Citation Nr: 21065983 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 14-41 387 DATE: October 28, 2021 ORDER 1. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected lumbar discogenic disease involving L5-S1 (back disability), is denied. 2. Entitlement to service connection for urinary incontinence/neurogenic bladder, to include as secondary to a service-connected back disability is denied. 3. Entitlement to increases in staged (30 percent prior to April 14, 2016 and 50 percent from that date) ratings for asthma with sleep apnea is denied. FINDINGS OF FACT 1. The Veteran's ED was not manifested in service, and a preponderance of the evidence is against finding that it is etiologically related to his service or was caused or aggravated by a service-connected back disability. 2. The Veteran's urinary incontinence/neurogenic bladder was not manifested in service, and a preponderance of the evidence is against finding that it is etiologically related to his service or was caused or aggravated by a service-connected back disability. 3. Prior to April 14, 2016 the Veteran's asthma is not shown to have been manifested by forced expiratory volume (FEV-1) 40-55 percent predicted; or FEV-1/Forced Vital Capacity (FVC) 40-55 percent; or at least monthly visits to a physician required for care of exacerbations; or by intermittent (at least three a year) courses of systemic (oral or parenteral) corticosteroids; required use of a breathing assistance device such as continuous airway pressure (CPAP) machine for obstructive sleep apnea (OSA) was not shown. 4. From April 14, 2016, the Veteran's asthma is not shown to have been manifested by forced expiratory volume in the first second (FEV-1) that is 40-55 percent predicted, or; FEV-1/Forced Vital Capacity (FVC) is 40-55 percent, or at least monthly visits to a physician required for care of exacerbations, or; with intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids; OSA with chronic respiratory failure with carbon dioxide retention or cor pulmonale or requiring tracheostomy is not shown. CONCLUSIONS OF LAW 1. Service connection for ED, to include as secondary to a service-connected back disability, is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 2. Service connection for urinary incontinence/neurogenic bladder, to include as secondary to service-connected back disability is denied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 3. A rating in excess of 30 percent for asthma with sleep apnea prior to April 14, 2016; and a rating in excess of 50 percent from April 14, 2016 are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321(a), 4.1, 4.10, 4.3, 4.7, 4.96, 4.97, Diagnostic Codes (Codes) 6602, 6847. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty (Federalized National Guard Service) from January 2002 to October 2002, and had additional service in the Army National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2013 Department of Veterans Affairs (VA) rating decision (which granted service connection for asthma, rated 10 percent, effective April 30, 2012, and denied service connection for ED and urinary incontinence). A June 2020 rating decision increased the rating for asthma to 30 percent effective August 20, 2015. A March 2021 decision review officer (DRO) decision granted service connection for sleep apnea, effective January 24, 2012, and rated 30 percent sleep apnea) effective January 24, 2012 and 50 percent effective April 14, 2016. In June 2018, January 2021, and June 2021 this case was remanded or further development. At the outset, the Board finds there has been substantial compliance with the June 2018, January 2021, and June 2021 remand directives pertaining to the matters on appeal. [The January 2021 remand directed the VA examiner address to address whether the Veteran's ED is proximately due to/or aggravated by his diabetes mellitus. The examiner declined to offer such opine as neither condition is service connected (and the question was moot). The Board agrees with the examiner's assessment and finds that further development for "strict" compliance with that instruction would serve no useful purpose. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease first diagnosed after service may be service connected if all the evidence, including pertinent service records, establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 104 (Fed. Cir. 1994). