Citation Nr: 21075135 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-59 017 DATE: December 17, 2021 ORDER A rating in excess of 20 percent for diabetes mellitus (DM), to include whether separate ratings should be established for right upper extremity and left upper extremity diabetic neuropathies of both the radial and ulnar nerves, is denied. A separate compensable rating for erectile dysfunction (ED) is denied. A compensable rating for bilateral sensorineural hearing loss, prior to November 29, 2017, is denied. A rating in excess of 10 percent for bilateral sensorineural hearing loss, since November 29, 2017, is denied. An effective date of May 3, 2013, but no earlier, for the grant of service connection for ED is granted. An effective date of May 3, 2013, but no earlier, for the grant of special monthly compensation (SMC) for loss of use of a creative organ is granted. Service connection for hypertension is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran served on active duty from October 1966 to October 1969, to include service in the Republic of Vietnam. 2. DM with ED has been manifested by treatment through a restrictive diet, prescribed oral hypoglycemic agent, but no restriction of activities. 3. ED has been manifested by subjective complaints of an inability to maintain an erection; objective findings included no penile deformity. 4. Prior to November 29, 2017, bilateral hearing loss was manifested by no worse than Level IV hearing acuity in the right ear and Level II hearing acuity in the left ear. 5. Since November 29, 2017, bilateral hearing loss has been manifested by no worse than Level V hearing acuity in the right ear and Level III hearing acuity in the left ear. 6. On May 3, 2013, the RO received a claim for increase for the Veteran's service-connected DM, which is also considered an informal claim for associated ED and SMC for loss of use of a creative organ; prior to this date there is no indication of receipt of a formal or informal claim for such disability. 7. The May 3, 2013, claim was not received within one year of the date on which it was factually ascertainable that the Veteran had ED associated with his service-connected DM, and there was no pending or unadjudicated claim relating to DM or erectile dysfunction prior to May 3, 2013. 8. Hypertension was not shown in service, was not shown to a compensable degree within one year of service, symptoms were not continuous since service, and hypertension was not proximately due to, or aggravated by, a service-connected disability. 9. The Veteran's service-connected disabilities do not preclude him from securing and maintaining gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for DM with ED have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.120, Diagnostic Code (DC) 7913. 2. The criteria for a separate compensable rating for ED associated with DM have not been met. 38 U.S.C. §§ 1155, 5103(a), 5107; 38 C.F.R. § 4.115b, DC 7522. 3. The criteria for a compensable rating for bilateral hearing loss, prior to November 29, 2017, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.85, 4.86, DC 6100. 4. The criteria for a rating in excess of 10 percent for bilateral hearing loss, since November 29, 2017, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.85, 4.86, DC 6100. 5. The criteria for an effective date of May 3, 2013, but no earlier, for the grant of service connection for ED have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.157, 3.400. 6. The criteria for an effective date of May 3, 2013, but no earlier, for the grant of SMC for loss of use of a creative organ have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.157, 3.400. 7. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.30, 3.307, 3.309, 3.310. 8. The criteria for a TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In May 2021, the Board remanded the appeal for additional development. The case has now been returned to the Board for further appellate action. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. DM with ED The Veteran is currently rated at 20 percent under DC 7913. In order to warrant a higher rating of 40 percent, the medical evidence must show DM requiring insulin, restricted diet, and regulation of activities. Within the criteria for a 100 percent rating, "regulation of activities" is defined as "avoidance of strenuous occupational and recreational activities." This definition also applies to the "regulation of activities" criterion for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Turning to the medical evidence, a January 2014 VA examiner reported that DM was managed by a restricted diet and oral hypoglycemic agent. The examiner specifically denied that the Veteran required regulation of activities as a part of management of DM. Further, there was no indication that the use of insulin was required. A December 2015 VA examiner reported that DM was managed by oral hypoglycemic agent. The examiner specifically denied that the Veteran required regulation of activities as a part of management of DM. Further, there was no indication that the use of insulin was