Citation Nr: 21065253 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 17-36 814 DATE: October 25, 2021 ISSUES 1. Whether new and material evidence has been received to reopen the claim for service connection for a neck disability. 2. Entitlement to service connection for a neck disability. 3. Entitlement to service connection for a skin disability. 4. Entitlement to an initial disability evaluation in excess of 30 percent for ischemic heart disease (IHD) prior to August 1, 2019. 5. Entitlement to an initial disability evaluation in excess of 60 percent for ischemic heart disease (IHD) from August 1, 2019. 6. Entitlement to an initial disability evaluation in excess of 30 percent for post-traumatic stress disorder, previously rated as unspecified anxiety disorder and depressive disorder. 7. Entitlement to an initial compensable evaluation for bilateral hearing loss disability prior to February 3, 2020. 8. Entitlement to an initial disability evaluation in excess of 10 percent for bilateral hearing loss disability from February 3, 2020. 9. Entitlement to service connection for a sleep disability. 10. Entitlement to service connection for a respiratory disability. 11. Entitlement to service connection for an artery disability. 12. Entitlement to service connection for a left knee disability. 13. Entitlement to service connection for a right hip disability. 14. Entitlement to service connection for a left hip disability. 15. Entitlement to an earlier effective date prior to July 15, 2013 for the grant of total disability rating based upon individual unemployability. ORDER New and material evidence sufficient to reopen the claim of service connection for a neck disability has been received, and to that extent only, the claim is granted. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a skin disability is denied. Entitlement to an initial disability evaluation in excess of 30 percent for ischemic heart disease (IHD) prior to August 1, 2019 is denied. Entitlement to an initial disability evaluation in excess of 60 percent for ischemic heart disease (IHD) from August 1, 2019 is denied. Entitlement to an initial disability evaluation in excess of 30 percent for post-traumatic stress disorder, previously rated as unspecified anxiety disorder and depressive disorder is denied. Entitlement to an initial compensable evaluation for bilateral hearing loss disability prior to February 3, 2020 is denied. Entitlement to an initial disability evaluation in excess of 10 percent for bilateral hearing loss disability from February 3, 2020 is denied. REMANDED Entitlement to service connection for a sleep disability is remanded. Entitlement to service connection for a respiratory disability is remanded. Entitlement to service connection for an artery disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to an earlier effective date prior to July 15, 2013 for the grant of total disability rating based upon individual unemployability is remanded. FINDINGS OF FACT 1. A May 1972 rating decision denied service connection for spondyloschisis, L5-S1. The implicit denial was for all neck and back pathology. The Veteran was notified of his rights, but did not express timely disagreement or submit new evidence within one year. That decision became final. 2. The evidence associated with the record since the May 1972 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a neck disability. 3. A neck disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 4. A skin disability was not manifest in service and is not otherwise attributable to service. 5. Prior to August 1, 2019, ischemic heart disease (IHD) was manifested by clinical results disclosing a workload of greater than five METs but not greater than seven METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; with additional symptoms of continuous medication required, left ventricular dysfunction with an ejection fraction of more than 50 percent, no acute episodes of congestive heart failure in the past year, and no evidence of cardiac hypertrophy dilation shown by testing. 6. From August 1, 2019, ischemic heart disease (IHD) was manifested by clinical results disclosing a workload of greater than three METs but not greater than five METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope; with additional symptoms of continuous medication required, left ventricular dysfunction with an ejection fraction of more than 50 percent, and no evidence of cardiac hypertrophy or dilation shown by testing. 7. For the entire period on appeal, post-traumatic stress disorder, previously rated as unspecified anxiety disorder and depressive disorder, has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; with such symptoms as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. Occupational and social impairment with reduced reliability and productivity was not demonstrated. 8. Prior to February 3, 2020, the Veteran demonstrated at worst, level I sensorineural hearing loss in the right ear, and level I in the left ear. 9. From February 3, 2020, the Veteran demonstrated at worst, level V sensorineural hearing loss in the right ear, and level III in the left ear. CONCLUSIONS OF LAW 1. New and material evidence sufficient to reopen the claim of service connection for a neck disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 2. A neck disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. A skin disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for a disability evaluation in excess of 30 percent disabling for ischemic heart disease (IHD) prior to August 1, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.104, 4.3, Diagnostic Code 7005. 5. The criteria for a disability evaluation in excess of 60 percent disabling for ischemic heart disease (IHD) from August 1, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.104, 4.3, Diagnostic Code 7006. 6. For the entire period on appeal, the criteria for the assignment of an initial disability rating in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD), previously rated as unspecified anxiety disorder and depressive disorder, have not been met or been approximated. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 7. Prior to February 3, 2020, the criteria for a compensable evaluation for bilateral hearing loss disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100. 8. From February 3, 2020, the criteria for a disability evaluation for bilateral hearing loss disability in excess of 10 percent have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1969 to February 1972. His awards and decorations include the Bronze Star. This matter is before the Board of Veterans Appeals (Board) on appeal from a July 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Next, in a January 2017 rating decision, the Agency of Original Jurisdiction (AOJ) assigned an earlier effective date of July 15, 2012, for the grant of service connection for ischemic heart disease. The AOJ also granted service connection for right ear hearing loss and assigned a noncompensable evaluation for bilateral hearing loss disability, effective from July 15, 2013. The issues were eventually remanded by the Board in June 2019 for additional development. The Board observes that as separate matters, the Veteran submitted a June 2021 Brief alleging Clear and Unmistakable Error (CUE) with respect to the effective dates for ischemic heart disease (IHD) and post-traumatic stress disorder (PTSD) issues. These issues were later adjudicated by the RO in a September 2021 rating decision. This rating decision was issued under the Appeals Modernization Act (AMA) and is distinct from the instant legacy appeals stream. These CUE issues are not before the Board at this time. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Veteran and his attorney were reminded of the critical evidentiary requirements necessary to substantiate his claims by way of a March 2021 Supplemental Statement of the Case (SSOC). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000).' Finality of Service Connection Claim 1. Whether new and material evidence has been received to reopen a claim for service connection for a neck disability The Board incorporates its discussion from the sections above by reference. By way of procedural history, a May 1972 rating decision denied service connection for spondyloschisis, L5-S1. The implicit denial was for all neck and back pathology. The Veteran was notified of his rights, but did not express timely disagreement or submit new evidence within one year. That decision became final. At the time of the decision, the record included the claims and the service records. There was no accepted evidence of accepted disability for VA purposes in service or post service. There was no evidence of a nexus to service. However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." See id. In July 2013, VA received the Veteran's application to reopen the claims of service connection for neck and spinal disabilities. The Board remanded the new and material evidence issues for the neck and back in June 2019. Later, the Board observes that a March 2021 rating decision granted service connection for a back disability, granted as L5 spondylolisthesis at L5-S1 with degenerative arthritis with an evaluation of 20 percent effective July 15, 2013. This distinct neck disability claim remained denied, as discussed in the March 2021 SSOC. The additional evidence presented includes post-service treatment reports from hospitals and medical centers, in addition to VA examinations. The law has also changed with respect to impairment due to pain. Indeed, evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (2018). The evidence establishes that the Veteran has neck impairment resulting in disability. As a lack of evidence supporting the presence of disability was one of the bases for the previous denial of the claim, this evidence is new and material under 38 C.F.R. § 3.156. In light of this new and material evidence, the Veteran's claim of service connection for a neck disability is reopened. Service Connection To establish service connection a Veteran must generally 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). 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). We note that arthritis is a chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as "chronic." See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 2. Entitlement to service connection for a neck disability 3. Entitlement to service connection for a skin disability The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a February 1972 Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the head, face, neck, and scalp, neurologic system, and spine, other musculoskeletal system. The separation examination also disclosed a clinically normal evaluation of the skin, lymphatics. Next, in June 2019, the Board remanded both of these issues for additional development. The reason for remand of these issues is not specifically addressed by Board counsel or the VLJ. Although private and SSA records were requested, the list of issues on appeal related to this request does not include the neck disability. Still, Social Security Administration (SSA) records were generally requested. The ongoing treatment records from the SSA received in December 2019 show that the Veteran has been adjudicated as disabled since September 9, 2008 with "CAD; S/P MI, PTCA WITH MULTIPLE STENTS." A secondary diagnosis is affective disorders. The included medical literature shows that the Veteran suffered from an injury at work on September 9, 2008. He experienced a rib roll, injuring his right shoulder, neck, and back. A Diagnostic Radiology Report from Boone Memorial Hospital located on page 105 of 134 of one of the sets of SSA records shows that the Veteran was in a mining accident and had neck trauma and pain. The impression was of mild degenerative changes of the cervical spine, with no acute fracture or malalignment. The issue remained a nexus. Later, the Veteran was afforded a battery of February and April VA examinations, including a VA neck and VA skin conditions examination with Disability Benefits Questionnaire (DBQ) and medical opinions. First, the Veteran was afforded a February 2021 VA neck conditions examination. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner identified neck pathology with a date of onset of 2008. The Veteran reported the onset of the conditions to 1972, when he was told to hold a 200 pound rack, which caused him severe neck and back pain. In the related medical opinion, the VA examiner ultimately rendered a negative nexus opinion, implicitly encompassing all theories of direct and presumptive service connection. The VA examiner reasoned: During service, the Veteran's injury involving his neck was acute only. He had mention of pain following injury, however no evidence of a chronic neck condition is noted on the Veteran's separation examination or for many years after separation from service. The Veteran had two injuries to his neck that occurred after separation from active duty and the Veteran was evaluated and given a disability rating related to the employment related neck injuries. There is no evidence that the Veteran had a chronic neck condition that began during active duty service. A nexus is not established. The April 2021 VA neck DBQ is substantially the same. Turning to the skin disability, the February 2021 VA examiner performed a complete physical examination. The VA examiner identified actinic keratosis with a date of onset of 2008 and skin cancer from 2008. The medical history from the Veteran includes skin cancer from 2008 on the left forearm and left lateral canthus of the eye, and actinic keratosis from 2008 over the face, trunk, and extremities. In the related medical opinion, the VA examiner ultimately rendered a negative nexus opinion, implicitly encompassing all theories of direct and presumptive service connection. The VA examiner explained: Veteran had no evidence of skin cancer or actinic keratosis during active duty service. The Veteran was treated one time for a skin rash in 1971 without evidence of residuals. There was no evidence of a skin condition noted on the Veteran's separation examination. Dermatology treatment records note diagnosis of actinic keratosis and skin cancer more than 30 years after separation from active duty service. There is no evidence that supports a skin condition that began during active duty service. The rash during service was acute only. A nexus is not established. Additional VA and private treatment records are substantially the same. The Veteran contends that he is entitled to service connection for a neck disability and a skin disability. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report pain in his neck and observing lesions on his left arm and trunk. The Veteran is also competent to relate what he has been told by a professional. He is competent to report when he was diagnosed with neck and skin disabilities. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of any arthritis is not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records, including the STRs, and the medical opinions of the February 2021 VA examiner. First, the STRs do not show any neck or skin disability, including any neurological manifestations. The separation examination was clinically normal for the spine, other musculoskeletal system, neurologic system, and skin. Any in-service neck or skin complaints were acute, transitory, and resolved without residuals. Years later, as documented in the VA examinations, neck and skin pathology first manifested in 2008. This is largely consistent with the Veteran's own lay history. The various treatment records obtained from the Social Security Administration (SSA) demonstrate that the Veteran suffered a mining accident at work in September 2008. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the comprehensive medical opinions of the February 2021 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. The VA examiner rendered negative nexus opinions for all theories of direct and presumptive service connection for neck and skin, which considered all neurological manifestations. The negative nexus opinions are supported by the evidence in the claims file, as cited to by the VA examiner. The VA examiner highlighted that the Veteran's own lay history placed the onset of disability to after separation. Any reference by the Veteran to a neck injury in 1972 was acute only, resolving without chronic residuals. The VA examiner noted other factors. For the neck, the VA examiner described, "The Veteran had two injuries to his neck that occurred after separation from active duty and the Veteran was evaluated and given a disability rating related to the employment related neck injuries." For the skin, the examiner utilized her medical expertise and opined, "The Veteran was treated one time for a skin rash in 1971 without evidence of residuals. There was no evidence of a skin condition noted on the Veteran's separation examination. Dermatology treatment records note diagnosis of actinic keratosis and skin cancer more than 30 years after separation from active duty service." The negative nexus opinions that followed are supported by additional reasons and bases citing to evidence in the claims file. Therefore, we assign substantial probative weight to the negative nexus opinions of the February 2021 VA examiner. Regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Neck and skin disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being told by his physician that he has a diagnosis of skin cancer, actinic keratosis, and cervical disc herniation and cervical osteophytes, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of chronic conditions many decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and April 2021 medical opinions does not demonstrate such continuity. The February 2021 VA examiner described the Veteran's medical history showing the remote onset of the claimed disease entities several decades after separation. Consequently, we find that service connection on a direct and presumptive basis for neck and skin disabilities is not warranted. We have also considered the Veteran's lay statements to the extent that he is competent to relate current pain in the neck. However, they are outweighed by the medical evidence of record. