Citation Nr: 21077069 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-49 455 DATE: December 28, 2021 ORDER An effective date prior to June 29, 2015, for service connection for coronary artery disease, right knee arthritis, and left knee arthritis is denied. An effective date prior to June 29, 2015, for service connection for bilateral hearing loss, tinnitus, and posttraumatic stress disorder (PTSD) is denied. Service connection for sleep apnea is denied. Service connection for an arthritis condition manifest by arthritis of the left ankle, is denied. A compensable disability rating for bilateral hearing loss is bilateral hearing loss is denied. A disability rating in excess of 10 percent for tinnitus is denied. Right knee is denied. A disability rating in excess of 10 percent for coronary artery disease is denied. A disability rating in excess of 50 percent for PTSD with depression and alcoholism is denied. A disability rating in excess of 10 percent for arthritis of the right knee is denied. A disability rating in excess of 10 percent for arthritis of the left knee is denied. A disability rating in excess of 10 percent for instability of the right knee is denied. A disability rating in excess of 20 percent for instability of the left knee is denied. REMANDED Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The Veteran's initial claim for service connection for coronary artery disease, right knee arthritis, and left knee arthritis was received by VA on June 29, 2015. 2. Service connection for tinnitus, bilateral hearing loss, and PTSD was denied in a March 2005 rating decision which is final; the claim to reopen was received by VA on June 29, 2015. 3. The preponderance of the evidence is against finding that sleep apnea began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that an arthritis condition manifest by arthritis of the left ankle began during service or is otherwise related to an in-service injury or disease. 5. The Veteran's service-connected bilateral hearing loss was manifested by no worse than Level I hearing in his both ears. 6. The Veteran is assigned a 10 percent rating for his service-connected tinnitus, the maximum schedular evaluation available for that disability. 7. The Veteran's service-connected coronary artery disease requires continuous medication but was otherwise asymptomatic. 8. Throughout the appeal period, the severity, frequency, and duration of the Veteran's service-connected PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 9. Throughout the appeal period the Veteran's right knee arthritis was manifest by at worst flexion to 110 degrees and full extension to 0 degrees. 10. Throughout the appeal period the Veteran's left knee arthritis was manifest by at worst flexion to 105 degrees and full extension to 0 degrees. 11. Throughout the appeal period the Veteran's right knee instability was manifest by no more than slight instability. 12. Throughout the appeal period the Veteran's left knee instability was manifest by no more than moderate instability. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to June 29, 2015, for service connection for coronary artery disease, right knee arthritis, and left knee arthritis have not been are met. 38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400, 20.1104, 20.1403, 20.1404. 2. The criteria for an effective date prior to June 29, 2015, for service connection for bilateral hearing loss, tinnitus, and PTSD have not been are met. 38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400, 20.1104, 20.1403, 20.1404. 3. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for arthritis condition manifest by arthritis of the left ankle, have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for an initial compensable disability rating for the Veteran's service-connected bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100, and Tables VI, VIA, and VII. 6. There is no legal basis for the assignment of a schedular disability rating higher than 10 percent for tinnitus. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, Diagnostic Code 6260. 7. The criteria for an initial disability rating in excess of 10 percent for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7005. 8. The criteria for a disability rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 9. The criteria for an initial disability rating in excess of 10 percent for service-connected right knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260. 10. The criteria for an initial disability rating in excess of 10 percent for service-connected left knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260. 11. The criteria for an initial disability rating in excess of 10 percent for service-connected right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 12. The criteria for an initial disability rating in excess of 20 percent for service-connected right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is the surviving spouse of a Veteran who served on active duty from December 1968 to December 1970. This matter is on appeal to the Board of Veterans' Appeals (Board) from an October 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran died February 2019; in April 2020 the Veteran's surviving spouse was substituted as the appellant for the appeal. Effective Date Claims Generally, the effective date of an evaluation and award of pension, compensation or dependency, and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.