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 1. Entitlement to service connection for ED, to include as secondary to a service-connected back disability, is denied. The Veteran's service treatment records (STRs) are silent regarding complaints, findings, treatment, or diagnosis pertaining to ED. A January 2005 VA treatment record shows that the Veteran reported problems with his libido and inability to obtain erections to his psychiatrist. Subsequent January and March 2005 VA treatment records note that he received a vacuum device to aid with his ED. On March 2005 VA post-traumatic stress disorder (PTSD) examination, the Veteran reported to a psychiatrist that he received a prescription of Viagra due to poor sexual desire and inability to obtain erections. On July 2013 VA examination, the examiner noted the 2005 ED diagnosis and that all urinary studies were normal. The Veteran reported that he responded well to Viagra and dribbles urine after voiding. The examiner determined that the etiology of the Veteran's ED was multifactorial to include hypertension, age, and diabetes mellitus. The examiner opined that his ED is less likely related, proximately due to, or the result of his service-connected back disability. The examiner based this opinion on a review of the record and medical literature which showed that there must be spinal cord damage [for back disability] to cause or aggravate ED. On February 2021 VA examination, the examiner reviewed the record, noted a 2005 ED diagnosis. The examiner opined that it is less likely than not that that his ED [was incurred] in service. The examiner cited medical literature, the silence of service records regarding diagnosis or symptoms of ED, and the duration of the intervening period between separation from active-duty service and the diagnosis of ED. The examiner further opined that it is less likely than not that his ED is caused or aggravated by his service-connected disabilities, and cited to medical literature. On July 2021 VA examination, the examiner opined that the Veteran's ED is less likely than not aggravated by his lumbar discogenic disease, involving L5-S1. The examiner stated medical literature does not establish that ED could be aggravated by lumbar discogenic disease involving L5-S1. The examiner explained that there must be nerve damage to the nerves that control the erection to cause or aggravate ED. The examiner noted that the Veteran has no damage to any spinal nerves to include the ones that enervate the (T10-T11 and S2-S3) area and the parasympathetic system. It is not in dispute that the Veteran has ED. As ED is not shown to have been manifested in service or to be due to an injury or event in service, the service connection for ED on the basis that it is directly rated to service (was incurred due to disease or injury in service) is not warranted. The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis of ED, and the earliest postservice notation of ED is in a January 2005 VA psychiatric treatment record, more than two years after his discharge from active duty. The analysis turns to the Veteran's (primary asserted) secondary service connection theory of entitlement, i.e., that his ED was caused or aggravated by a service-connected disability. The record shows (it is not in dispute) that he has established service connection for lumbar discogenic disease involving L5-S1 and for degenerative changes of the cervical spine. [It was alternatively claimed that it is due to his diabetes; however, service connection for diabetes has not been established, and that theory of entitlement lacks legal merit.] Thus, the critical question that must be addressed is whether there is competent evidence that the Veteran's ED was caused or aggravated by his service-connected disabilities of the spine. Although laypersons are competent to provide opinions on some medical questions, see Kahana, 24 Vet. App. at 428, whether ED may (in the absence of onset in service/continuity since) be related to directly to a Veteran's service and disease or injury therein or was caused or aggravated by a disability of the spine is a medical question outside the scope of common knowledge. It requires medical expertise. Jandreau, 492 F.3d at 1372. Although the July 2013 VA opinion is inadequate by itself to decide the case because the examiner did not adequately address the aggravation secondary service connection theory of entitlement, the July 2013, February 2021, and July 2021 VA opinions are cumulatively probative evidence against the Veteran's claims and the Board finds them persuasive. See Allen v. Brown, 7 Vet. App. 439, 449 (1995. The examiners reviewed the record, considered the Veteran's lay statements, and supported the opinions with rationale that cites to supporting factual data and medical literature. The providers explained the Veteran's back disability is not shown to be an etiologic, contributory or aggravating factor for the development or aggravation of ED, essentially because they are different disease entities with different pathophysiological processes and are not etiologically related. The July 2021 provider expanded on the explanation, indicating that to impact on ED a spinal disc disability must include some damage to the nerves that enervate the GU system, and indicated that such nerve damage is not shown. The providers are medical professionals with subject matter expertise. Because there is no probative evidence to the contrary, their opinions are cumulatively persuasive. The Veteran is a layperson and has not submitted supporting competent (medical opinion or treatise) evidence that his ED is directly related to his military service or was caused or aggravated by a service-connected disability. Consequently, his own opinions are not probative evidence in the matter. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for ED. The benefit-of-the-doubt standard of proof does not apply; the appeal seeking service connection for ED must be denied. 2. Entitlement to service connection for urinary incontinence/neurogenic bladder secondary to service-connected back disability is denied. The Veteran's STRs are silent regarding complaints, findings, treatment, or diagnosis pertaining to urinary incontinence/neurogenic bladder. On March 2004 VA peripheral nerves examination, the Veteran reported urine incontinence attributed to treatment for prostatitis. A May 2004 cytoscopy was interpreted as normal regarding his urethra and prostate, with no inflammation shown. A July 2004 VA treatment record shows that the Veteran underwent a procedure involving insertion of a bladder catheter to measure his urine and conduct a cystometrogram. The findings were interpreted as normal. A November 2004 VA treatment record notes that the July 2004 cystometrogram revealed a low volume bladder. On July 2013 VA examination, the examiner noted an April 2004 diagnosis of urinary incontinence; the Veteran's statements reporting dribbling after upon urination; and that the Veteran underwent several urinary studies that were determined to be normal. The examiner opined that the Veteran's urinary incontinence is not likely related, proximately due to, or the result of his service-connected back disability. The examiner indicated that based on a review of medical literature the Veteran's type of back disability does not produce urinary incontinence as there is no evidence of a spinal cord injury. A November 2018 VA treatment record notes the Veteran's report that he no longer has urinary complaints, and his urinary urgency had resolved. On February 2021 VA (telehealth) examination, the examiner and noted that review of the Veteran's record showed a 2004 diagnosis of urinary incontinence. The Veteran related that he urinates frequently and continues to dribble thereafter. The examiner noted that he underwent several urinary studies for this condition, and all were normal. The examiner found that the Veteran has a voiding dysfunction with an unknown etiology, and opined that it is less likely than not that the urinary incontinence was incurred in or caused by his military service. The examiner explained that service records are silent regarding any diagnosis or symptoms for this condition, and that the record is silent regarding any manifestation or diagnosis of urinary incontinence within a year following the Veteran's separation from service (noting that a review of medical literature did not reveal a basis for relating the urinary incontinence to service). The examiner further opined that it is less likely than not that the Veteran's urinary incontinence is proximately due to or aggravated by his service-connected disabilities. The examiner cited to a lack of supporting medical literature for a premise the Veteran's service-connected disabilities would aggravate urinary frequency. On July 2021 VA examination, the examiner opined that it is less likely than not that the Veteran's urinary incontinence/neurogenic bladder was aggravated beyond its natural progression by lumbar discogenic disease, involving L5-S1. The examiner opined that there is no objective evidence that the Veteran's urinary incontinence/neurogenic bladder was aggravated by his back disability. The examiner stated that medical literature does not establish that urinary incontinence/neurogenic bladder could be aggravated by lumbar discogenic disease involving L5-S1. It is not in dispute that the Veteran has had urinary incontinence, and has established service connection for disability of the spine, including involving disc pathology. His Veteran's STRs are silent for complaints, findings, treatment, or diagnosis regarding urinary incontinence, or a neurogenic bladder. The first postservice notation of urinary incontinence is in a March 2004 (over a year after his discharge from active duty) VA treatment record that attributed the urine incontinence to treatment for prostatitis. Accordingly, service connection urinary incontinence/neurogenic bladder on the basis that such disability became manifest in service and persisted is not warranted. What remains for consideration is whether the s urinary incontinence/neurogenic bladder is otherwise shown to be etiologically directly related to the Veteran's service or to have been caused or aggravated by a service-connected disability, as alleged. Although laypersons are competent to provide opinions on some medical questions, see Kahana, 24 Vet. App. at 428, whether urinary incontinence or neurogenic bladder