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Later, in Wait v. Wilkie, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause "functional impairment of earning capacity," and therefore meet the current disability requirement under Saunders. Wait v. Wilkie, 33 Vet. App. 8, 2020 U.S. App. Vet. Claims LEXIS 1609, 2020 WL 5200689. The CAVC held that, to meet the current disability requirement under Saunders, "there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." The CAVC clarified that the Board must make the factual determination whether the appellant's manifestations rise to the level of a functional impairment in earning capacity. Such is not the case as the most probative medical evidence of record weighs against a finding of the claimed disabilities manifesting in service or within one year from separation. In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the findings of the February 2021 VA examiner. The VA examiner reviewed the STRs, VA treatment records, private treatment records, and considered the Veteran's lay history. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. The most probative evidence establishes the remote onset of any neck and skin impairment. Additionally, we considered Saunders for all theories of entitlement. We note other, post-service factors, as highlighted in the SSA records and cited by the VA examiner. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for neck and skin disabilities is not warranted. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. 4. Entitlement to an initial disability evaluation in excess of 30 percent for ischemic heart disease (IHD) prior to August 1, 2019 5. Entitlement to an initial disability evaluation in excess of 60 percent for ischemic heart disease (IHD) from August 1, 2019 The Board incorporates its discussion from the sections above by reference. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability rating has been previously staged. As discussed below, a staged rating is still warranted. IHD is currently assigned a 30 percent rating prior to August 1, 2019, and 60 percent thereafter. For the first stage, IHD was evaluated under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). From August 1, 2019, the disability is evaluated under DC 7006 for myocardial infarction, and with a history of myocardial infarction. We find these diagnostic codes are still fitting, and neither the Veteran nor his attorney have contended otherwise. There is also a brief period from April 4, 2019 of a 100 percent disability evaluation due to a retroactive increase under 38 C.F.R. § 3.105(a) which is not on appeal because he is already in receipt of the maximum rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). Under DC 7005, a 30 percent rating is warranted for workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Under DC 7006, a 60 percent rating is warranted for a history of more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. By way of evidentiary history, the Veteran was afforded a series of May 2014 VA examinations, including an IHD Disability Benefits Questionnaire (DBQ). Upon clinical examination, the VA examiner identified the Veteran's METS level to be 7 and an ejection fraction of 60 percent. This was verified through myocardial perfusion testing. Later, evidence from Stanton Cardiology Center shows that the Veteran suffered a myocardial infarction on April 4, 2019. Additional medical records from Stanton Cardiology show an ejection fraction of 50 percent on July 22, 2019. The Board observes these were submitted with a batch of records from the Veteran's attorney in September 2019. Next, the Veteran was afforded a January 2020 VA examination. He reported current symptoms include intermittent, unprovoked, dull chest pain on left side and shortness of breath with any mild activity. He was prescribed Plavix, Aspirin, Imdur, Losartan, Nitroglycerine, and Ranolazine for heart disease. There was no evidence of cardiac hypertrophy or dilatation based on echocardiogram results of January 24, 2020. His left ventricular ejection fraction was measured at 50 to 55 percent. The VA examiner estimated the Veteran's METs at 3 to 5 based on his report of dyspnea, fatigue, and angina with activities consistent with light year work, mowing the lawn, and brisk walking. This METs level is solely due to the heart condition. Later that year, the September 2020 rating decision found a clear and unmistakable error and assigned a retroactive 100 percent rating for IHD from April 4, 2019. In other words, VA has now already provided a temporary 100 percent disability rating for three months following this event in accordance with the rating schedule. This is the highest schedular evaluation allowed under the law for this stage. Additional VA and private treatment records are substantially the same. The Veteran contends that he is entitled to an increased rating for ischemic heart disease, status post myocardial infarction. Ischemic disease, status post myocardial infarction is currently assigned a 30 percent rating prior to prior to August 1, 2019, exclusive of the period in which he is in receipt of a total rating. The 30 percent evaluation prior to contemplates evidence on clinical examination of a workload of greater than five METs but not greater than seven METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; with additional symptoms of continuous medication required, left ventricular dysfunction with an ejection fraction of more than 50 percent, no acute episodes of congestive heart failure in the past year, and no evidence of cardiac hypertrophy dilation shown by testing. In order to have a higher evaluation, there must be more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. This is not the case here, as the most probative evidence does not demonstrate such severe impairment or symptomatology. For this stage, the most probative evidence is the findings of the May 2014 VA examination, presenting a consistent picture of the Veteran's ischemic heart disease. In relevant part, the examination revealed that the Veteran's METS level was 7 and an ejection fraction of 60 percent. This fits within the 30 percent criteria for a workload of greater than 5 METs but not greater than 7 METs. The evidence also establishes an ejection fraction of more than 50 percent. DC 7005. This was verified through myocardial perfusion testing. Prior to August 1, 2019, VA has already applied the highest rating allowed under the rating schedule and the specific rating criteria. The severity of the Veteran's disability is most closely approximated by the current 30 percent rating. Indeed, there is no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or substantially lower METs. We have considered that the Board should afford the Veteran the benefit of the doubt. Nevertheless, a disability evaluation in excess of 30 percent prior to August 1, 2019 is not warranted. Turning to the period from August 1, 2019, there was evidence of a change in the severity of the disability. Prior to this, a total evaluation was continued for three months following myocardial infarction. Thereafter, the disability is rated on cardiovascular residuals according to symptomatology and currently assigned a 60 percent rating from August 1, 2019. 