required. A November 2017 VA examiner reported that DM was managed by oral hypoglycemic agent. The examiner specifically denied that the Veteran required regulation of activities as a part of management of DM. Further, there was no indication that the use of insulin was required. Likewise, the Veteran reported that he visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia, less than two times per month. Even more, the Veteran did not report any episodes of ketoacidosis or hypoglycemic reactions that required hospitalization over the past twelve months. Next, the clinical treatment records do not reflect the use of insulin or regulation of activities for the treatment of DM. As such, the medical evidence does not support a rating in excess of 20 percent for DM. Additionally, regarding ED, a compensable rating for ED requires deformity of the penis with loss of erectile power. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. The December 2015 VA examination report reflected that the Veteran did not describe any penile deformity and declined a physical examination. Next, the November 2016 VA examination report reflected a normal physical examination of the penis. The November 2017 VA examination report reflected that the penis was not examined as a penis examination was not relevant to condition. A review of treatment notes also does not reflect findings of penile deformity or other symptoms that could support a compensable rating for ED. As such, a separate compensable rating for ED is not warranted. Further, the Board concludes that providing separate ratings for each upper extremity under the codes for radial and ulnar nerves (DCs 8514 and 8516) is not warranted. The Veteran's peripheral neuropathy of the upper extremities is currently evaluated under DC 8514. The Veteran underwent a VA examination in May 2017. The Veteran reported that his symptoms began 5 years ago. He experienced intermittent paresthesias, pain, and numbness in the fingers and toes. The Veteran was noted to be right hand dominant. The examiner noted the following upper extremity symptoms: mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the bilateral upper extremities. Muscle strength testing were found to be normal. Deep tendon reflexes were decreased in the biceps, triceps, and brachioradiales. Light touch/monofilament testing was normal except a decrease in the left hand/fingers. Muscle atrophy was not found. Trophic changes were not observed. The examiner found normal right radial nerve and mild incomplete paralysis of the left radial nerve. The examiner also found mild incomplete paralysis of the right and left ulnar nerves. Next, in a November 2017 VA examination, the Veteran reported that his symptoms had worsened. The Veteran was noted to be right hand dominant. The examiner noted the following upper extremity symptoms: mild intermittent pain and mild numbness in the bilateral upper extremities. Muscle strength testing and deep tendon reflexes were found to be normal. Light touch/monofilament testing was normal, except decreased hand/fingers. Muscle atrophy was not found. Trophic changes were not observed. The examiner found mild incomplete paralysis of the right and left radial and ulnar nerves. The Veteran underwent a VA examination in January 2020. The examiner noted the Veteran's reports that his symptoms began in 2015 with daily numbness and tingling in the upper and lower extremities. The Veteran was noted to be right hand dominant. The examiner noted the following upper extremity symptoms: moderate constant pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the bilateral upper extremities. Muscle strength testing and deep tendon reflexes were found to be normal, except wrist flexion was 3/5 in the right wrist. Light touch/monofilament testing was normal. Muscle atrophy was not found. Trophic changes were not observed. The examiner found mild incomplete paralysis of the right and left radial and ulnar nerves. Under Diagnostic Code 8514, for the radial nerve, incomplete paralysis is rated for the major extremity at 20 percent for mild severity, and for the minor extremity at 20 percent for mild severity. Under Diagnostic Code 8516, for the ulnar nerve, incomplete paralysis is rated for the major extremity at 10 percent for mild severity, and for the minor extremity at 10 percent for mild severity. See 38 C.F.R. § 4.124a. Assigning the rating most beneficial to the Veteran, the current 20 percent rating for both extremities for incomplete, mild paralysis of the radial nerve is appropriate. See 38 C.F.R. § 4.124a. A rating under both the radial and ulnar nerve is not permitted, as the rating of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disabilities. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Although the examiners noted separate findings of incomplete paralysis of the radial and ulnar nerves, the Board finds that separate ratings are not warranted as the Veteran is presently compensated for the totality of symptoms and the single impact on his bilateral upper extremities. In sum, separate ratings for the bilateral, upper extremity peripheral neuropathy are not warranted. Bilateral Hearing Loss Ratings for hearing loss disability are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level, in decibels (dB) as measured by pure tone audiometric tests in frequencies 1000, 2000, 3000, and 4000 Hertz (Hz). 