss, hypertension, GERD, cervical spine, and lumbar spine disorders, and right and left knee disorders has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which the disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and the appeals are denied. Effective Date Claims The assignment of effective dates is governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Generally, if a claim is received within one year of a veteran's separation from service, the effective date will be the date of separation from active duty or the date that entitlement arose. Otherwise, the effective date for an award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase, will be the date of receipt of the claim or the date that entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date of an award based on a claim for increase of compensation "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application." 38 U.S.C. § 5110(a). Increases are effective on the "earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date, otherwise, date of receipt of claim." 38 C.F.R. § 3.400(o)(2). OSA Service connection for OSA was granted in a rating decision issued in October 2012. A noncompensable initial rating was assigned, effective September 25, 2012. In November 2012, the Veteran filed a claim for an increased rating for OSA, which was adjudicated in January 2013. A 30 percent rating was assigned from the date the claim was received. Thereafter, he appealed the October 2012 rating decision with regard to the noncompensable initial rating assigned for OSA. This appeal effectively incorporated the November 2012 claim and January 2013 increase to 30 percent. In March 2016, a rating decision was issued that increased the rating for OSA to 50 percent, effective September 25, 2012. The Veteran then filed a timely appeal with the effective date for this rating. As an initial matter, September 25, 2012, is the date service connection went into effect for OSA. As that date was granted in the October 2012 rating decision and not timely appealed, his disagreement cannot represent a claim for an earlier effective date for service connection. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). Regarding whether an earlier effective date is warranted pursuant to the criteria for effective dates for increased ratings, such is not available. As service connection has been in effect for OSA since September 25, 2012, that is the earliest date from which any rating evaluation may be assigned. There is no legal basis for an earlier date. Accordingly, an effective date prior to September 25, 2012, for the grant of an initial 50 percent rating for OSA is denied. Left Knee The October 2012 rating decision granted service connection for left knee degenerative changes and assigned a noncompensable rating, effective September 25, 2012. The Veteran appealed with regard to the initially assigned rating. In the March 2016 rating decision, an increased rating of 10 percent for the left knee disability was granted, effective January 26, 2015. In May 2017, the Veteran appealed the effective date assigned to the 10 percent rating. In an October 2020 rating decision, a 10 percent rating for the left knee disability was assigned from September 25, 2012. Notably, this rating was assigned in connection with the appeal of the initially assigned rating filed in 2013, not the appeal of the effective date for the increase filed in 2017. Hence, the effective date appeal is still pending. As with the OSA, September 25, 2012, is the date service connection went into effect for the left knee disability. Therefore, there is no earlier effective date available for the assignment of a 10 percent rating, or for any rating evaluation for the left knee disability as the Veteran was on active duty prior to that date. It is unclear on what legal basis the Veteran and his attorney assert an earlier effective date but none is available under the law. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND The most recent adjudication of the Veteran's PTSD rating claim was in a March 2020 statement of the case (SOC). Since that time, additional, relevant VA treatment notes have been added to the claims file. The law provides that if new evidence is submitted with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the veteran explicitly requests AOJ consideration. See Section 501 of the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law 112-154, amended 38 U.S.C. § 7105. The substantive appeal was received in May 2020; however, the above provision only applies to evidence submitted by the Veteran. Thus, he is not presumed to have waived AOJ consideration of the VA treatment notes added to the claims file. Therefore, the appeal is remanded to allow for AOJ adjudication in light of the evidence added to the claims file since the March 2020 SOC. The PTSD effective date and TDIU claims are in part dependent on the outcome of the PTSD rating claim; therefore, the issues are inextricably intertwined with the rating issue, and must also be remanded. The matters are REMANDED for the following actions: 1. Direct the claims file to an appropriate clinician to evaluate the effect of all the service-connected disabilities on the Veteran's employability (the ability to obtain or maintain substantially gainful employment). Specifically, the clinician is directed to assess the extent of functional and industrial impairment resulting from each of the Veteran's service-connected disabilities. A medical, educational, and employment history should be taken into consideration. The Veteran's age and the effects of nonservice-connected disabilities cannot be factors for consideration in making the determination; however, the effects of treatments and medications used to treat the service-connected disabilities should be considered in the opinion. In addition, for any period during which the Veteran was working, the examiner should consider whether the position was in a "protected" work environment or one that provided special accommodation for his disabilities. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. M. Schaefer, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.