Citation Nr: 21067270 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 16-34 626 DATE: November 3, 2021 ORDER Entitlement to a non-initial rating in excess of 20 percent for a low back disorder, to include arthritis, is denied. A non-initial rating of 60 percent, but no higher, for left total knee replacement is granted. A non-initial rating of 60 percent, but no higher, for right total knee replacement is granted. Entitlement to a non-initial rating in excess of 10 percent for hypertension is denied. FINDINGS OF FACT 1. The Veteran's low back disorder is not manifested by limitation of forward flexion to 30 degrees or less or ankylosis. 2. After bilateral total knee replacement, the Veteran's bilateral knees are manifested by chronic residuals consisting of severe painful motion or weakness in the bilateral knees. 3. The Veteran's hypertension is not shown to have been productive of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. CONCLUSIONS OF LAW 1. The criteria for a non-initial rating in excess of 20 percent for a low back disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5237. 2. The criteria for a non-initial rating of 60 percent, but no higher, for the left total knee replacement have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055. 3. The criteria for a non-initial rating of 60 percent, but no higher, for the right total knee replacement have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055. 4. The criteria for a non-initial rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1982 to May 2002. These issues were remanded by the Board in an August 2019 decision for further development. The issues have since returned to the Board for appellate review. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). More generally, 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). And although VA is required to apply 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment for disabilities evaluated on the basis of limitation of motion, where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, these regulations are not for application. Johnston, 10 Vet. App. at 84-85. Moreover, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 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. Id.; see 38 C.F.R. § 4.40. 1. Entitlement to a non-initial rating in excess of 20 percent for a low back disorder, to include arthritis, is denied. The Veteran asserts that his low back disorder is more severe than the rating currently assigned. Disabilities of the spine are currently rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or 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. The General Rating Formula for Diseases and Injuries of the Spine provides a 20 precent disability rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Note (2) provides that, 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 normal combined range of motion of the thoracolumbar spine is 240 degrees. See also Plate V, 38 C.F.R. § 4.71a. When rating degenerative arthritis of the spine (Diagnostic Code 5242), in addition to consideration of rating under the General Rating Formula for Diseases and Injuries of the Spine, rating for degenerative arthritis under Diagnostic Code 5003 should also be considered. 38 C.F.R. § 4.71a. Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides a 20 percent rating for IVDS 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 for IVDS 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 for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. In a May 2015 private treatment letter, the Veteran stated he experiences low back pain since his bilateral knee replacement surgery. On the November 2015 private treatment record, the medical provider stated the Veteran experiences increased pain and decreased mobility. The medical provider stated the Veteran's back pain is constant in varying degrees and the pain intensifies on standing, sitting, walking, stairs, and changing positions especially in weight bearing. The medical provider stated the Veteran's back pain is significantly exacerbated by minor lifting. The medical provider observed the Veteran's lumbar spine range of motion are flexion to 20 degrees; extension to minus 5 degrees (he walks and stands in a 5-degree flexed position as an orthopedic restriction), right rotation to 15 degrees; left rotation to 15 degrees; right lateral flexion to 15 degrees; and left lateral flexion to 15 degrees. The medical provider also observed the Veteran to have significant loss of 50 percent or more of the normal mobility. On the April 2016 VA back examination, the examiner indicated the Veteran has degenerative arthritis of the spine. Since his last examination, the Veteran reported he experienced more pain, difficulty with lifting, and the need for prescription medication for pain. The Veteran stated he did not experience flare-ups of the thoracolumbar spine. The April 2016 VA back examiner observed the Veteran's range of motion to be