38 C.F.R. § 4.85, DC 6100. An examination for hearing impairment for VA purposes must include a controlled speech discrimination test (Maryland CNC). To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Exceptional patterns of hearing impairment allow for assignment of the Roman numeral designation using Table VI or an alternate table, Table VIA, whichever is more beneficial to the Veteran. 38 C.F.R. § 4.86. This applies to two patterns. In both patterns each ear will be evaluated separately. The first pattern is where the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 dB or more. 38C.F.R. § 4.86 (a). The second pattern is where the pure tone threshold is 30 decibels or less at 1000 Hz and 70 dB or more at 2000 Hz. If the second pattern exists, the Roman numeral will be elevated to the next higher numeral. Prior to November 29, 2017 The Veteran contends that he is entitled to a compensable rating for bilateral hearing loss. Turning to the medical evidence, in a January 2014 VA examination, the puretone thresholds, in decibels, were reported as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 65 80 LEFT 5 10 15 40 45 The average pure tone threshold was 46 in the right ear, and 28 in the left ear. Speech audiometry revealed speech recognition ability of 72 percent in the right ear and 88 percent in the left ear. Applying those values to the rating criteria results in a numeric designation of Level IV in the right ear, and II in the left ear, resulting in a noncompensable rating. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown in either ear. In a December 2015 VA examination, the puretone thresholds, in decibels, were reported as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 25 60 80 LEFT 10 0 10 35 35 The average pure tone threshold was 41 in the right ear, and 20 in the left ear. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 96 percent in the left ear. Applying those values to the rating criteria results in a numeric designation of Level II in the right ear, and I in the left ear, resulting in a noncompensable rating. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown in either ear. As such, the medical evidence does not support a compensable rating prior to November 29, 2017. Since November 29, 2017 Turning to the medical evidence, in a November 2017 VA examination, the puretone thresholds, in decibels, were reported as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 30 35 70 80 LEFT 25 25 30 50 50 The average pure tone threshold was 54 in the right ear, and 39 in the left ear. Speech audiometry revealed speech recognition ability of 68 percent in the right ear and 80 percent in the left ear. Applying those values to the rating criteria results in a numeric designation of Level V in the right ear, and III in the left ear, resulting in a 10 percent rating. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown in either ear. As such, the medical evidence does not support a rating in excess of 10 percent since November 29, 2017. Clinical treatment records were reviewed, but there were no audiograms which showed bilateral hearing loss severe enough to warrant a higher rating during each rating period under appeal. With respect to all the increased rating claims, the Board has considered the lay statements that the Veteran's disabilities were worse. While laypersons are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses, either through experience or observation, they are not competent to identify a specific level of disability of a disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities was provided by the medical personnel who examined him during his lifetime and who rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly addressed the criteria under which these disabilities are evaluated. Moreover, as the examiners had the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology and any observations of his symptoms by the appellant. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and the appeals are denied. Effective Date for ED and SMC The Veteran claims that he is entitled to an effective date prior to December 18, 2015, for the grants of service connection for ED and SMC for loss of use of a creative organ. Specifically, he asserts that the date should be July 19, 2010, the effective date for the grant of service connection for DM. Turning to the relevant laws and regulations, unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. An effective date for secondary service connection is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400; Ellington v. Peake, 531 F.3d 1364 (Fed. Cir. 2008); Roper v. Nicholson, 20 Vet. App. 173, 181 (2006). Turing to the merits, the Veteran submitted a claim for an increased rating for his service-connected DM that was received by VA on May 3, 2013. The Veteran's claim for increase for his service-connected