Citation Nr: 21065778 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 17-65 421 DATE: October 27, 2021 ORDER Entitlement to an earlier effective date for the grant of service connection for a left elbow condition has been withdrawn and is dismissed. Entitlement to service connection for benign prostatic hypertrophy with bladder neck outlet obstruction (benign prostate hypertrophy), as secondary to chronic prostatitis, is granted. Entitlement to service connection for erectile dysfunction, as secondary to benign prostate hypertrophy, is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an effective date prior to June 26, 2020, for the award of an increased disability rating of 100 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a compensable rating for chronic prostatitis is remanded. Entitlement to a rating in excess of 10 percent for left elbow condition is remanded. FINDINGS OF FACT 1. On July 7, 2021, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that withdrawal of the appeal for an earlier effective date for the grant of service connection for a left elbow condition is requested. 2. The Veteran's benign prostate hypertrophy is caused or aggravated by the Veteran's service-connected chronic prostatitis. 3. The Veteran's erectile dysfunction is caused or aggravated by the Veteran's service-connected benign prostate hypertrophy. 4. The preponderance of the evidence is against finding that the Veteran's current bilateral hearing loss is due to service. 5. The preponderance of the evidence is against finding that the Veteran's current bilateral tinnitus is due to service. 6. The preponderance of the evidence does not show that, prior to June 26, 2020, the Veteran's PTSD was manifested by symptomatology that causes 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. CONCLUSIONS OF LAW 1. The criteria for withdrawal of entitlement to an earlier effective date for the grant of service connection for a left elbow condition by the appellant (or his authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for service connection for benign prostate hypertrophy have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 6. The criteria for an effective date prior to June 26, 2020, for the award of a 100 percent disability rating for PTSD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 to March 1970. These matters come before the Board of Veterans' Appeals (Board) from multiple rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2016 the Board remanded the Veteran's claim for further development. It has now returned to the Board for further appellate review. In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file and has been reviewed. As a threshold matter, as to the issue of entitlement to service connection for benign prostate hypertrophy, secondary to the Veteran's service-connected chronic prostatitis, the Board notes the Veteran filed a VA 21-526EZ, Fully Developed Claim for this condition in April 2018. However, the RO declined to accept the Veteran's filing due to a pending claim for chronic prostatitis. See VA Correspondence, June 2018. For the reasons outlined in this decision, the Board will address the two issues separately. The Board apologies for the confusion. It is also important to note that the Veteran was awarded a 100 percent disability rating for posttraumatic stress disorder (PTSD), effective June 26, 2020. As to the matter of PTSD, the Board is only dealing with the limited outstanding issue that it must address under the law. Importantly, the Board apologizes to the Veteran for the delays in the full adjudication of his claim. Withdrawal 1. Entitlement to an earlier effective date for the grant of service connection for a left elbow condition The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 19.55. On July 07, 2021, prior to the promulgation of a decision in the appeal, the Veteran requested a withdrawal of his claim for entitlement to an earlier effective date for the grant of service connection for a left elbow condition at his Board hearing. The withdrawal request has been documented in the Veteran's claims file. The Board concludes that the Veteran has withdrawn his appeal as to entitlement to an earlier effective date for the grant of service connection for a left elbow condition and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal for entitlement to an earlier effective date for the grant of service connection for a left elbow condition and it is dismissed. SERVICE CONNECTION Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability, (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury, and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To establish service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a)(b) (2016); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 1. Entitlement to service connection for benign prostate hypertrophy The Veteran contends the symptoms of his urinary dysfunction are related to his prostate condition. The Veteran is already service connected for chronic prostatitis, rated as 0 percent disabling, effective December 15, 1977. By way of history, the Veteran filed a claim for an increased rating for his chronic prostatitis in June 2015. During the pendency of the appeal, he reported symptoms of