38 C.F.R. § 4.104, DC 7006. The 60 percent evaluation contemplates evidence of a workload of greater than three METs but not greater than five METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope; with additional symptoms of continuous medication required, left ventricular dysfunction with an ejection fraction of more than 50 percent, and no evidence of cardiac hypertrophy or dilation shown by testing. In order to have a higher evaluation, there must be chronic congestive heart failure, or; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. That is not the case here, as the most probative evidence does not show such severe impairment. Here, the most probative evidence is the findings of the January 2020 VA examination, presenting a comprehensive picture of the Veteran's disability. IHD, status post myocardial infarction is most closely approximated by the current 60 percent rating from August 1, 2019 based upon left ventricular ejection fraction measured at 50 to 55 percent, and METs at 3 to 5 based on his report of dyspnea, fatigue, and angina with activities consistent with light year work, mowing the lawn, and brisk walking. The VA examiner indicated that this METs level is solely due to the heart condition. See 38 C.F.R. § 4.104, DC 7006. These findings are generally within the same range as the medical records dated July 22, 2019 from Stanton Cardiology showing an ejection fraction of 50 percent. There is no probative evidence establishing chronic congestive heart failure, a workload of 3 METs or less, or a LVEF of less than 30 percent. In reaching these conclusions during the respective stages, the Board has sympathetically considered the rating criteria for each stage. The current 30 and 60 percent disability evaluations most closely approximate the severity of IHD during the respective stages. We have found the VA examination results to the be the most probative evidence of record. Although the Veteran has continued to pursue his appeal, VA has applied the highest ratings allowed under the rating schedule and specific criteria. See 38 C.F.R. § 4.104, DCs 7005, 7006. There is no probative evidence of chronic congestive heart failure or a workload of three METs or less, such that a higher rating during these stages would be warranted. The weight of the evidence is against the assignment of a rating in excess of the currently assigned 30 percent rating prior to August 1, 2019 and 60 percent thereafter, exclusive of the period of a total rating based on myocardial infarction. Therefore, increased disability ratings for IHD are not warranted at any time during the appeals period. 6. Entitlement to an initial disability evaluation in excess of 30 percent for post-traumatic stress disorder, previously rated as unspecified anxiety disorder and depressive disorder The Board incorporates its discussion from the sections above by reference. In the instant case, PTSD previously rated as unspecified anxiety disorder and depressive disorder is currently rated at 30 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. As an initial matter, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability rating has not been staged. As discussed below, a uniform evaluation is still warranted. DC 9411 and other DC's addressing psychiatric disabilities are addressed under the General Rating Formula for Mental Disorders. Ratings are assigned according to the manifestation of particular symptoms. A 30 percent rating is warranted for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; 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); inability to establish and maintain effective relationships. A rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms 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; memory loss for names of close relatives, own occupation, or own name. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The such symptoms as language means for example, and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Veteran and his attorney assert that the 30 percent initial rating for PTSD does not accurately depict the severity of the disability. They assert that the Veteran is entitled to an increased evaluation. By way of evidentiary history, the Veteran was afforded a May 2014 VA Initial PTSD examination with Disability Benefits Questionnaire (DBQ). The Veteran arrived on time for his appointment and was neatly groomed. The VA examiner documented a social history for the Veteran. He his close to his daughter and youngest son but does not see his eldest son much. He attends church weekly as much as he can, but does not like being around groups. He goes hunting and fishing with his grandsons as often as he can, but he has lost interest doing anything social beyond his immediate family. His health issues have caused him to slow down a lot and he is not able to hunt and fish as much as in the past. Next, the VA examiner identified symptoms of depressed mood, anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The VA examiner indicated that the Veteran's psychiatric disorder is best summarized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Years later, in January 2020, the Veteran was afforded another Initial PTSD Disability Benefits Questionnaire (DBQ). Upon clinical examination, the VA examiner diagnosed