may (in the absence of onset in service/continuity since) be related directly to service or be secondary to a service-connected disability is a medical question outside the scope of common knowledge. It requires medical expertise. Jandreau, 492 F.3d at 1372. The July 2013 VA opinion is inadequate by itself to decide the matter because the rationale provided was insufficient, the July 2013, February 2021, and July 2021 VA opinions are cumulatively probative evidence against the Veteran's claims and the Board finds them persuasive. See Allen v. Brown, 7 Vet. App. 439, 449 (1995. The providers reviewed the record, considered the Veteran's lay statements, and supported the opinions with rationale that cites to supporting factual data and medical literature. Their opinions explained the Veteran's back disability is not shown to be an etiologic, contributory or aggravating factor for the development or aggravation of urinary incontinence/neurogenic bladder, essentially because they are different disease entities with different pathophysiological processes and are not etiologically related. The providers are medical professionals and are competent to provide the opinions. Because there is no competent (medical opinion or treatise) evidence to the contrary, the opinions are cumulatively persuasive. The Veteran is a layperson and has not presented any probative medical evidence in support of his theory that his urinary incontinence is related to his military service or were caused or aggravated by a service-connected disability. Consequently, his own opinions are not probative evidence in the matter. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for urinary incontinence/neurogenic bladder. The benefit-of-the-doubt standard of proof does not apply. The appeal seeking service connection for urinary incontinence/neurogenic bladder must be denied. 3. Entitlement to increases in staged (30 percent prior to April 14, 2016 and 50 percent from that date) ratings assigned for asthma with sleep apnea is denied. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. Functional impairment is to be assessed on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the appeal is from the initial rating assigned with a grant of service connection, the severity of the disability during the entire period from the grant of service connection to the present is to be considered. "Staged" ratings may be assigned for distinct periods when different levels of impairment are shown. Fenderson v. West, 12 Vet. App. 119 (1999). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is to be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. As the instant claim for increase for asthma with OSA is an appeal of an initial rating effective January 24, 2012, the period for consideration is from January 24, 2012. Under 38 C.F.R. § 4.96(a) ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 (which includes the rating for asthma under Code 6602 and that for OSA under Code 6847) may not be combined. Instead, a single rating is to be assigned under the diagnostic code which reflects the predominant disability, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Under Code 6602, a 100 percent evaluation is warranted for asthma when FEV-1 is less than 40 percent predicted, or; FEV-1/FVC is less than 40 percent, or; with more than one attack per week with episodes of respiratory failure, or; when daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications is required. A 60 percent evaluation is warranted when FEV-1 is 40-55 percent predicted, or; FEV-1/FVC is 40-55 percent, or; with at least monthly visits to a physician required for care of exacerbations, or; with intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. 38 C.F.R. § 4.97. Under Code 6847, a 50 percent rating is warranted for sleep apnea that requires the use of a breathing assistance device such as a CPAP machine. 38 C.F.R. § 4.97. A 100 percent rating is warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonale, or where; tracheostomy is required. Post-bronchodilator results are required when pulmonary function tests (PFTs) are done for disability evaluation purposes (except when the results of pre-bronchodilator PFTs are normal, or when the examiner determines that post-bronchodilator studies should not be done, and explains why). 