DM is also considered an informal claim for associated erectile dysfunction and SMC based on the same. In this case, the February 2016 rating decision granted service connection for ED and SMC based on loss of use of a creative organ. An effective date of December 22, 2015, was assigned for those awards based on the date of a VA examination pursuant to which an examiner concluded that the Veteran's erectile dysfunction is the result of his DM. In the October 2016 rating decision, an effective date of December 18, 2015, was assigned for those awards, the correct date of the VA examination pursuant to which an examiner concluded that the Veteran's erectile dysfunction is the result of his DM. Review of the claims file shows that service connection for ED was granted as secondary to the Veteran's DM disability during the course of a claim for an increased rating for DM that was received on May 3, 2013. Thus, the award of service connection for ED is viewed as a component of the Veteran's May 3, 2013, claim for an increased rating for his DM disability. Accordingly, an effective date as early as May 3, 2012, is assignable if it is factually ascertainable that erectile dysfunction secondary to DM was incurred in the one-year period prior to May 3, 2013. 38 C.F.R. § 3.400(o)(2). However, if the evidence shows that the increase occurred earlier than one year prior to the date of the claim, then the effective date is no earlier than the date of the claim. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). Here, during the Veteran's December 2015 VA examination, the examiner diagnosed the Veteran with ED and the date of diagnosis was 2010, placing the onset over one year prior to May 3, 2013. Thus, the earliest effective date possible in this case is the May 3, 2013, date of receipt of the underlying claim for an increased rating. Moreover, there is no indication of any pending or unadjudicated formal or informal claim for erectile dysfunction prior to the May 2013 DM increased rating claim. Nor is there evidence of an unadjudicated or pending claim for increased rating for DM. Based on the foregoing, the Board finds that the evidence of record reveals that an informal claim for ED and SMC for loss of use of a creative organ was constructively received on May 3, 2013 (date of receipt of the increased rating claim for DM disability), and the earliest factually ascertainable date that the Veteran was entitled to service connection for ED and SMC for loss of use of creative organ is more than one year prior to receipt of the increased rating claim. For these reasons, the date of claim controls and an effective date of May 3, 2013, but no earlier, for the awards of service connection for erectile dysfunction and SMC for loss of use of creative organ is warranted. Service Connection for Hypertension Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may also be granted on a presumptive basis for diseases associated with herbicide exposure under 38 C.F.R. § 3.309 if a veteran served in the Republic of Vietnam between January 1962 and May 1975. 38 C.F.R. § 3.307 (a)(6). Notwithstanding the foregoing provisions regarding presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has hypertension which he asserts is related to service. Importantly, he has advanced several theories of entitlement to service connection. He has asserted that hypertension began in service, or shortly thereafter. Alternatively, he suggests that hypertension is a result of exposure to herbicides in service. Finally, he suggests that his hypertension is proximately due to, or aggravated by, his service-connected DM or other specified trauma and stress related disorder. Turning to the evidence of record, the medical records reveal that the Veteran has been diagnosed with hypertension since at least 2008. As such, a current diagnosis has been shown and the first element of service connection is met. As to an in-service incurrence, service treatment records (STRs) are silent for complaint, treatment, or diagnosis of hypertension. The September 1969 separation examination reflected a blood pressure reading of 120/80, which is not considered hypertension for VA compensation purposes. The Veteran also denied any high or low blood pressure readings at his separation examination. Accordingly, as no in-service incurrence is shown, the second element of service-connection is not met. To the extent that the Veteran asserts a medical nexus between hypertension and service, the third element of service connection a medical nexus is not shown. In an August 2021 VA Medical Opinion Disability Benefit Questionnaire (DBQ), the examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner reviewed the record and reasoned that the Veteran's STRs were silent for a diagnosis of hypertension during service. The examiner noted the earliest notation of hypertension in the claims file was December 4, 2009, which showed a past medical history of hypertension, and also noted the Veteran's age as 63, and his weight as 204 lbs. (calculated BMI 32.9). The examiner indicated that a BMI > 30 was consistent with obesity. The