increased urinary frequency, voiding between two and three hours during the day and three to four times during the night. The Veteran was also noted to have a slow and weak stream with decreased force. In July 2015, the Veteran underwent a VA examination for prostate cancer. The examiner diagnosed the Veteran with benign neoplasm of prostate at bladder neck, with bladder neck partial obstruction, as well as separately confirming the prior diagnosis for his service-connected chronic prostatitis. In October 2015, the RO requested an addendum medical opinion to clarify the Veteran's diagnosis of his multi-faceted prostate condition. Here, the examiner opined, inter alia, that the symptoms of his urinary dysfunction were "entirely related to his benign prostatic hypertrophy." In December 2017 the RO issued a statement of the case (SOC), denying the Veteran's claim for an increased rating for chronic prostatitis because the October 2015 VA examiner opined that his urinary dysfunction symptoms are due to his, at that time, non-service connected benign prostate hypertrophy and aging. As noted on the title page, the Veteran filed VA 21-526EZ, Fully Developed Claim, in April 2018, indicating he was seeking a separate claim for enlarged prostate (i.e., hypertrophy) with bladder neck obstruction secondary to his service-connected chronic prostatitis condition. In this regard, it is not in dispute that the Veteran has a current diagnosis of a benign prostate hypertrophy with bladder neck obstruction. Thus, the first element of a claim for service-connection, a current disability, has been met. In May 2018, the Veteran underwent a VA examination for male reproductive system conditions. The examiner again diagnosed the Veteran with two separate prostate conditions chronic prostatitis and benign prostate hypertrophy with bladder neck outlet obstruction and Lower Urinary Tract Symptoms (LUTS). After reviewing the Veteran's claims file and interviewing the Veteran via telephonic conference, the examiner opined the Veteran's benign prostatic hypertrophy with bladder neck outlet obstruction and chronic lower urinary tract symptoms is at least as likely as not proximately due to his service connected chronic prostatitis. In this case, the Board finds the May 2018 VA examination is the most probative evidence of record as to whether the Veteran's current benign prostatic hypertrophy is secondary to his service-connected chronic prostatitis. Accordingly, the preponderance of the evidence is in favor of finding the Veteran's claimed benign prostatic hypertrophy condition is secondary to his service connected chronic prostatitis condition. Under such circumstances the Board concludes that secondary service connection for benign prostatic hypertrophy is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Entitlement to service connection for erectile dysfunction The Veteran contends his erectile dysfunction is due to his prostate condition. In July 2015 the Veteran underwent a VA examination that diagnosed him with erectile dysfunction. The examiner opined the Veteran's erectile dysfunction was secondary to his diagnosed benign prostate tumor obstructing bladder neck condition. The Board finds the July 2015 VA examination is the most probative evidence of record. Accordingly, in light of the above finding that the Veteran's benign prostatic hypertrophy condition is service-connected, the preponderance of the evidence is in favor of finding the Veteran's current erectile dysfunction is secondary to his service-connected benign prostate hypertrophy condition. Under such circumstances the Board concludes that secondary service connection for erectile dysfunction is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 3. Entitlement to service connection for bilateral hearing loss 4. Entitlement to service connection for tinnitus The Veteran contends that his hearing loss and tinnitus are related to service. Specifically, the Veteran reports that during service he was around or driving heavy equipment and that the noise in service was very loud, to include gunfire and mortar fire, experienced in Vietnam. The Veteran reports he had no ear protection. Initially, the Board finds the Veteran has been diagnosed with bilateral hearing loss and tinnitus during the pendency of the claim. See VA Examination for Hearing Loss and Tinnitus, July 2015. Turning to the evidence, the Veteran's service treatment records (STRs) are silent for diagnosis, treatment or complaints of hearing loss and/or tinnitus. In March 1970, the Veteran's Report of Medical Examination shows no hearing loss present at separation. The Veteran's remaining post-service treatment records are silent for diagnosis, treatment or complaints of hearing loss and tinnitus until June 2015 (the date of his application), more than forty-five years after service. While the service and post-service treatment records fail to disclose diagnoses, treatment or complaints of hearing loss and tinnitus, the Board nonetheless finds the Veteran competent and credible to report the types of noise exposure he incurred in service. Accordingly, the Board finds his testimony of in-service noise exposure to be probative evidence of at least some noise exposure in service. However, the central inquiry in this