38 C.F.R. § 4.96(d)(4). Factual Background VA treatment records for the period on appeal show that the Veteran reported episodes of air hunger, chest palpations, difficulty sleeping, problems remaining asleep, and tiredness. On May 2012 VA examination, the Veteran reported he did not have a diagnosis of sleep apnea. A November 2012 private treatment record shows the Veteran underwent a sleep study and received a diagnosis of "very mild obstructive sleep apnea" (OSA). The physician described the Veteran's sleep as snoring, labored breathing, repetitive obstructive apneas, hypopneas, episodic desaturations, repetitive arousals, and sleep fragmentation. The physician predicted a high chance for improvement with ten to twenty percent weight loss, addressing nasal congestion issues, and sleeping in a non-supine (not lying face upward) position. On August 2013 VA respiratory conditions examination, asthma was diagnosed. Pulmonary function studies (PFT) showed an FVC of 88, an FEV-1 of 90, and an FEV-1/FVC of 102 percent. The examiner indicated that the FEV-1 more accurately reflected the severity of the disability. The Veteran reported sporadic use of an albuterol inhaler for asthma, denied usage of oral or parenteral corticosteroid medications, and reported that he had not had an asthma attack with episodes of respiratory failure in the past twelve months. The examiner noted the Veteran's inhalational bronchodilator therapy and his reference to about three visits to private hospitals due to asthma exacerbations per year, especially during winter months. The examiner noted a mild obstructive ventilatory impairment not responsive to bronchodilator therapy and mild air trapping. On August 2013 VA sleep apnea examination, very mild OSA was diagnosed. The Veteran reported poor sleep and that he is awaiting receipt of a CPAP. After reviewing the November 2012 sleep study, the examiner opined that a CPAP and continuous medication were not required for his OSA. The examiner advised a treatment plan of weight loss and positional therapy. The examiner noted there was no evidence that the Veteran's sleep apnea impacted his ability to work. A December 2014 VA treatment record notes that the Veteran was still awaiting receipt of a CPAP machine On August 2015 VA respiratory conditions disability benefits questionnaire (DBQ), diagnoses of asthma and mild OSA were noted. The provider noted that the Veteran requires a chronic low dose of inhaled corticosteroids three to four times daily, and he did not recall any asthma attacks with episodes of respiratory failure in the past twelve months, and that he visited a hospital several times in the past twelve months, but less frequently than monthly, for exacerbations of asthma. August 2013 PFT showed an FVC of 2.99, an FEV-1 of 2.48, and an FEV-1/FVC of 83 percent. The examiner indicated that FVC more accurately reflected the severity of the disability. She opined that the Veteran's respiratory disability did not impact his ability to work and stated that environmental conditions worsened his asthma. On October 2015 VA respiratory conditions examination, the examiner noted the Veteran's diagnosis of asthma and noted that he suffers shortness of breath episodes about twice a week that he treats with power nebulizer therapies. He also reported that the Sahara dust and temperature changes activate his asthma. Daily use of inhalational bronchodilator therapy and inhalational anti-inflammatory medication was noted. The examiner determined that the Veteran's respiratory disability does not require the oral use of a bronchodilator, antibiotics, or oxygen. An October 2015 PFT showed an FVC of 85, an FEV-1 of 84, and an FEV-1/FVC of 99 percent. The examiner indicated that the FEV-1 more accurately reflected the severity of the disability and stated that post-bronchodilator testing was not conducted as the pre-bronchodilator testing was normal (thus use of a bronchodilator was not medically indicated). The examiner found that the Veteran's asthma did not impact his ability to work. A December 2016 VA treatment record notes that VA requested an auto CPAP machine for the Veteran. On February 2021 VA respiratory conditions examination, the examiner noted the Veteran's diagnosed asthma, and determined that a PFT could not be performed due to COVID-19 procedures. The Veteran reported coughing day and night with chest tightness, intermittent shortness of breath, and exacerbations every other week lasting two days. He recalled using his albuterol inhaler and mometasone inhaler two to three times daily and visiting his physician every other month for his asthma. He further reported at minimum monthly visits to a physician for required care of exacerbations. The doctor examined the Veteran noting scattered intermittent end-expiratory wheezes with no evidence of dull percussion on either lung field. The examiner stated that the Veteran's respiratory condition did not impact his ability to work. On February 2021 VA sleep apnea examination, the examiner called the Veteran due to COVID-19 precautions. The Veteran reported daytime sleepiness, difficulty breathing, chest tightness while sleeping, difficulty falling asleep, and problems staying asleep. He also informed the examiner that he did not use an oral bronchodilator, or require the usage of antibiotics. He recalled visiting a physician at least monthly for exacerbations of his asthma requiring physician visits. The examiner noted the Veteran's report of using a CPAP machine and opined that the Veteran's sleep apnea does not impact his ability to work. On July 2021 VA