Citation Nr: 21066860 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 18-01 500 DATE: November 2, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for the period prior to September 6, 2016 for a cervical spine disability is denied. Entitlement to a rating in excess of 20 percent for the period from September 6, 2016 to July 15, 2020 for a cervical spine disability is denied. Entitlement to a 40 percent rating, but no higher, for the period since July 16, 2020 for a cervical spine disability is granted. Entitlement to an initial rating of 40 percent, but no higher, for a lumbar spine disability is granted. Entitlement to service connection for bilateral hearing loss is denied. FINDINGS OF FACT 1. For the period prior to September 6, 2016, the Veteran's cervical spine disability was not manifested by forward flexion of the cervical spine less than 30 degrees or incapacitating episodes having a total duration of least 2 weeks during any 12 month period. 2. For the period from September 6, 2016 to July 15, 2020, the Veteran's cervical spine disability had not been manifested by forward flexion of the cervical spine of 15 degrees or less, favorable ankylosis of the entire cervical spine, or incapacitating episodes having a total duration of at least 4 weeks during any 12-month period. 3. For the period since July 16, 2020, the Veteran's cervical spine disability has been manifested by pain and limitation of motion that is equivalent to unfavorable ankylosis of the cervical spine. 4. The Veteran's service-connected back disability has been manifested by pain and limitation of motion, but not by incapacitating episodes or unfavorable ankylosis of the thoracolumbar spine. 5. The Veteran is not currently shown to have a bilateral hearing loss by VA standards. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for the period prior to September 6, 2016 for a cervical spine disability have not been met. 38 U.S.C. § 1155 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5242 (2020). 2. The criteria for a rating in excess of 20 percent for the period from September 6, 2016 to July 15, 2020 for a cervical spine disability have not been met. 38 U.S.C. § 1155 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5242 (2020). 3. The criteria for a rating of 40 percent, but no higher, for the period since July 16, 2020 for a cervical spine disability have been met. 38 U.S.C. § 1155 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5242 (2020). 4. The criteria for an initial rating of 40 percent, but no higher, for the Veteran's lumbar spine disability have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 5. Bilateral hearing loss was not incurred in the Veteran's active military service, and it may not be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1995 to January 1999. These matters are before the Board of Veterans' Appeals (the Board) on appeal of May 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2020 the Veteran testified at a videoconference hearing in front of the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claim file. In August 2021 the Board remanded these issues and the issue of entitlement to service connection for a penile disability for additional development. Notably, in a September 2021 rating decision, the RO granted service connection for a penile disability. As a result, this issue is no longer before the Board. An October 2017 rating decision granted an initial 20 percent disability rating for a cervical spine disability, effective September 6, 2016 and an October 2020 rating decision granted an initial 30 percent disability rating for a cervical spine disability, effective July 16, 2020. The Board notes that the increases from 10 to 20 percent and from 20 to 30 percent for a cervical spine disability did not constitute a full grant of the benefits sought. Accordingly, the issues of entitlement to an initial rating in excess of 20 percent for the period from September 6, 2016 to July 15, 2020 and entitlement to an initial rating in excess of 30 percent for the period since July 16, 2020 for a cervical spine disability remain in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Higher Initial Ratings Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). Where there is a question as to which of two ratings 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 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his cervical and lumbar spine disabilities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). A May 2015 rating decision granted service connection for a lumbar spine disability at an initial 20 percent disability rating, effective September 3, 2014 and granted service connection for a cervical spine disability at an initial 10 percent disability rating, effective September 3, 2014. An October 2017 rating decision granted an initial 20 percent disability rating for a cervical spine disability, effective September 6, 2016. An October 2020 rating decision granted an initial 30 percent disability rating for a cervical spine disability, effective July 16, 2020. Currently, the Veteran has 10, 20 and 30 percent disability ratings for his cervical spine disability under Diagnostic Code 5242 and a 20 percent disability rating for his lumbar spine also under Diagnostic Code 5242. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Under the applicable criteria, the General Rating Formula for Diseases and Injuries of the Spine provides that a 10 percent rating is assignable for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees. A 20 percent rating is assignable for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees. A 30 percent rating is assignable for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assignable for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assignable for unfavorable ankylosis of the entire spine. These criteria are applied with and without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. These criteria are disjunctive. See Johnson v. Brown, 7 Vet. App. 95 (1994) [only one disjunctive "or" requirement must be met in order for an increased rating to be assigned]; Cf. Melson v. Derwinski, 1 Vet. App. 334 (1991) [use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met]. The rating criteria define normal range of motion for the various spinal segments for VA compensation purposes. Normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion is zero to 45 degrees, and left and right lateral rotation is zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), as added by 68 Fed. Reg. 51,454 (Aug. 27, 2003). Under the applicable criteria, the General Rating Formula for Diseases and Injuries of the Spine provides that a rating of 20 percent is assignable for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. A 40 percent rating is assignable where forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assignable for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assignable for unfavorable ankylosis of the entire spine. These criteria are applied with and without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. These criteria are disjunctive. See Johnson v. Brown, 7 Vet. App. 95 (1994) [only one disjunctive "or" requirement must be met in order for an increased rating to be assigned]; Cf. Melson v. Derwinski, 1 Vet. App. 334 (1991) [use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met]. Ankylosis is the immobility and consolidation of a joint due to disease, injury or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. The rating criteria define normal range of motion for the various spinal segments for VA compensation purposes. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Further, the normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), as added by 68 Fed. Reg. 51,454 (Aug. 27, 2003). Also, the current schedular rating criteria instructs to evaluate intervertebral disc syndrome (IVDS or degenerative disc disease) either under the general rating formula for diseases and injuries of the spine or under the formula for rating IVDS based on incapacitating episodes, whichever method results in the higher evaluation. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (in pertinent part): a 10 percent disability rating is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1): For purposes of evaluations under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The evaluation criteria are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine. Therefore, an evaluation based on pain alone would not be appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51, 455 (Aug. 27, 2003). Cervical Spine The Veteran underwent a VA examination in February 2015. The Veteran reported having neck pain and a stiff neck which was worse with sleeping. He did not report flare-ups of the cervical spine and did not report any functional loss of the cervical spine. On examination, flexion of the cervical spine was from 0 to 40 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. He did not have guarding or muscle spasms. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He did not have intervertebral disc syndrome of the cervical spine and did not use any assistive devices. The Veteran's cervical spine disability did not impact his ability to work. The Veteran underwent a VA examination in September 2016. The Veteran reported having flare-ups of the cervical spine as he had pain. On examination, flexion of the cervical spine was from 0 to 30 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. He did not have guarding or muscle spasms. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He had intervertebral disc syndrome of the cervical spine. The Veteran's cervical spine disability did not impact his ability to work. The Veteran underwent a VA examination in November 2019. The Veteran did not report flare-ups of the cervical spine nor functional loss. On examination, flexion of the cervical spine was from 0 to 30 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. He did not have guarding or muscle spasms. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal. The Veteran had mild radiculopathy of the right and left upper extremities. He had intervertebral disc syndrome of the cervical spine but it did not require bedrest and there were no incapacitating episodes in the past 12 months. The Veteran's cervical spine disability did not impact his ability to work. Passive range of movement was the same as active range of movement. The Veteran underwent a VA examination in October 2020. The Veteran reported having constant, daily neck pain as well as stiffness and episodes of "locking up". He reported flare-ups that were so severe that he was unable to get up out of his chair all day. This occurred 2-3 times a week and were moderate to severe. He reported functional loss as his pain limited him with normal excursion, strength, speed, coordination and endurance. On examination, flexion of the cervical spine was from 0 to 20 degrees. Pain was noted on the examination that caused functional loss. There was no pain with weight bearing and no pain and tenderness on palpation. The Veteran was able to perform repetitive use testing with additional loss of function or range of motion as flexion was from 0 to 10 degrees after 3 repetitions. Pain, weakness, fatigue, incoordination and lack of endurance significantly limited functional ability as flexion was from 0 to 10 degrees after repetitions over a period of time. He had guarding and muscle spasms which resulted in abnormal gait or spinal contour. Muscle strength testing showed active movement against gravity (3/5) but there was no atrophy. There was no ankylosis. Reflexes were decreased and the Veteran had moderate radiculopathy of the bilateral upper extremities. He did not have intervertebral disc syndrome of the cervical spine and did not use any assistive devices. The Veteran's cervical spine disability impacted his ability to work as he lost 1-2 weeks of work in the past 12 months due to persistent, daily neck pain. There was pain with non-weight bearing. The Veteran underwent a VA examination in August 2021. The Veteran reported having pain in his neck which had worsened over the years. The neck pain was present all of the time. He slept on a chair because his neck pain worsened when he was lying flat on the ground. He took daily pain medication and had to take days off from his part time job due to neck pain. He was hospitalized for neck pain 2 years ago. He reported flare-ups which consisted of pain and stiffness of his neck which lasted 1-2 hours. There may be several episodes of exacerbations a day. The Veteran reported having functional loss as his neck stiffness prevented him from movement of his neck to a large extent. On examination, active and passive range of motion demonstrated flexion of the cervical spine that was from 0 to 20 degrees. There was evidence of pain with weight-bearing, nonweight-bearing, active motion, passive motion and on rest/non-movement. The pain caused functional loss as the Veteran's neck was mostly in a straight position without much movement. There was evidence of crepitus and tenderness to palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. Pain, weakness, fatigue, incoordination or lack of endurance did not significantly limit functional ability after repetitions over a period of time or during flare-ups. He had guarding which resulted in abnormal gait or spinal contour. There was interference with sitting, interference with standing, disturbance of locomotion and less movement than normal. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and sensory examinations were normal. The Veteran had moderate radiculopathy of the bilateral upper extremities. He had intervertebral disc syndrome of the cervical spine but there were no incapacitating episodes requiring bedrest in the past 12 months. The Veteran's cervical spine disability impacted his ability to work as he was unable to do physical work. Period prior to September 6, 2016 Considering the pertinent facts in light of applicable rating criteria, the Board finds that an initial evaluation in excess of 10 percent is not warranted for the Veteran's cervical spine disability for the period prior to September 6, 2016. As enumerated above, an initial rating in excess of 10 percent is warranted only if the competent medical and other evidence of record reflects no less than either (1) incapacitating episodes having a total duration of least 2 weeks but less than 4 weeks during the past 12 months or (2) forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. See the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes and The General Rating Formula for Diseases and Injuries of the Spine, respectively. The record does not contain evidence of forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. Notably, the February 2015 VA examination demonstrated flexion from 0 to 40 degrees. As such, the general rating criteria do not entitle the Veteran to an initial rating in excess of 10 percent. The Board also finds that there is no basis for the assignment of any higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. Competent medical evidence reflects that the currently assigned 10 percent rating properly compensates him for the extent of functional loss resulting from any such symptoms for the period prior to September 6, 2016. Although it was noted on the February 2015 VA examination report that there was pain on motion, repetitive use was done with no change in motion. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements as the February 2015 VA examiner again specifically noted that the Veteran did not report flare-ups and pain weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. In addition to testing, the Veteran had been asked to describe functional loss and impairment in various situations and he has not identified that he has loss of motion to the degree required for a higher rating. The Board again acknowledges that the Veteran had pain and less movement than normal. This is well documented in the lay and medical evidence. Furthermore, the Board again accepts that he has functional impairment, pain and limited motion as demonstrated at the February 2015 VA examination. See DeLuca, supra. The Board further finds that the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for an initial evaluation in excess of 10 percent for the period prior to September 6, 2016. Therefore, even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board does not find that the Veteran's functional losses equate to the criteria required for a higher rating as the reported functional loss is not equivalent to forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. Since flexion had not been limited to greater than 15 degrees but not greater than 30 degrees even after repetitive use, the criteria for an initial 20 percent evaluation have not been met. Thus, the Board finds that the current initial 10 percent evaluation adequately portrays any functional impairment, pain, and weakness that the Veteran experiences as a consequence of use of his service-connected cervical spine disability for the period prior to September 6, 2016. Regarding an evaluation in excess of 10 percent based on incapacitating episodes, the Board again notes that under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a higher rating of 20 percent is warranted where the evidence reveals incapacitating episodes having a total duration of least 2 weeks but less than 4 weeks during the past 12 months. However, both the February 2015 VA examiner specifically noted that the Veteran had no incapacitating episodes of intervertebral disc syndrome that required bedrest prescribed by a physician in the past 12 months. Accordingly, an initial rating in excess of 10 percent under the Formula for Rating intervertebral disc disease on the basis of Incapacitating Episodes is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating greater than 10 percent for a cervical spine disability for the period prior to September 6, 2016. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Period from September 6, 2016 to July 15, 2020 Considering the pertinent facts in light of applicable rating criteria, the Board finds that an initial evaluation in excess of 20 percent is not warranted for the Veteran's cervical spine disability for the period from September 6, 2016 to July 15, 2020. As noted above, a rating in excess of 20 percent is available if the competent medical and other evidence of record reflects no less than either (1) incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months or (2) forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. See the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes and The General Rating Formula for Diseases and Injuries of the Spine, respectively. Regarding the orthopedic manifestations, the record does not contain evidence of forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine, as such, the general rating criteria do not entitle the Veteran to a rating in excess of 20 percent. Specifically, the September 2016 and November 2019 VA examinations both demonstrated forward flexion from 0 to 30 degrees. The current general rating formula provides for disability ratings without regard to symptoms such as pain, stiffness, or aching. Additionally, all of the VA examiners specifically found that there was no ankylosis. The Board also finds that there is no basis for the assignment of any higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. Competent medical evidence reflects that the currently assigned 20 percent rating properly compensates him for the extent of functional loss resulting from any such symptoms for the period from September 6, 2016 to July 15, 2020. Although it was noted on the VA examinations that the Veteran exhibited pain on cervical spine motion, the functional loss is not equivalent to limitation of flexion to 15 degrees or less; or, favorable ankylosis of the entire cervical spine to meet the criteria for a 30 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. As noted above, the September 2016 and November 2019 VA examiners also noted that the Veteran did not have additional limitation in range of motion of the cervical spine following repetitive use. Since flexion has not been limited to 15 degrees or less even after repetitive use; and the Veteran's spine is not ankylosed since he has demonstrated the ability to flex, extend, and laterally flex and rotate, the criteria for a 30 percent evaluation have not been met. Thus, the Board finds that the current initial 20 percent evaluation adequately portrays any functional impairment, pain, and weakness that the Veteran experiences as a consequence of use of his service-connected cervical spine disability. Regarding an evaluation in excess of 20 percent based on incapacitating episodes, the Board again notes that under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a higher rating of 40 percent is warranted where the evidence reveals incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. As noted by the November 2019 VA examiner, the Veteran had a diagnosis of intervertebral disc syndrome but had not had any incapacitating episodes of back pain in the last 12 months. Therefore, a higher rating based on incapacitating episodes is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). Thus, for all the foregoing reasons, the Board finds that an initial rating in excess of 20 percent for a cervical spine disability for the period from September 6, 2016 to July 15, 2020 is not warranted. Finally, the Board also acknowledges that Note (1) to the General Rating Formula for Diseases and Injuries of the Spine provide for separate rating(s) for associated neurologic impairment. The Board notes that the Veteran demonstrated some sensory deficits as the November 2019 VA examiner noted that the Veteran had mild radiculopathy of the right and left upper extremities. As a result, in a January 2020 rating decision, the RO granted service connection for left and right upper extremity radiculopathy. However, the Veteran has not disagreed with the January 2020 grants of separate evaluations for right and left upper extremity radiculopathy or the subsequent increased ratings that have been granted for these disabilities. Accordingly, these issues are not before the Board. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 20 percent for a cervical spine disability for the period from September 6, 2016 to July 15, 2020. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Period since July 16, 2020 Based on the August 2021 VA examination, the Board finds that when affording the Veteran the benefit of the doubt, an initial 40 percent rating is warranted for the Veteran's service-connected cervical spine disability for the period since July 16, 2020. Turning to the orthopedic manifestations, the Board notes that for a 40 percent evaluation, the Veteran must demonstrate unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2020). Notably, on the October 2020 and August 2021 VA examinations, forward flexion of his cervical spine was only limited to at worst 10 degrees. However, on the August 2021 VA examination, the VA examiner also specifically indicated that the Veteran reported flare-ups which resulted in functional loss as his neck stiffness prevented him from movement of his neck to a large extent. The examiner also noted that the pain caused functional loss as "the Veteran's neck was mostly in a straight position without much movement". As noted above, under the General Rating Formula, a 40 percent evaluation is warranted for favorable ankylosis of the entire cervical spine. As a result, based on the August 2021 VA examination, the Board finds that when affording the Veteran the benefit of the doubt that an initial 40 percent rating is warranted for the Veteran's service-connected cervical spine disability for the period since July 16, 2020. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for a higher evaluation in excess of 40 percent. Initially, the Board notes that under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent disability rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The record demonstrates that while the Veteran had a diagnosis of intervertebral disc syndrome, he had not had any incapacitating episodes of back pain in the last 12 months. Therefore, a higher rating based on incapacitating episodes is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). Turning to the orthopedic manifestations, in order for the Veteran to be awarded a disability rating higher than 40 percent under the general spine formula, the evidence must show the presence of unfavorable ankylosis of the entire spine. As discussed in detail above, the evidence fails to demonstrate unfavorable ankylosis of the entire spine to obtain a higher evaluation. See supra 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2020). In that regard, the evidence simply does not show unfavorable ankylosis of the entire spine as multiple VA examinations have demonstrated the ability to flex, extend, and laterally flex and rotate the entire spine. As the Veteran has not been noted to have unfavorable ankylosis of the entire spine at any time, the Board finds that a rating in excess of 40 percent is not warranted for his orthopedic findings. The Board again acknowledges that Note (1) to the General Rating Formula for Diseases and Injuries of the Spine provide for separate rating(s) for associated neurologic impairment. The Board notes that the Veteran demonstrated some sensory deficits as the August 2021 VA examiner noted that the Veteran had moderate radiculopathy of the right and left upper extremities. As a result, in a January 2020 rating decision, the RO granted service connection for left and right upper extremity radiculopathy. However, the Veteran has not disagreed with the January 2020 grants of separate evaluations for right and left upper extremity radiculopathy or the subsequent increased ratings that have been granted for these disabilities. Accordingly, these issues are not before the Board. Accordingly, the Board finds that the evidence supports the assignment of an initial 40 percent rating for a cervical spine disability for the period since July 16, 2020. However, the Board finds that the preponderance of the evidence is against the assignment of an initial rating greater than 40 percent. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Lumbar Spine The Veteran underwent a VA examination in February 2015. The Veteran reported having back pain with regular activity and when bending forward. He did not report flare-ups of the lumbar spine and did not report any functional loss of the lumbar spine. On examination, flexion of the lumbar spine was from 0 to 40 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. He did not have guarding or muscle spasms. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He did not have intervertebral disc syndrome of the lumbar spine and did not use any assistive devices. The Veteran's lumbar spine disability impacted his ability to work as he could not lift more than 20 pounds. The Veteran underwent a VA examination in June 2015. The Veteran reported flare-ups of the lumbar spine as he had occasional back pain. He did not report any functional loss of the lumbar spine. On examination, flexion of the lumbar spine was from 0 to 40 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. He had muscle spasms that did not result in an abnormal gait or abnormal spine contour. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He did not have intervertebral disc syndrome of the lumbar spine and did not use any assistive devices. The Veteran's lumbar spine disability did not impact his ability to work. The Veteran underwent a VA examination in November 2016. The Veteran reported flare-ups of the lumbar spine as he reported having persistent back pain that was 10/10 level intensity when it was severe. His baseline back pain level is 3/10. His pai was triggered by prolonged walking and prolonged standing. On examination, flexion of the lumbar spine was from 0 to 75 degrees. Pain was noted on the examination but it did not cause functional loss. There was no pain with weight bearing and no pain or tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. He had no muscle spasms or guarding. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He did not have intervertebral disc syndrome of the lumbar spine and did not use any assistive devices. The Veteran's lumbar spine disability impacted his ability to work as he could have problems in a job setting performing jobs that required strenuous activity. The examiner noted that the Veteran had a lumbar strain of mild severity. The Veteran underwent a VA examination in March 2018. The Veteran indicated that he had increased back pain which caused him to increase his medication. He reported flare-ups of the lumbar spine as he reported having severe back pain that was brought on by more extreme activity such as heavy lifting. He had functional loss as he was unable to bend over and tie his shoes. On examination, flexion of the lumbar spine was from 0 to 50 degrees. Pain was noted on the examination and caused functional loss as he had difficulty bending forward. There was no pain with weight bearing but there was pain and tenderness on palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or with flare-ups. He had no guarding but had muscle spasms that did not result in abnormal gait or spinal contour. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and the sensory examination were normal and the Veteran did not have radiculopathy. He did not have intervertebral disc syndrome of the lumbar spine and did not use any assistive devices. The Veteran's lumbar spine disability did not impact his ability to work. The Veteran underwent a VA examination in October 2020. The Veteran indicated that he had episodes of lower back pain that were aggravated by strenuous activity and weight bearing exercises. He also reported an inability to be in prolonged positions due to extreme pain. He had difficulty ambulating on uneven terrain and noted sleep disturbance due to pain. He noted that these episodes were becoming more frequent and severe. He reported flare-ups that were so severe that he was unable to get up out of his chair all day. This occurred 1-3 times a week and were moderate to severe. He reported functional loss as his pain limited him with normal excursion, strength, speed, coordination and endurance. On examination, flexion of the lumbar spine was from 0 to 60 degrees. Pain was noted on the examination that caused functional loss. There was pain with weight bearing but there was no pain and tenderness on palpation. The Veteran was able to perform repetitive use testing with additional loss of function or range of motion as flexion was from 0 to 50 degrees after 3 repetitions. Pain, weakness, fatigue, incoordination and lack of endurance significantly limited functional ability as flexion was from 0 to 50 degrees after repetitions over a period of time. He had guarding and muscle spasms which resulted in abnormal gait or spinal contour. Muscle strength testing showed active movement against gravity (3/5) but there was no atrophy. There was no ankylosis. Reflexes were decreased and the Veteran had moderate radiculopathy of the bilateral lower extremities. He did not have intervertebral disc syndrome of the lumbar spine and did not use any assistive devices. The Veteran's lumbar spine disability impacted his ability to work as he lost 1-2 weeks of work in the past 12 months due to persistent, daily back pain. There was pain with non-weight bearing. The Veteran underwent a VA examination in August 2021. The Veteran reported having pain in his back which had worsened over the years. The back pain was present all of the time as he had pain sitting, standing, walking or even just resting. He reported flare-ups which consisted of pain and stiffness of his back which lasted 1-2 hours many times a day. There were no episodes of incapacitation which required hospitalization or bedrest. The Veteran reported having functional loss as he had pain and stiffness on bending. On examination, active and passive range of motion demonstrated flexion of the lumbar spine was from 0 to 40 degrees. There was evidence of pain with weight-bearing, nonweight-bearing, active motion, passive motion and on rest/non-movement. The pain caused functional loss. There was evidence of crepitus and tenderness to palpation. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. Pain, weakness, fatigue, incoordination or lack of endurance did not significantly limit functional ability after repetitions over a period of time or during flare-ups. He had tenderness and spasms which did not result in abnormal gait or spinal contour. There was interference with sitting, interference with standing, disturbance of locomotion and less movement than normal. Muscle strength testing was normal and there was no atrophy. There was no ankylosis. Reflexes and sensory examinations were normal. The Veteran had moderate radiculopathy of the bilateral lower extremities. He had intervertebral disc syndrome of the lumbar spine but there were no incapacitating episodes requiring bedrest in the past 12 months. The Veteran's lumbar spine disability impacted his ability to work as he was unable to do physical work. Based on the reported symptomatology of the Veteran's limitation of motion and reported functional impairment and flare-ups at his November 2016, March 2018, October 2020 and August 2021 VA examinations, the Board finds that when affording the Veteran the benefit of the doubt, an initial 40 percent rating is warranted for the Veteran's service-connected lumbar spine disability. Turning to the orthopedic manifestations, the Board notes that for a 40 percent evaluation, the Veteran must demonstrate forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2020). The Board notes that the VA examination in October 2020 noted flexion from 0 to 60 degrees and the most recent VA examination in August 2021 noted flexion of 0 to 40 degrees The October 2020 VA examiner also indicated that the Veteran would have flexion from 0 to 50 degrees with repeated use over time. This correlates to only a 20 percent rating. However, the October 2020 VA examiner also indicated that the Veteran reported an inability to be in prolonged positions due to extreme pain, had difficulty ambulating on uneven terrain and noted sleep disturbance due to pain. The Veteran also noted that these episodes were becoming more frequent and severe while he also reported flare-ups that were so severe that he was unable to get up out of his chair all day. The examiner noted that the Veteran had reported functional loss as his pain limited him with normal excursion, strength, speed, coordination and endurance. Additionally, the most recent August 2021 VA examiner noted that the Veteran had pain sitting, standing, walking or even just resting and reported flare-ups which consisted of pain and stiffness of his back which lasted 1-2 hours many times a day. There was evidence of pain with weight-bearing, nonweight-bearing, active motion, passive motion and on rest/non-movement and there was also interference with sitting, interference with standing, disturbance of locomotion and less movement than normal. Based on the reported symptomatology of the Veteran's reported functional impairment and flare-ups at his VA examinations, the Board finds that when affording the Veteran the benefit of the doubt that an initial 40 percent rating is warranted for the Veteran's service-connected lumbar spine disability. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for a higher evaluation more than 40 percent. Initially, the Board notes that under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent disability rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. As noted by the VA examiners, the Veteran had a diagnosis of intervertebral disc syndrome but had not had any incapacitating episodes of back pain in the last 12 months. Therefore, a higher rating based on incapacitating episodes is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). Turning to the orthopedic manifestations, in order for the Veteran to be awarded a disability rating higher than 40 percent under the general spine formula, the evidence must show the presence of spinal ankylosis. As discussed in detail above, the evidence fails to demonstrate unfavorable ankylosis of the entire thoracolumbar spine to obtain a higher evaluation. See supra 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2020). In that regard, the evidence simply does not show any ankylosis of the lumbar spine. In fact, the documented range of motion findings do not demonstrate that the joint was immobile or fixed in place. As the Veteran has not been noted to have ankylosis of the spine at any time, the Board finds that a rating in excess of 40 percent is not warranted for his orthopedic findings. Finally, the Board also acknowledges that Note (1) to the General Rating Formula for Diseases and Injuries of the Spine provide for separate rating(s) for associated neurologic impairment. The Board notes that the Veteran has demonstrated sensory deficits. As a result, in an October 2019 rating decision the RO granted service connection for left lower extremity radiculopathy (sciatic nerve) at an initial 40 percent disability evaluation and granted service connection for right lower extremity radiculopathy (sciatic nerve) at an initial 20 percent disability evaluation. Additionally, in an October 2020 rating decision, the RO granted service connection for right and left lower extremity radiculopathy (femoral nerves) at initial 20 disability evaluations and granted service connection for right and left lower extremity radiculopathy (external cutaneous nerves of the thighs, ilio inguinal nerves, obturator nerves) at initial noncompensable evaluations. However, the Veteran has not disagreed with the October 2019 and October 2020 grants of separate evaluations for right and left lower extremity radiculopathy. Accordingly, these issues are not before the Board. Accordingly, the Board finds that the evidence supports the assignment of an initial 40 percent rating for a lumbar spine disability. However, the Board finds that the preponderance of the evidence is against the assignment of an initial rating greater than 40 percent. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include sensorineural hearing loss, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as sensorineural hearing loss is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran contends that he has current bilateral hearing loss that is related to noise exposure in service. Notably, the Veteran has been granted service connection for tinnitus as his military noise exposure has been conceded. The Veteran's service treatment records are negative for complaints of, treatment for, or findings of bilateral hearing loss. The Veteran's January 1995 entrance audiological examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 0 0 5 LEFT 5 10 5 5 10 The Veteran's November 1998 separation audiological examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 5 LEFT 0 0 0 0 5 The Veteran underwent a VA audiological examination in March 2015. Audiological examination results were not provided as the examiner noted that the test results were not valid for rating purposes due to inconsistent responses by the Veteran. The examiner noted that the Veteran had normal hearing. The Veteran underwent a VA audiological examination in March 2020. The March 2020 audiological examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 20 30 30 LEFT 20 20 20 20 30 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The examiner found that the use of the word discrimination score was appropriate for the Veteran. The examiner noted that no hearing loss etiology opinion for right and left ear hearing loss was requested. Considering the claim for service connection for bilateral hearing loss, in light of the record and the governing legal authority, the Board finds that the claim must be denied. The Veteran contends that he has hearing loss a result of his service and as reflected above, the Board notes that the Veteran has been granted service connection for tinnitus based on this conceded in-service noise exposure. However, the post-service evidence demonstrates that the Veteran does not have a current bilateral hearing loss disability as defined by 38 C.F.R. § 3.385, as the auditory thresholds obtained during the pendency of this claim were not 40 decibels or greater at any of the frequencies, the auditory thresholds at the minimum three of the frequencies were not 26 decibels or greater, and the Maryland CNC speech recognition score was not less than 94 percent. See 38 C.F.R. § 3.385. Notably, the VA examination in March 2020 does not show a bilateral hearing loss disability by VA standards. Thus, there is no competent evidence reflective of a hearing loss disability as defined by 38 C.F.R. § 3.385 at any time during the pendency of this appeal. The Board appreciates the Veteran's contentions and statements related to his claimed bilateral hearing loss. However, even conceding that the Veteran was exposed to significant noise in service, the evidence does not show a bilateral hearing loss disability by VA standards. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. Thus, where, as here, competent and persuasive medical evidence establishes that the Veteran does not have a bilateral hearing loss disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the claim for service connection for bilateral hearing loss must be denied because the first essential criterion for a grant of service connection-competent evidence of the currently claimed disability-has not been met. With respect to the Veteran's contention that he currently has a bilateral hearing loss disability, a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). As a layperson, the Veteran is competent to report that he experiences difficulty hearing. However, he is not competent to render a diagnosis of a bilateral hearing loss disability that satisfies the regulatory criteria set forth in 38 C.F.R. § 3.385. Absent evidence of a current bilateral ear hearing loss disability diagnosis, the Board concludes that the claim of entitlement to service connection for a bilateral hearing loss disability must be denied. The Board notes the Veteran's contentions regarding the etiology of his claimed bilateral hearing loss disability. To the extent that the Veteran himself contends that a medical relationship exists between his claimed bilateral hearing loss disability and service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that a bilateral hearing loss disability is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding the claimed bilateral hearing loss etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the VA examiners provided detailed rationale in support of their opinions and cited to the relevant evidence. For this reason, the VA examiners' opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.