case is whether there is a nexus, or link, between the Veteran's current hearing loss and tinnitus and his in-service noise exposure. In this regard, the Veteran underwent a VA examination in July 2015. The examiner opined that the Veteran's hearing loss and tinnitus are less likely than not caused by or a result of military noise exposure. In support, the examiner identified that there is no report of hearing loss or tinnitus in his service treatment records or at separation. Moreover, the examiner acknowledged that in civilian life the Veteran operated construction equipment and worked as a welder. Further, the examiner noted that the Veteran did not provide any narrative to relate onset of tinnitus to his service period nor did he incur hearing loss in the Army. Importantly, the examiner opined that the current medical literature does not support late onset noise-induced hearing loss. In December 2015, the Veteran submitted a private medical opinion from SONUS Hearing Care Professionals. During the examination, the Veteran reported he did not have a hearing examination at separation. Based on the Veteran's claim of not having a hearing examination at separation from service, the examiner opined, "[s]hould the patient's claim of there being no hearing records upon exit be true," his hearing loss and tinnitus are at least likely as not due to military noise exposure. While supportive of the claim, the Board assigns the December 2015 private opinion little probative weight because it is speculative in nature and does not provide the degree of certainty required for persuasive nexus evidence in this case. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The use of the words "possible," "may," or "can be" make a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 12728 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). Importantly, an adequate examination "must rest on correct facts and reasoned medical judgement so as to inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports." Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). In this regard, the conclusion reached by the December 2015 private examiner was made solely on the basis that there was no audio examination at separation from service. As noted above, the Veteran did in fact have an audio examination at separation that showed no hearing loss. See March 1970 Separation Report of Medical Examination. The Board finds the July 2015 VA opinion to be the most probative evidence of record because it is based on a review of the Veteran's claims file and an examination of the Veteran and it provides an explanation that contains clear conclusions and supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also, the opinion is supported by the evidence found in the record, including the Veteran's lay statements and controlling medical principles. See also VA Addendum Medical Opinion, January 2016 (considering both the July 2015 VA examination and the December 2015 private opinion and agreeing with the conclusions made in the July 2015 VA examination). At a minimum, the opinion from the private examiner is outweighed by the VA opinion, as the VA examiner reviewed the Veteran's service and post-service treatment records and provided a more detailed rationale for the conclusions reached. While the Veteran is certainly competent to report as to the observable symptoms of hearing loss and tinnitus that he experiences and their history, he is not competent to render an opinion as to the etiology of his current disability, because of the medically complex nature of such an opinion. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Importantly, the United States Court of Appeals for Veterans Claims (Court) has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that Veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition). Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for bilateral hearing loss and tinnitus. The July 2015 VA opinion is the most probative evidence of record, and the opinion reflects consideration of the Veteran's history, both in service and after service, as well as his lay statements concerning his noise exposure in service as well as after service. Accordingly, the Board finds that the preponderance of the evidence weighs against a nexus for the issue of service connection for hearing loss and tinnitus. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, that doctrine is not applicable in this appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 5. Entitlement to an effective date for the award of a rating of 100 percent for PTSD The Veteran contends that he is entitled to an effective date earlier than June 26, 2020, for the award of an increased disability rating of 100 percent for his service-connected PTSD. By way of procedural history, the Veteran filed a claim for service connection for PTSD on July 05, 2007. In an October 2018 rating decision, the Veteran was granted service connection for PTSD with alcohol use disorder with a disability rating of 30 percent, effective July 5, 2007. In January 2019, the Veteran filed a notice of disagreement (NOD) for entitlement to an increased disability rating for his PTSD. In a July 2020 rating decision, the Veteran was awarded an increased disability rating of 100 percent for his PTSD, effective June 26, 2020. The applicable laws and regulations concerning effective dates state that, except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(a). Here, the effective date of June 26, 2020, was assigned as the date entitlement to an increased rating of 100 percent arose. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(o)(2). Specifically, the increased 100 percent rating was based on a June 2020 VA mental health evaluation that found depression, anxiety, suspiciousness, panic attacks, chronic sleep impairment, disturbance of motivation and mood, difficultly establishing work and social relationships, and persistent delusions or hallucinations. Prior to that time, the evidence did not indicate such problems. The Veteran contends that he met the criteria for a 100 percent rating disability rating since the receipt date of his claim, July 5, 2007. The Veteran's mental health disability is rated under DC 9411 for PTSD. 38 C.F.R. § 4.130. Under DC 9411, a 10 percent rating is prescribed when there is evidence of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational task only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is prescribed when there is evidence of 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, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is prescribed when there is evidence of 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; impaired judgement; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is prescribed when there is evidence of 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 work like setting); and inability to establish and maintain effective relationships. A 100 percent rating is prescribed when there is evidence of 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 as to time or place; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, 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, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). With the above criteria in mind, when considering not only the presence of certain symptoms, but also whether those symptoms have caused occupational and social impairment in most of the referenced areas under the rating criteria (see Vazquez-Claudio, supra), as well as the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission (see 38 C.F.R. § 4.126(a)), and when considering the appellant's competent reports of his observable adverse symptomatology, based on all the evidence of record that bears on occupational and social impairment related to his PTSD, he does not meet the criteria for at least the next higher, 100 percent, rating at any time prior to June 26, 2020 because his symptoms are not shown to be productive of total occupational and social impairment during that time. The Board has reached this conclusion because the adverse symptomatology of the Veteran's PTSD, prior to June 26, 2020, considering the above criteria, were as follows: There is not persistent delusions or hallucinations. In fact, the April 2011 and May 2017 VA examinations reported there were not delusions or hallucinations. Moreover, while treatment records periodically document the Veteran's complaints and treatment related to his PTSD, to include occasional reporting of hallucinations over a period of roughly the past 15 years, such as seeing shadows after movement, having a sense someone is behind him, and visual hallucinations of bugs crawling on him, the preponderance of the evidence indicates these delusions or hallucinations were not found on a persistent basis, at any time prior to June 26, 2020. See e.g., VA Mental Health Outpatient Notes from May 2007 March 2008, July 2008, June 2012, October 2012, May 2015, January 2016, May 2016, June 2016, August 2016, October 2016, May 2017, August 2017, November 2017, February 2018, May 2018, August 2018 (on each treatment noted herein, the Veteran either expressly denied having hallucinations/delusions or the examiner specifically found they were absent); see also VA Mental Health Outpatient Note, April 12, 2011 (examiner specifically noting hallucinations are not persistent). Moreover, prior to June 26, 2020, there is no evidence indicating the Veteran experienced gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) due to his PTSD, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. In fact, the April 2011, May 2017, and June 2020 VA examinations uniformly found there was not gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Moreover, while treatment records periodically document the Veteran's complaints and treatment related to his PTSD, nothing in these records show that he experienced any of these adverse symptoms at any time prior to June 26, 2020. Instead, the Board finds that when considering the Veteran's competent reports of his observable adverse symptomatology and the findings in the April 2011 and May 2017 VA examinations, along with his VA mental health treatment records, he meets the criteria for a 30 percent rating, but not higher, at all times prior to June 26, 2020. Specifically, the April 2011 VA examiner identified the following symptoms, as reported by the Veteran: difficulty falling or staying asleep, irritability or outburst of anger, diminished interest or participation in significant activities, intrusive