forward flexion to 70 degrees; extension to 30 degrees; right lateral flexion to 30 degrees; left lateral flexion to 30 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. The examiner noted pain on examination but found the pain did not cause functional loss. The examiner observed the Veteran to experienced pain on forward flexion. The examiner indicated there is no pain on weight bearing. The examiner also indicated the Veteran does not have ankylosis of the spine or thoracic vertebral fracture with loss of 50 percent or more of height. On the July 2016 private treatment letter, the medical provider stated that the Veteran has discogenic sciatic radicular pain and weakness of the left upper extremity, which clearly indicates that the Veteran's low back disorder is more involved than indicated on the November 2015 report. The medical provider stated that the range of motion measurements from November 2015 report were not properly performed. The medical provider asserts that if the November 2015 report range of motion testing was done properly, the Veteran's range of motion would be flexion to 20 degrees; extension to 5 degrees; right rotation to 15 degrees; left rotation to 15 degrees; right lateral flexion to 15 degrees; and left lateral flexion to 15 degrees. The medical provider also stated there is significant loss of 50 percent or more of the normal mobility of a lumbar segment. On the August 2020 VA back examination, the examiner indicated the Veteran has a diagnosis of a lumbar strain. The Veteran stated that he experiences stiffness, pain, pain shooting down the leg, and requires treatment for pain. The Veteran stated during flare-ups it is difficulty to perform tasks. The Veteran stated he experiences flare-ups two times a month and last two to three days. The Veteran stated flare-ups are precipitated by "sleeping wrong," getting out of bed, lifting, or wrong movements. The Veteran stated the flare-ups are alleviated by rest and pain medication. The Veteran also stated that he experiences functional loss or functional impairment due to extreme back pain that does not allow him to sit or stand for prolonged periods of time. On examination, the August 2020 VA examiner observed the Veteran's range of motion to be forward flexion to 60 degrees; extension to 15 degrees; right lateral flexion to 15 degrees; left lateral flexion to 15 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 15 degrees. The examiner noted pain on examination that causes functional loss. The examiner indicated the Veteran experiences pain on forward flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The examiner indicated the examination was conducted during a flare-up. The examiner found that pain, weakness, and lack of endurance limit functional ability with flare-ups. In terms of range of motion, the examiner described the range of motion as forward flexion to 50 degrees; extension to 10 degrees; right lateral flexion to 10 degrees; left lateral flexion to 10 degrees; right lateral rotation to 10 degrees; and left lateral rotation to 10 degrees. The examiner indicated the Veteran does not have guarding or muscle spasm, ankylosis, or IVDS of the lumbar spine. Upon review of the record, the Board finds that a disability rating in excess of 20 percent for the Veteran's back disorder is not warranted. To obtain a higher rating, it is necessary to show forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Here, however the Veteran has not been found to have ankylosis or forward flexion limited to 30 degrees or less. Further, there is no evidence that the Veteran is diagnosed with IVDS or found to have incapacitating episodes. Thus, the Board finds that a higher rating is not warranted for the Veteran's low back disorder at any time during the appeal period. The Board acknowledges the November 2015 private treatment record findings of lumbar spine flexion limited to 20 percent; however, the Board finds this record to not be persuasive as the findings are not supported by the other medical evidence. All other VA examinations have documented forward flexion limited to, at worst, 50 degrees even when examination was conducted during a flare-up, as found at the August 2020 VA examination. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the preponderance of the evidence is against the Veteran's claim, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to a non-initial rating of 60 percent for left total knee replacement is granted. 3. Entitlement to a non-initial rating of 60 percent for right total knee replacement is granted. The Veteran asserts that his bilateral knee disorder is more severe than the rating currently assigned. Under DC 5055, a 30 percent rating is warranted as a minimum rating for knee replacement. With intermediate degrees of residual weakness, pain, or limitation of motion, the condition is rated by analogy to DC 5256 (limitation of extension), 5261 (ankylosis of the knee), or 5262 (impairment of the tibia and fibula). A 60 percent rating is warranted for knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A maximum rating of 100 percent is warranted for one year following implantation of prosthesis. 