examiner also noted a September 2011 note documenting the Veteran as a former smoker and a September 2011 note showing a family history of hypertension, specifically the Veteran's father. The examiner explained that a review of the medical literature showed known risk factors for hypertension included age, race, obesity, physical inactivity, family history, tobacco use, diet and alcohol use. There is no contradictory medical opinion. As such, the medical evidence does not support service connection based on medical nexus. Next, the Veteran claims that hypertension is due to exposure to herbicide agents during service. Hypertension is not on the list of presumptive diseases associated with herbicide agent exposure. Nonetheless, direct service connection as due to herbicide exposure will still be considered on a direct causation basis; however, no medical professional has established a direct etiological connection between hypertension and herbicide agent exposure in service. Therefore, the medical evidence does not support service connection on a direct causation basis under Combee. In support of the appeal, the Veteran submitted research citations and summary of research in the April 2021 Appellate Brief. In this regard, in an August 2021 VA Medical Opinion DBQ, the examiner opined that it was less likely than not that the that hypertension was incurred during active service or was caused by an event, injury, or illness during active service including exposure to herbicide agent. The examiner noted that while recent studies have shown an association with hypertension and veterans assigned to the Chemical corps who had a high exposure to herbicides, there was no association with veterans with other military occupational specialties (MOS). He explained that the prospect of exposure to TCDD from Agent Orange in ground troops in Vietnam seemed unlikely in light of the environmental dissipation of TCDD, little bioavailability, and the properties of the herbicides and circumstances of application that occurred. The examiner indicated that photochemical degradation of TCDD and limited bioavailability of any residual TCDD present in soil or on vegetation suggests that dioxin concentrations in ground troops who served in Vietnam would have been small and indistinguishable from background levels even if they had been in recently treated areas. The examiner noted the laboratory and field data reported in the literature provided compelling evidence on the fate and dislodge ability of herbicide and TCDD in the environment. This evidence of the environmental fate and poor bioavailability of TCDD from Agent Orange was consistent with the observation of little or no exposure in the veterans who served in Vietnam. Appreciable accumulation of TCDD in veterans would have required repeated long-term direct skin contact of the type experienced by United States (US) Air Force RANCH HAND and US Army Chemical Corps personnel who handled or otherwise had direct contact with liquid herbicide, not from incidental exposure under field conditions where Agent Orange had been sprayed. The examiner further noted that the Framingham study revealed that 90 percent of people 55 and over would develop hypertension eventually. Therefore, he indicated, by definition, all Vietnam era veterans had a 90 percent chance of developing hypertension whether they were exposed to Agent Orange or not. He explained that a review of the Veteran's claims file showed a personal history of established risk factors for the development of hypertension including obesity, prior history of tobacco and family history. There is no contradictory medical opinion. Therefore, the medical evidence does not support service connection based on nexus. Importantly, the only evidence in support were the research citations and summary of research submitted in the April 2021 Appellate Brief. The research citations and summary of research are broad and general and are not directly and specifically pertinent to his individual case, such that they possess any real probative value toward establishing a clinical association between the Veteran's hypertension and herbicide exposure. As such, they are speculative in nature and do not present an actual conclusive clinical finding of a definitive link and do not apply to the specific facts and circumstances of the Veteran's case. Accordingly, they are afforded less probative weight. By contrast, the available VA opinions were the result of a review of the Veteran's extensive medical record and considered and addressed all of his assertions and submitted evidence. There is no evidence that any relevant fact was misstated or improperly relied upon, and they were obtained for the specific purpose of assessing the Veteran's history and disease. Finally, and perhaps most importantly, there is no medical opinion of record which tends to contradict them. As such, and in consideration of the foregoing, there is no evidence which supports the theory of direct service connection based on herbicide exposure as the evidence weighed heavily against the claim. As to presumptive service connection under 