sleep apnea examination, the Veteran stated that his sleep apnea persisted despite using a CPAP. He reported that he frequently wakes up during the night due to wearing the mask. The examiner noted the Veteran's usage of a CPAP machine and his symptoms of persistent daytime hypersomnolence. The examiner related that the Veteran's OSA did not impact his ability to work. On July 2021 VA respiratory conditions examination, the Veteran reported that his bronchial asthma worsened. He related that his fatigue increased, that he is intolerant to fumes and chemicals, and that changes in weather like Sahara dust exacerbate his disability. He described continuing to use daily respiratory therapy. The examiner noted the Veteran's reports of daily usage of inhalational bronchodilator therapy and inhalational anti-inflammatory medication. The examiner determined that the Veteran's respiratory disability does not require the use of oral bronchodilators, antibiotics, or oxygen therapy. The examiner stated that the Veteran's asthma interferes with his ability to sustain a regular employment as he works outside the home and needs to remain inside the home as his disability exacerbates. Analysis The most recent (March 2021) rating decision assigned a 30 percent rating under Code 6602 (throughout prior to April 2016), and a 50 percent rating under the criteria in Code 6847 from that date. These ratings reflect that prior to April 14, 2016 rating the disability under Code 6602 (for asthma) afforded the Veteran the greater benefit, and from the date, rating the disabilities under Code 6847 (for OSA) affords him the greater benefit. They also reflect that the overall severity of the disability was not found to such that "bump-up" of the ratings to the next higher level was warranted. Under the regulatory guidelines in 38 C.F.R. § 4.96, the process for assessing the these service-connected respiratory disabilities (asthma and OSA) requires first a determination of the rating that would be warranted for the symptoms and impairment, each, for asthma under Code 6602 for OSA under Code 6847; determining which provides the greater benefit (with such rating to be assigned); then determining whether the overall severity of the disability warrants elevation of that rating to the next higher rating for the disability. The reports of VA examinations, treatment records, and lay statements in the record do not show or suggest that at any time under consideration the Veteran has met or approximated the criteria for a 60 percent rating under Code 6602 (for asthma). It is not shown that he has had FEV-1 that is 40-55 percent predicted, or; FEV-1/FVC is 40-55 percent, or; with at least monthly visits to a physician required for care of exacerbations, or; with intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. The August 2015 respiratory DBQ notes that he reported some exacerbations, daily usage of an oral bronchodilator, and less than monthly visits to the hospital for asthma exacerbations. The examiner's selection for the most accurate severity of the disability (FVC 2.99) falls within the 10 percent rating criteria. The October 2015 VA examiner PFT results (FEV-1 of 84) also fall within the 10 percent rating criteria (the 30 percent rating criteria were met by the noted use of daily oral bronchodilator therapy). The record for this period on appeal (prior to April 14, 2016) does not reflect any of the criteria for a 60 percent rating under Code 6002. The Veteran denied monthly visits to physicians for care of exacerbations and denied intermittent courses of systemic corticosteroids. The exact number of private hospital visits is unknown as the Veteran declined to authorize VA to obtain his private treatment records, and has not submitted any evidence that the requirements for a higher rating were met. Accordingly, a 60 percent rating under Code 6602 was not warranted. Turning to the criteria under Code 6847, the evidentiary record does not show that at any time prior to April 14, 2016 that the Veteran required a CPAP machine. In fact, a CPAP was not ordered for him until December 2016 (more than half a year after the date on which a 50 percent rating under Code 6947 was assigned. The Veteran has not alleged that use of a CPAP machine was required prior to April 14, 2016. [While he stated on August 2013 VA examination that he was "awaiting receipt" of a CPAP machine, his account then does not establish that use of such breathing assistance devise was required at the time. In fact, both the August 2013 VA examiner and a November 2012 private provider indicated that weight loss and positional therapy were the Veteran's best treatment options, and did not mention that CPAP was needed, or ordered. Consequently, a 50 percent rating for OSA under Code 6847 prior to April 14, 2016 is not warranted. What remains for consideration is whether the severity of the overall disability was such that elevation of the 30 percent rating for