thoughts, intense fear, helplessness or horror, difficulty concentrating and making decisions, feelings of sadness, decrease level of energy and sexual interest, and use of alcohol. The examiner made the following behavioral observations of the Veteran at the April 2011 examination: he was clean, neatly groomed, appropriately dressed, attitude becoming more friendly and relaxed as the interview went on, flat affect with depressed mood, orientation to person time and place, thought process was logical and goal-oriented, no delusions, with intact judgement and insight. Moreover, the May 2017 VA examiner found that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. For VA rating purposes, the May 2017 VA examiner identified the following symptoms of the Veteran's PTSD: depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The examiner made the following behavioral observations of the Veteran: he was neat and clean in appearance with no obvious impairment in personal care tasks, displayed euthymic mood with congruent affect, ambulated without assistance, was calm and relaxed in his demeanor throughout the examination, insight and judgment appeared intact, displayed good eye contact and was easily engaged with the examiner, speech was clear, logical, goal directed, and relevant, there was no evidence of any psychotic processes, denied current suicidal or homicidal ideation, oriented to time, person, place, and situation, successfully completed simple and complex arithmetic problems and was able to display good social judgment and abstraction skills. Tellingly, the medical findings at these VA examinations are not contradicted by any other medical or lay evidence of record for the period on appeal prior to June 26, 2020. Important in this case, a higher, 50 percent, rating is not shown prior to June 26, 2020, because the evidence does not show a disability picture for the Veteran's PTSD consistent with 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; impaired judgement; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Put simply, the disability picture painted by the rating criteria for a 50 percent, or higher, rating for PTSD under the Diagnostic Code is not present in this Veteran, prior to June 26, 2020. Moreover, in certain cases, the evidence does not support even a 30 percent rating for the Veteran's PTSD prior to June 26, 2020, based on the relevant rating criteria. Accordingly, the Board finds that the criteria for a rating in excess of 30 percent for the Veteran's PTSD is not met at any time prior to June 26, 2020 under 38 C.F.R. § 4.130, Diagnostic Code 9411. In this regard, the Veteran believes that entitlement to an increased 100 percent disability rating for PTSD arose prior to June 26, 2020. However, the evidence of record does not support this belief. In fact, it important for the Veteran to understand that a review of the evidence, some of which has been cited above, does not always clearly support the current findings, let alone an earlier effective date for the 100% for PTSD. This does not suggest the Veteran is not having problems with his PTSD prior to this time (if he did not have problems, there would be no basis for a compensable evaluation prior to the 100% finding). The only question is the degree. While the Veteran is competent to report the symptoms of his disabilities, he is not competent to opine on matters requiring medical knowledge, such as determining the nature and severity of his medical condition and interpreting complicated diagnostic medical testing. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Again, nothing above suggests that the Veteran is not, and was not, having problems with this disability. The only question is the degree of the problem based on the evidence and the law. It is important for the Veteran to understand that the medical findings provide highly probative evidence against the claim that the Board cannot, unfortunately, ignore. The medical findings outweigh the Veteran's belief that entitlement to an increased 100 percent rating arose prior to June 26, 2020. Also, notwithstanding the Court holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) the Board finds that the record does not raise a claim for a total rating based on individual unemployability (TDIU), prior to June 26, 2020. The Board has reached this conclusion because the Veteran has not claimed, and the record does not show that his service-connected PTSD interfered with his substantial gainful employment prior to June 26, 2020. Therefore, the Board provides more weight to the competent medical evidence of record and must deny the claim for an earlier effective date for the award of an increased disability rating of 100 percent under DC 9411. As the date entitlement arose is later than the July 5, 2007 date of receipt of the Veteran's claim for service connection for PTSD, the current and proper effective date for award of an increased disability rating of 100 percent for PTSD in this case is the date entitlement arose, June 26, 2020. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. As the preponderance of the evidence is against the claim for an earlier effective date for the award of an increased 100 percent rating for PTSD, the benefit-of-the-doubt doctrine is not applicable and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, an earlier effective date is not warranted. REASONS FOR REMAND 1. Entitlement to a compensable rating for chronic prostatitis As noted above, the RO denied the Veteran's claim that his current urinary dysfunction symptoms are due to his service-connected chronic prostatitis condition throughout the appeal. See Rating Decision, October 2015; Statement of the Case (SOC), December 2017. Moreover, multiple VA examiners have opined that the Veteran's current urinary dysfunction symptoms are due to his benign prostatic hypertrophy, rather than his chronic prostatitis condition. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Accordingly, at this time the Board cannot determine that the Veteran's current symptoms of urinary dysfunction are due to his chronic prostatitis condition prior to the RO assigning a rating for the Veteran's benign prostatic hypertrophy. As such, this claim must be remanded pending the assignment of ratings for the Veteran's benign prostatic hypertrophy condition. 2. Entitlement to a rating in excess of 10 percent for left elbow condition The Veteran underwent a VA elbow and forearm examination in August 2018, but subsequently submitted testimony at his July 2021 hearing that indicates the left elbow disability increased in severity, after the August 2018 examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (holding that the Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). Moreover, the evidence shows that the Veteran was in an accident in 2018 that has left him confined to a wheelchair, which may have also caused a worsening of his service-connected left elbow condition. Accordingly, remanding for a new examination is the only way to obtain the evidence needed to properly evaluate the service-connected left elbow disability. The matters are REMANDED for the following action: 1. Associate with the record any outstanding VA treatment records. 2. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran, or his representative, should submit any new pertinent evidence the Board does not have (if any). 3. Following the assignment of a disability rating for the Veteran's benign prostatic hypertrophy, and any additional development deemed necessary to address the issue, adjudicate the issue of entitlement to an increased rating for chronic prostatitis, keeping in mind the rule against pyramiding under 38 C.F.R. § 4.14. The Board notes that an addendum opinion may be required to determine whether the Veteran's benign prostatic hypertrophy is a progression of his chronic prostatitis condition or a separate disease altogether. Moreover, the opinion, if determined to be necessary, should relate the Veteran's symptoms of urinary dysfunction to one or the other of these issues, if they are indeed separate medical conditions. If benign prostatic hypertrophy is simply a progression of chronic prostatitis, the RO should update the rating for the Veteran's chronic prostatitis condition and notify the Veteran of any changes to his rating schedule, as appropriate. If the Veteran's benign prostatic hypertrophy is found to be a separate medical condition, and should the benefit for chronic prostatitis remain denied, issue a supplemental statement of the case prior to returning the appeal to the Board for further appellate review. 4. Schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of his left elbow condition during the pendency of the appeal. The claims file should be made available and reviewed by the examiner in conjunction with conducting the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After a review of the claims file, any needed testing, and an examination of the Veteran, the examiner should provide answers to the following questions: 5. The examiner should identify all left elbow musculoskeletal and neurological pathology found to be present during the pendency of the appeal. 6. The examiner should conduct all indicated tests and studies, to include range of motion studies. Full range of motion testing must be performed where possible. The joint involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case than, he or she should clearly explain why that is so. 7. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. 8. In order to comply with the Court's holding in Sharp, the examiner should state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. In order to comply with the Court's holding in Sharp, the examiner based on the Veteran's lay statements at the current examination and the other evidence of record must attempt to provide an opinion estimating any additional degrees of limited left elbow flexion and extension as well as left forearm pronation and supination caused by functional loss during a flare-up and after repeated use over time. In providing the above opinions, the examiner should consider the Veteran's competent lay claims regarding observable symptomatology. The examination report must include a complete rationale for all opinions expressed. 9. After the above development has been completed, and after any additional development as required, readjudicate the issue(s) on appeal. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Davidson 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.