38 C.F.R. § 4.71a, DC 5055. Full range of motion of the knee is from 0 degrees to 140 degrees in extension and flexion. See 38 C.F.R. § 4.71, Plate II. At the outset, the Board notes that the evidence does not support an award for increased ratings for the right or left knee under Diagnostic Code 5256 for ankylosis; Diagnostic Code 5161 for limitation of extension to 30 degrees or more; or Diagnostic Code 5262 for impairment of tibia and fibula. This is because none of these disabilities have been demonstrated upon the private November 2015 examination or VA examinations performed in April 2016 or August 2020 and are not otherwise reflected in the record before the Board at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262. The Board notes that the Schedule of Ratings for the Musculoskeletal System was amended in February 2021 so that it more clearly reflects VA's policies concerning the evaluation of musculoskeletal disorders, specifically, 38 C.F.R. § 4.71a. The Board notes that only two Diagnostic Codes 5257 and 5262 for knee disabilities were amended in the recent regulatory change. However, the remaining diagnostic codes relating to knee and leg disabilities, including 5256 and 5261, were not amended. Although there is no specific effective date provided for rating issues under the new criteria, the regulation is not retroactive prior to February 7, 2021. Therefore, the new regulation applies to claims filed on or after February 7, 2021 and claims pending on February 7, 2021, if the new regulation is more favorable for the Veteran. 38 C.F.R. § 4.71a (2021). As this appeal was pending prior to the February 2021 effective date for revised ratings for the musculoskeletal system, the Board will consider its application to the Veteran's claim for increased rating from February 7, 2021 onward. Under the revised criteria, Diagnostic Code 5055 for knee resurfacing or replacement (prosthesis) provides a 30 percent rating is assigned as the minimum evaluation for total replacement only. A 60 percent rating is assigned for prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity or with intermediate degrees of residual weakness, pain, or limitation of motion rated by analogy to Diagnostic Codes 5256, 5261, or 5262. And a 100 percent rating is assigned for 4 months following implantation of prosthesis or resurfacing. The note following stated that at the conclusion of the 100 percent evaluation period, evaluate resurfacing under Diagnostic Codes 5256 through 5262. The note stated there is no minimum evaluation for resurfacing. In a May 2015 private treatment letter, the Veteran stated he has residual bowleggedness since his bilateral knee replacement and he believes that he is compensating as a result. The medical provider opined that the Veteran likely does have some degrees of a limb length discrepancy since undergoing bilateral knee replacement surgery. The medical provider stated that the Veteran is likely compensating for bowleggedness. In November 2015 private treatment record, the medical provider stated that the Veteran has increased pain and decreased function in the bilateral knees. The medical provider stated that the pain intensifies with walking, standing, sitting, arising from a seated position, and generally repositioning the limb. The medical provider stated that since surgery, the Veteran experiences clicking and popping in the knees with walking. The medical provider found that the Veteran's knees lock and cause the Veteran to nearly fall. On examination, the medical provider observed the Veteran's right knee flexion to 80 degrees and adequate extension. The Veteran's left knee flexion to 30 degrees and adequate extension with pain. In an April 2016 VA knee examination, the examiner indicated the Veteran has a diagnosis of bilateral knee status post prosthesis. The examiner stated the Veteran had a right knee replacement in 2012 and 2013. The Veteran reported that he experiences pain and stiffness in the bilateral knees. He stated he can walk about one half of a city block before his knees "get really tight and painful." The Veteran reported he does not experience flare-ups. The Veteran stated he experiences functional loss or functional impairment of the bilateral knees when he walks more than one half of a city block. On examination, the April 2016 VA knee examiner observed the Veteran's right knee and left knee range of motion to be flexion to 60 degrees and extension to 0 degrees. The examiner observed the Veteran to experience pain on rest and non-movement and in flexion and extension in the bilateral knees. The examiner stated that the Veteran's range of motion is under subjective control of the Veteran and there is no objective medical evidence of failed total knee arthroplasty bilaterally. The examiner