asthma to 60 percent, based on the overall severity of the disability is warranted. The evidence of record for the period under consideration does not show that the criteria for a 30 percent rating for asthma were exceeded or nearly so. A review of the Veteran's VA medication record from January 2012 to April 2016 did not find a prescription for Prednisone listed (and, as noted above, the Veteran has declined to authorize VA to obtain his private treatment records to determine if systemic corticosteroids were prescribed, and if so, the frequency of such, suggesting that private records do not support his claim). Likewise, the OSA was considered to be mild, treatable by weight loss and positional (non-supine) sleep. VA examiners did not find significant impact on employment. The overall level of severity of the disability picture presented by these disabilities was far less than warranting a "bump up" (to 60 percent) prior to April 14, 2016. From April 14, 2016, the reports of VA examinations, treatment records, and lay statements in the record do not show or suggest that at any time the Veteran has met or approximated the criteria for a 100 percent rating under Code 6487 (for OSA). It is not shown that he has chronic respiratory failure with carbon dioxide retention, cor pulmonale, or required a tracheostomy. Turning to the criteria for a 60 percent rating for asthma under Code 6602, it is not shown that the Veteran has had FEV-1 that is 40-55 percent predicted, or; FEV-1/FVC of 40-55 percent, or; with at least monthly visits to a physician required for care of exacerbations, or; with intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. The February 2021 VA examiner noted the Veteran's statement that he visited a hospital monthly for asthma exacerbations, and the July 2021 VA examiner noted the Veteran's reports of daily usage of inhalational bronchodilator therapy and inhalational anti-inflammatory medication. However, once again it is noteworthy that he has not authorized VA to obtain the private records of such treatment, nor has he submitted any evidence (such as a statement by his private provider) indicating that he has required at least monthly visits for care of asthma exacerbations. The actual number of his visits for care for exacerbations of asthma, is undocumented and unknown. His recollection of at a minimum monthly private provider visits required for care of exacerbations of asthma on February 2021 examination is inconsistent with the disability picture otherwise shown, and considering his failure to cooperate with VA in development for records which would readily corroborate his account, suggests that the accounts are less than credible at face value. Consequently, a 60 percent rating for asthma under Code 6602 is not warranted. What remains for consideration is whether the severity of the overall disability is such that elevation of the 50 percent rating for the predominant disability (which is OSA by virtue of the finding that asthma does not warrant a rating in excess of 30 percent) based on the overall severity of the disability is warranted. The evidence of record for the period under consideration does not show that the criteria for a 50 percent rating for OSA were exceeded or nearly so (in fact, treatment records and examination reports show that he does not regularly use his CPAP machine, if at all). The overall level of severity of the disability picture presented is far less than the level of impairment contemplated by the criteria for a 100 percent rating under Code 6602, and a "bump up" to a 100 percent rating is not warranted. The record shows that the Veteran's service-connected disabilities have been rated as totally disabling from October2014 , either on a 100 schedular rating basis or based on a total disability rating based on individual unemployability (from February 2015). While the record shows that his OSA may have impacted on his employability, and he Veteran reported daytime sleepiness, difficulty breathing, chest tightness while sleeping, difficulty falling asleep, and problems staying asleep, no medical provider has opined that the Veteran's service-connected respiratory disabilities are of such severity as to preclude his participation in regular substantially gainful employment. The Board acknowledges that the July 2021 VA examiner noted that the respiratory disabilities interfere with employment "as he works outside the home" [which suggests he may have been working] and needs to remain in his home during exacerbations [of undocumented and unknown frequency]. The Board finds that the matter of entitlement to a separate TDIU rating (based on respiratory disability alone) has not been raised by the record in the context of the instant claim for increase. The preponderance of the evidence is against this claim. Therefore, the appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lederman, Michael 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.