38 C.F.R. § 3.309, no chronic disease or injury was shown in service. As noted above, STRs are silent for complaints of, treatment for, or a diagnosis of hypertension; therefore, the medical evidence does not support presumptive service connection on a "chronic disease or injury shown in service" basis. The medical evidence also does not support presumptive service connection based on continuity of symptomatology since service. Specifically, the medical evidence shows that the Veteran was first diagnosed with hypertension, at the earliest, in 2008. As he separated from service in 1969, the medical evidence shows that symptoms of his current disability developed almost 40 years after service. As such, the medical evidence does not support service connection on a "continuity of symptomatology" basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. As stated, the Veteran separated from service in 1969 but treatment notes did not note symptoms until 2008. This evidence does not support presumptive service connection on a "manifest within one-year from separation" basis. Therefore, the medical evidence does not support presumptive service connection on any basis. As to secondary service connection, the Veteran's main contention is that hypertension was caused, or aggravated by, service-connected DM. Alternatively, he suggests it was caused or aggravated by service-connected other specified trauma and stress related disorder. As he has been diagnosed with hypertension and is already service connected for the listed disabilities, the first and second elements of secondary service connection are met. As to the third element of secondary service connection a link between hypertension and the Veteran's service-connected disabilities, the weight of the medical evidence does not support the claim. Specifically, a January 2014 VA examiner found that it could not be determined without mere speculation whether the Veteran's hypertension was proximately due to or the result of his service-connected disabilities. The examiner noted that there was nothing in the medical records to indicate when the Veteran's hypertension started. However, the Veteran recalled that his DM and hypertension started around the same time and the DM was documented to start in 2008. In a January 2014 VA addendum medical opinion, the examiner opined that the Veteran's hypertension "clearly and unmistakably existed prior to service, [and] was clearly and unmistakably not aggravated beyond its natural progression..." The examiner then explained that for hypertension to be considered aggravated by a comorbid condition of DM, there needed to be evidence of diabetic neuropathy by urine spot testing. The examiner noted that the Veteran did not have evidence of diabetic neuropathy at the present time. He concluded that it was less likely than not that the Veteran's hypertension had been aggravated by his service-connected DM. In a December 2015 VA DM examination, the examiner opined that the Veteran had hypertension that was at least as likely as not permanently aggravated by DM. However, the examiner provided no rationale for her conclusion. In a January 2016 VA addendum medical opinion, the December 2015 clinician indicated that it was noted that the Veteran was diagnosed with hypertension prior to diagnosis of DM. She explained that she was unable to establish the baseline of the non- service condition. She noted that the Veteran did not presently have nephrotomy. She concluded, "[s]o, therefore, I have to change my initial impression, that hypertension was not aggravated by Diabetes Mellitus." The Board found that the January 2014 and December 2015 VA examiners' opinions were not adequate and remanded the claim to obtain a new medical opinion. The resulting August 2021 VA medical opinion was that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected DM. The examiner noted that the earliest notation of DM in the claims file was December 2009, showing a past medical history of DM, treatment with Metformin, as well as hypertension. The examiner indicated that hypertension could occur as a complication of kidney damage from DM. However, the Veteran's claims file showed both conditions in the past medical history in 2009 and no evidence at that time of kidney dysfunction. Further, the examiner noted that the December 4, 2009 urinalysis was negative for protein. As to aggravation, the examiner opined that the hypertension was less likely than not aggravated beyond its natural progression by the Veteran's service-connected DM disability. He noted that the claims file showed the Veteran's hypertension was controlled with medication and did not show evidence of hypertensive end organ damage to include chronic kidney disease. Further, the examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected other specified trauma and stress related disability and found that it was less likely than not that the Veteran's hypertension was aggravated by his service-connected other specified trauma and stress related disability. The examiner noted that temporary elevation/fluctuations of blood pressure readings were associated with emotional/physical stress and pain, however, the medical literature had not shown a direct causal relationship between hypertension and the mental health condition other specified trauma and stress related disorder. Based on the above, the medical evidence does not support service connection on a secondary basis as hypertension was neither caused by nor aggravated by service-connected disabilities. The Board has considered the Veteran's lay statements that hypertension was caused by service or a service-connected disability. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16. Substantially gainful employment is that employment that is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned, if the scheduler rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In this case, the Veteran is currently service connected for other specified trauma and stress related disorder (rated as 30 percent), DM (rated as 20 percent), peripheral neuropathy of the right and left lower extremities (each rated as 20 percent), peripheral neuropathy of the right and left upper extremities (rated as 20 percent), bilateral tinnitus (rated as 10 percent), and bilateral sensorineural hearing loss (rated as 10 percent). In determining whether the Veteran has one disability ratable at 40 percent or more, he meets the schedular requirements for entitlement to a TDIU based on his peripheral neuropathy. As discussed above, the following will be considered as one disability: disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor. Therefore, the Veteran's aforementioned peripheral neuropathy service-connected disabilities will be considered as one disability for purposes of TDIU compensation purposes. The combined rating was 60 percent as of November 17, 2015, 70 percent as of February 17, 2017, 80 percent as of February 27, 2017, and 90 percent since January 15, 2020. Therefore, the schedular criteria for a TDIU have been met as of February 17, 2017. Thus, he meets the criteria for consideration of a TDIU on a schedular basis. In a November 2017 VA 21-8940, Veterans Application for Increased Compensation Based on Unemployability, the Veteran reported that he last worked as a supervisor at a steel company in October 2003. His highest education was a high school diploma. As to the medical evidence, in a November 2017 PTSD examination, the Veteran reported that he last worked in 2003 after retiring due to a back condition. His symptoms were anxiety. The examiner found that the Veteran's other specified trauma and stress related disorder caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. In a May 2017 VA peripheral neuropathy examination, the examiner found that the Veteran's peripheral neuropathy impacted his ability to work as the Veteran would have difficulty with fine motor tasks like typing. In a November 2017 VA bilateral hearing loss and tinnitus examination, the examiner found that the Veteran's bilateral hearing loss and tinnitus impacted his ability to work. The Veteran reported that he could not hear people in group situations and large groups without looking at the person and that the tinnitus noises were there all the time and interfered with his concentration when trying to hear. In subsequent November 2017 and January 2020 VA examinations, the examiners reported that the Veteran's ED, DM, and peripheral neuropathy did not impact his ability to work. Based on the above, a TDIU is not warranted. In this regard, the May and November 2017 VA examiners opined that the Veteran's peripheral neuropathy, bilateral hearing loss and tinnitus affected his ability to work as the Veteran would have difficulty with fine motor tasks like typing, not hearing people in group situations and large groups without looking at the person and his tinnitus interfered with his concentration when trying to hear. However, as detailed above, the VA examiners identified the functional impact resulting from his service-connected disabilities but did not find that he was unemployable or otherwise unable to obtain and maintain substantially gainful employment. Furthermore, medical treatment notes do not otherwise establish that he was unable to secure or maintain employment as a result of his service-connected disabilities. Accordingly, the medical evidence does not support entitlement to a TDIU. The Board has considered lay statements submitted by the Veteran regarding his capacity to work throughout the entire period on appeal. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of symptomatology sufficient to satisfy the requirements of 38 C.F.R. § 4.16. Such competent evidence concerning the nature and extent of the Veteran's employability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which his employability is evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by his service-connected disability and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective evidence of unemployability. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). M. J. IN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Grzeczkowicz 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.