stated that the expected range of motion after total knee arthroplasty would be at minimum 75 degrees of flexion. The examiner noted muscular resistance with passive and active range of motion. The examiner indicated the Veteran does not have ankylosis. The examiner also found the Veteran does not have a history of recurrent subluxation, lateral instability, or recurrent effusion. Further, the examiner indicated the Veteran does not have recurrent patellar dislocation, "shin splints," or meniscal conditions. However, the examiner did find that the Veteran's bilateral knee total knee replacement resulted in intermediate degrees of residual weakness, pain, or limitation of motion. In a July 2016 private treatment letter, the medical provider asserts that the Veteran has bilateral knee failed surgical syndrome as a result of substantial lateral instability. The medical provider also observed the Veteran to have substantial pain when the prosthetic knees give out causing the Veteran to fall. The medical provider stated that when the Veteran's bilateral knees give out there is evidence of chronic residuals of painful motion and dangerous weakness of the affected extremity. The medical provider opined that the Veteran's bilateral knee replacement surgery is failed and has caused the abovementioned residuals. In a May 2018 VA treatment record, the Veteran stated he has anxiety when walking because he feels his knees may give out. In an August 2019 VA treatment record, the Veteran is requesting bilateral knee braces to assist with stabilizing his knees. In a November 2019 VA treatment record, the medical provider indicated the Veteran denied knee pain. The medical provider observed the Veteran to have full range of motion of all extremities. On the August 2020 VA knee examination, the examiner indicated the Veteran has a diagnosis of bilateral knee arthritis and bilateral knee replacement. The Veteran stated that he experiences a little stiffness, difficulties with balance, pain, an inability to extend legs. He stated he is unable to participate in ordinary activities and uses a cane to help walk short distances. The Veteran reported that he has flare-ups in the right and left knee. The Veteran also reported he has functional loss or functional impairment because he has difficulty standing, sitting, walking, pain, stiffness, and inability to extend legs. On examination, the August 2020 VA examiner observed the Veteran's right knee range of motion to be flexion to 50 degrees and extension to 0 degrees. The examiner indicated the Veteran has pain in flexion and extension that causes functional loss. The examiner observed the Veteran's left knee range of motion to be flexion to 60 degrees and extension to 0 degrees. The examiner observed the Veteran to experience pain in flexion and extension that causes functional loss. The examiner indicated there is no pain, weakness, fatigability, or incoordination that significantly limit functional ability with flare-ups. The examiner indicated there is no recurrent subluxation, lateral stability, or recurrent effusion. The examiner also found the Veteran did not have joint instability in the right or left knee. The examiner observed the Veteran to experience chronic residuals consisting of severe painful motion or weakness in the bilateral knees after the total knee replacements. Upon review of the record, the Board finds that a 60 percent rating is warranted for the Veteran's left total knee replacement and a 60 percent rating is warranted for the Veteran's right total knee replacement. In so finding, the Board notes that the July 2016 private treatment letter stated the Veteran's bilateral knees show evidence of chronic residuals of painful motion and dangerous weakness of the affected extremity. Also, the April 2020 VA examiner indicated the Veteran experiences chronic residuals consisting of severe painful motion or weakness in the bilateral knees after the total knee replacements. This evidence is most consistent with a 60 percent disability rating under Diagnostic Code 5055. Under the 2021 revised Schedule of Ratings for the Musculoskeletal System, from February 7, 2021 onward, the Board finds that the Veteran would qualify for the 60 percent rating assigned under Diagnostic Code 5055 (2021) for the same reasons previously stated. As the maximum 100 percent rating is only available one year after total knee replacement surgery under Diagnostic Code 5055 and only for four months after total knee replacement surgery under the revised Schedule of Ratings for the Musculoskeletal System under DC 5055 (2021) and the Veteran's total knee replacement surgeries occurred in 2012 and 2013, any extension of the initial 100 percent ratings is not warranted under the code. Accordingly, for the reasons discussed above, the Board finds that 60 percent ratings, but no higher are warranted for the left total knee replacement and right total knee replacement. 