PTSD pursuant to the DSM-V. The VA examiner documented that the Veteran takes Zoloft and Wellbutrin. The Veteran reported that his wife passed away last year. His daughter and oldest son along with two grandsons live with him. The VA psychologist indicated that PTSD is best summarized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA psychologist went on to identify symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. Regarding his behavioral, the VA examiner wrote that the Veteran was appropriate with dress and hygiene. Regarding the procedural posture, the March 2021 Supplemental Statement of the Case (SSOC) clarified in part: It is unclear why a diagnosis of PTSD was not given at that time [of the May 2014 VA examination]. The examiner did discuss the presence of subclinical PTSD symptoms; however, again, you do meet full criteria for PTSD under DSM-V criteria. The examiner opined that the PTSD is at least as likely as not caused by in-service stressors. Thus, service connection is granted. The disability takes the place of the previous diagnosis of unspecified anxiety disorder and depressive disorder (38 C.F.R. § 38 C.F.R. § 4.13). Additional VA and private treatment records are substantially the same. The issue at bar is the initial rating of now-diagnosed PTSD. The Veteran through his attorney contends that he is entitled to an initial evaluation in excess of 30 percent for PTSD. Generally, the Veteran is competent to report his feelings, including anxiety, sleep impairment, and depressed mood. He is competent to report that he has been diagnosed with PTSD with and previously unspecified anxiety disorder with depressive disorder. The Veteran competently endorsed symptoms of difficulties related to his mood, physical limitations, and social interaction. The Board assigns significant probative weight to the Veteran's lay reports of his symptoms, including those exhibited at the time of the VA examinations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). PTSD is currently rated at 30 percent across the appeals period under Diagnostic Code (DC) 9411, 38 C.F.R. § 4.130. This was based upon occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The weight of competent lay and medical evidence demonstrates that a higher evaluation is not warranted. A higher evaluation is not warranted unless there is occupational and social impairment with reduced reliability and productivity due to such symptoms 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; difficulty in establishing and maintaining effective work and social relationships. In reaching a decision, the Board has considered the Veteran's lay reports of avoiding crowds and some isolative behavior. The Board has found these reports credible. The Board finds the most probative evidence to be the relatively recent January 2020 VA examination. This is the examination that identified PTSD. It also contains more symptoms than the earlier May 2014 VA examination, although the overall level of occupational and social impairment remained the same. At the VA examination, the VA psychologist indicated that PTSD is best summarized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. While competent and credible, the lay histories also do not suggest a higher rating is warranted. The Veteran reported that his wife passed away last year. Some of his children live with him. In other words, although he socially isolates, he still has a relationship with his immediate family. The VA psychologist identified depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. Nevertheless, the Veteran was appropriate with dress and hygiene. The Board assigns significant probative weight to the findings of the VA psychologist. The Board finds that the evidence of record, taken together, describes a consistent picture of symptomatology associated with the Veteran's PTSD. The highly probative January 2020 VA examination results paint a comprehensive picture of the Veteran's disability. The Veteran has consistently denied suicidal ideation. His speech was been normal. There was no evidence of thought disturbance or auditory verbal hallucinations. The examination did not show consistent symptoms such as impaired judgment, circumstantial, circumlocutory, or stereotyped speech, more frequent panic attacks, and neglect of hygiene. Such findings are relatively consistent with the May 2014 VA examination results from years earlier. They most closely approximate the criteria for a 30 percent disability rating. There is no other probative evidence that the Veteran's anxiety, depressed mood, and sleep disturbance are of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating than the current 30 percent evaluation. See Bankhead v. Shulkin, No. 15-2404, slip op. at 10 (U.S. Vet. App. Mar. 27, 2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). There is no doubt to resolve. Consequently, the preponderance of the evidence is against the assignment of a rating in excess of the 30 percent rating for PTSD. 7. Entitlement to an initial compensable evaluation for bilateral hearing loss disability prior to February 3, 2020 8. Entitlement to an initial disability evaluation in excess of 10 percent for bilateral hearing loss disability from February 3, 2020 The Board incorporates its discussion from the sections above by reference. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability rating has been previously staged. As discussed below, a staged rating is still warranted. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Under the applicable criteria disability ratings are determined by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from 0 percent to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. The vertical lines in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. See 38 C.F.R. § 4.85. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. The percentage evaluation is found from Table VII by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. For example, if the better ear has a numeric designation Level V and the poorer ear has a numeric designation Level VII, the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies of: 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86 (a), (b). The Veteran contends that he is entitled to a compensable disability evaluation for bilateral hearing loss disability prior to February 3, 2020, and in excess of 10 percent thereafter. DC 6100. By way of probative evidentiary history, the Veteran was afforded a June 2014 VA audiological examination with Disability Benefits Questionnaire (DBQ). On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follow: HERTZ 1000 2000 3000 4000 Average RIGHT 10 15 55 55 33.75 LEFT 10 10 45 60 31.25 The average decibel loss is 33.75 in the right ear. The average decibel loss is 31.25 in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The VA examiner indicated that use of speech discrimination score is appropriate for this Veteran. The Board has considered the data obtained from the three available frequencies and their related puretone averages. From Table VI of 38 C.F.R. § 4.85, Roman Numeral I is derived for the right ear and Roman Numeral I for the left ear when intersecting the percent of speech discrimination row with the puretone threshold average column. A 0 percent, noncompensable evaluation is derived from Table VII by intersecting row I, the left ear, with column I, the right ear. The evaluation for hearing loss is based on objective testing. Higher evaluations are assigned for more severe hearing impairment. Application of these findings to Table VII corresponds to a noncompensable rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. The Board also considered the provisions of 38 C.F.R. § 4.86 governing exceptional patterns of hearing impairment. Next, in relevant part, the Veteran was afforded a February 3, 2020 VA audiological examination. As a related matter, we note that this is the date when there was evidence of a change in the severity of bilateral hearing loss disability. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follow: HERTZ 1000 2000 3000 4000 Average RIGHT 35 40 65 65 51.25 LEFT 30 30 65 65 47.50 The average decibel loss is 51.25 in the right ear. The average decibel loss is 47.50 in the left ear. Speech audiometry revealed speech recognition ability of 70 percent in the right ear and of 80 percent in the left ear. The VA examiner indicated that use of speech discrimination score is appropriate for this Veteran. The Board has considered the data obtained from the three available frequencies and their related puretone averages. From Table VI of 38 C.F.R. § 4.85, Roman Numeral V is derived for the right ear and Roman Numeral III for the left ear when intersecting the percent of speech discrimination row with the puretone threshold average column. A 10 percent evaluation is derived from Table VII by intersecting row III, the left ear, with column V, the right ear. The evaluation for hearing loss is based on objective testing. Higher evaluations are assigned for more severe hearing impairment. Application of these findings to Table VII corresponds to a 10 percent rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. The Board also considered the provisions of 38 C.F.R. § 4.86 governing exceptional patterns of hearing impairment. Additional VA and various private treatment records are substantially the same. The Veteran contends that his hearing acuity warrants a compensable disability evaluation for bilateral hearing loss disability prior to February 3, 2020, and in excess of a 10 percent evaluation thereafter. DC 6100. The Veteran is competent to report difficulty hearing. The Board finds these reports credible. The Veteran is competent to provide evidence of that which he experiences, including a history of noise exposure and difficulty hearing. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Here, there are impressions or diagnoses of hearing loss. The Veteran is competent to relate such facts. The Board finds the results of the June 2014 and February 3, 2020 VA audiological examinations to be the most probative evidence of record. The Veteran's lay contentions regarding the severity of bilateral hearing loss disability during the two stages are outweighed by the more probative, objective medical evidence. The currently assigned disability ratings best summarize the objective audiometric test results. Once again, February 3, 2020 is the date when there was evidence of a change in his hearing acuity. VA recognizes the Veteran's belief that he is entitled to increased disability ratings for bilateral hearing loss disability across the two stages. However, the Board is bound to apply the VA rating schedule, under which the rating criteria are defined and limited by audiometric findings. This criteria measures hearing acuity directly in a controlled laboratory environment. There are no probative objective audiometric evaluations to the contrary that would suggest a higher rating is warranted for either stage. See 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. Throughout the lengthy appeals period, the Veteran's attorney has not specifically pointed to any audiometric testing results that establish that a higher rating is warranted under the governing criteria. Consequently, a compensable disability rating prior to February 3, 2020, and a rating in excess of 10 percent thereafter for bilateral hearing loss disability is not warranted. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND In light of the Veteran and his attorney's continued pursuit of the appeals, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a sleep disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the July 2014 rating decision on appeal shows no diagnosed sleep disorder in the VA treatment records. The evidentiary issue remained a diagnosed sleep disability and a nexus. Next, the January 2020 VA Initial PTSD DBQ showed an indication of sleep disturbance. Next, in the March 2021 Supplemental Statement of the Case (SSOC), the RO explained, "The evidence submitted in connection with this claim does not show any stand-alone sleep disorder that is not subsumed by the diagnosis of PTSD. The current 30 percent evaluation contemplates the symptoms of chronic sleep impairment. You do not have a diagnosis for an actual diagnosed sleep disorder." Since the rating decision on appeal, the law governing such circumstances has changed. Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). In Martinez-Bodon v. Wilkie, No. 18-3721CAVC addressed the scope of Saunders, holding that the Federal Circuit's decision is not limited to pain. Rather, the definition of "disability" in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) includes any "condition" that results in "functional impairment of earning capacity," including a psychiatric condition. The CAVC also held that VA has the authority to adopt and apply its rating schedule and has used this authority (in 38 C.F.R. §§ 4.125 and 4.130) to limit compensation for psychiatric disabilities to those with a DSM-5 diagnosis. Nevertheless, it is longstanding law that when it is not possible to separate the effects of a nonservice-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In making such a determination, VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Veteran's sleep impairment is already considered to be a component of PTSD, but it may also be a freestanding disability. Saunders has also liberalized how VA handles the presence of "disability." He has not yet been afforded a VA examination to explore the nature and etiology of the claimed sleep disability despite continuing to pursue his appeal since 2014. To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a VA examination with medical opinion for the claimed sleep disability is necessary. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a respiratory disability is remanded. 3. Entitlement to service connection for an artery disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran was afforded a January 2020 VA Heart Conditions DBQ. The VA examiner diagnosed in part, "Mild to Moderate Aortic stenosis with Calcific disease." The VA examiner identified shortness and breath and discussed it in the answers to the questions at the end. Recently, the March 2021 SSOC reads in relevant part, "Your shortness of breath appears to be attributed to your heart condition." There is no clear source cited for such a medical determination. With respect to the artery disability, there is accepted disability by way of the VA heart examination, however, there is no nexus. Similar to above, with respect to the claimed respiratory disability and under Saunders, there is not yet a VA examination with medical opinion attributing this impairment solely to a heart condition rather than as a standalone disability. See Mittleider, supra. Turning to the claimed artery disability, there is a VA heart examination, but no VA artery or veins conditions DBQ. Indeed, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claims, a set of VA examinations with medical opinions is necessary specifically for these claimed disabilities. 4. Entitlement to service connection for a left knee disability is remanded. 5. Entitlement to service connection for a right hip disability is remanded. 6. Entitlement to service connection for a left hip disability is remanded. The Board incorporates its discussion from the sections above by reference. We note that arthritis and pain as organic disease of the nervous system are recognized chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013. In Wait v. Wilkie, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause "functional impairment of earning capacity," and therefore meet the current disability requirement under Saunders. Wait v. Wilkie, 33 Vet. App. 8, 2020 U.S. App. Vet. Claims LEXIS 1609, 2020 WL 5200689. The CAVC held that, to meet the current disability requirement under Saunders, "there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." By way of background, the Veteran was afforded a February 2021 VA back examination. Under current symptoms, the VA examiner documented, "Significant pain in low back and into right hip. Pain radiates down to right lower leg. Pain is nearly constant but varies in intensity." Next, in the March 2021 SSOC, the RO addressed the presence of remote impairment of the bilateral hips and left knee, however, there was no concrete diagnosis and no nexus. For the hips, the RO accepted VA treatment records showing complaints of right hip pain, in addition to recently documented right hip pain at the 2021 VA examination. The RO attributed this to radiculopathy in the SSOC, however, there is no hip examination to rule out another etiology. Turning to the left knee, the RO accepted a possible left knee injury from a work-related incident, as shown in the SSA records. The issue remained what the RO referred to as an "actual diagnosis." The Board is mindful of Saunders and its progeny. Moreover, the lack of an examination on point means there could still be a definitively diagnosed disability. VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, to fully address the Veteran's contentions, and to assist in fully developing the Veteran's claims, a set of VA examinations with medical opinions for these claimed disabilities is necessary. 7. Entitlement to an earlier effective date prior to July 15, 2013 for the grant of total disability rating based upon individual unemployability is remanded. The TDIU issue is inextricably intertwined with the claims being remanded for additional development. Therefore, a final decision on this issue cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Hence, a remand of this issue is also warranted. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran's VA treatment records, and associate them with the Veteran's claims folder. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any sleep disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of any respiratory disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any artery disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left knee disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 6. Please schedule the Veteran for a VA examination to determine the nature and etiology of any claimed right and left hip disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. (Continued on the next page.) 7. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate Supplemental Statement of the Case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.