4. Entitlement to a non-initial rating in excess of 10 percent for hypertension is denied. The Veteran asserts that his hypertension is more severe than the rating currently assigned. Under DC 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. And a 60 percent rating is warranted for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means the diastolic blood pressure is predominantly 90mm. or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). February 2015 VA treatment records show the Veteran's blood pressure to be 140/70 and 124/74 respectively. A July 2015 VA treatment record shows the Veteran's blood pressure to be 129/80. In a November 2015 private treatment letter, the medical provider stated that the Veteran has suffered significant extension of the conditions. The medical provider stated the Veteran has suffered from control issues. The medical provider stated that the Veteran takes his blood pressure at home daily and the blood pressure runs in the 130s over the 90s, which is marginal. On the April 2016 VA hypertension examination, the examiner indicated the Veteran has a diagnosis of hypertension. The examiner noted the Veteran's treatment plan includes taking continuous medication for hypertension. The examiner found that the Veteran does not have a history of a diastolic blood pressure elevation to predominantly 100 or more. The examiner read the Veteran's blood pressure to be 156/101; 148/93; and 144/98. The examiner found the Veteran's average blood pressure to be 149/97. A February 2016 VA treatment record indicates the Veteran's blood pressure is 135/93. In a July 2016 private treatment letter, the medical provider stated that the Veteran has control issues with the hypertension medication. As a result, the prescribed medication is not working satisfactorily and therefore the Veteran has unstable blood pressure issues. In an August 2016 VA treatment record, the Veteran's blood pressure is 138/98. In another record, the Veteran's blood pressure is 152/114. In a January 2019 private treatment record, the Veteran complained of dizziness. The medical provider observed the Veteran's blood pressure ot be 175/120. The medical provider also noted the Veteran's last four vital signs to be 151/108; 140/103; 151/96; and 134/84. A December 2019 VA treatment record shows blood pressure readings from April 2019 to July 2019 as 131/86; 131/83; 145/83; 130/95; 133/97; 123/95; and 119/80. In a January 2020 VA treatment record, the Veteran's blood pressure is 123/87. In a February 2020 VA treatment record, the Veteran's blood pressure is 131/91. In an April 2020 VA treatment record, the Veteran's blood pressure is 140/90. On the August 2020 VA examination, the Veteran's blood pressure is reported as 122/80; 115/79; and 115/79. Upon review of the record, the Board finds that the Veteran's service-connected hypertension does not warrant a rating in excess of 10 percent. The treatment records include multiple blood pressure readings throughout the period on appeal. None show a diastolic pressure of predominantly 110 or more and none of the systolic blood pressure readings of record rise to the level of 200 or more. As such, a disability rating in excess of 10 percent for hypertension cannot be granted. The Board acknowledges the August 2016 and January 2019 diastolic blood pressure readings of 114 and 120 respectively. However, these two readings do not show that the Veteran's diastolic pressure is predominantly 110 or more, as the records show multiple readings over the period on appeal with diastolic pressure under 100. Therefore, a rating in excess of 10 percent is not warranted. Furthermore, while the Veteran has been prescribed medicine to treat his hypertension, the Board notes that the rating criteria for hypertension specifically contemplates the use of medication to ameliorate symptoms and that a higher rating may not be assigned based solely on the fact that the Veteran uses medication to treat his symptoms. Cf. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), ("[a]bsent a clear statement [in the diagnostic code] setting out whether or how the Board should address the effects of medication...the Board may not deny entitlement to a higher disability rating on the basis of relief provided by medication."). Indeed, in McCarroll v. McDonald, 28 Vet. App. 267 (2016), the Court specifically held that the Board did not err in failing to discount the ameliorative effects of blood pressure medication as the plain language of DC 7101 contemplates the effects of medications. Further, despite the Veteran's use of medications, as discussed above, there is simply no evidence of record to support a finding that his diastolic pressure has historically been predominantly 110 or more or systolic pressure over 200 to warrant a 20 percent rating. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the preponderance of the evidence is against the Veteran's claim, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, 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.