§ 5110(a); 38 C.F.R. §§ 3.400, 3.400(b)(2). The regulations also provided that for claims involving direct service connection, the effective date will be the "day following separation from active service or date entitlement arose if claim is received within 1 year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later. Separation from service means separation under conditions other than dishonorable from continuous active service which extended from the date the disability was incurred or aggravated." 38 C.F.R. § 3.400 (b)(2)(i). 1. Entitlement to an effective date prior to June 29, 2015, for service connection for coronary artery disease, right knee arthritis, and left knee arthritis. In the present case, the RO granted service connection for coronary artery disease, right knee arthritis, and left knee arthritis effective June 29, 20153, which is the date of receipt of the Veteran's VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. On this form the Veteran indicated that he was treated for all his claimed disabilities at the VA Medical Center. Review of the record does not reveal any claim for these disabilities filed prior to this date. On the Notice of Disagreement submitted in January 2016, the appellant's attorney merely checked boxes indicating disagreement with the effective date of service connection for all disabilities for which service connection had been granted; no actual argument as to why an earlier effective date for the grants of service connection has been put forth. The Veteran's claim for service connection for coronary artery disease, right knee arthritis, and left knee arthritis was received by VA on June 29, 2015; the proper effective date of service connection has been assigned and the appeal for an effective date is denied. 2. Entitlement to an effective date prior to June 29, 2015, for service connection for bilateral hearing loss, tinnitus, and PTSD. In March 2005, an RO rating decision denied service connection for hearing loss, tinnitus, and PTSD; the Veteran was notified of this decision that same month but did not appeal the decision and new and material evidence was not received within the one-year appeal period. Accordingly, that rating decision is final. The RO granted service connection for hearing loss, tinnitus, and PTSD effective June 29, 20153, which is the date of receipt of the Veteran's VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, which served as his claim to reopen. Review of the record does not reveal any claim for these disabilities filed prior to this date. On the Notice of Disagreement submitted in January 2016, the appellant's attorney merely checked boxes indicating disagreement with the effective date of service connection for all disabilities for which service connection had been granted; no actual argument as to why an earlier effective date for the grants of service connection has been put forth, and no assertion of any error in the prior RO rating decision has been made. The Veteran's claim to reopen the claims for service connection for hearing loss, tinnitus and PTSD was received by VA on June 29, 2015; the proper effective date of service connection has been assigned and the appeal for an effective date is denied. Service Connection Claims Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as arthritis. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 3. Service connection for Sleep Apnea. The Veteran claims entitlement to service connection for sleep apnea. Review of the Veteran's service treatment records does not reveal any complaints of treatment for, or diagnosis of sleep apnea during service. In October 2015, a VA Compensation and Pension examination of the Veteran was conducted. The Veteran reported that he had been diagnosed with sleep apnea eight years earlier. He reported having trouble sleeping since service and that he has snored since service. The diagnosis was obstructive sleep apnea. The examiner's medical opinion was that the sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner considered the Veteran's statements as well as the service treatment records noting that no sleeping problems or breathing difficulty were indicated. The preponderance of the evidence is against the claim for service connection for sleep apnea. A sleep apnea disability is not shown by medical evidence until approximately 2007, almost four decades after the Veteran's separation from service. The Board has considered the Veteran's report of having trouble sleeping and snoring since service. As a lay person he was competent to report (1) symptoms that are observable to a layperson, e.g., such as snoring and trouble sleeping; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. To the extent the Veteran asserts a continuity of symptomatology of trouble sleeping and snoring beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with the Veteran's report of medical history at separation from service which did not show sleep or breathing trouble. For the above reasons, the preponderance of the evidence is against the claim and service connection for sleep apnea is denied. 4. Service Connection for an Arthritis Condition manifest by Arthritis of the Left Ankle. On his June 2015 claim, the Veteran asserted a general claim for service connection for arthritis. The Board notes that he also asserted a claim for a bilateral knee condition, and service connection for bilateral knee arthritis has been granted. VA treatment records dated in June 2015 reveal that the Veteran was treated for complaints of left ankle swelling, which was warm, red, and painful to the touch. Rheumatology treatment notes indicated that it was a presumed gout attack and was treated as such. In October 2015 VA examination of the Veteran indicated a diagnosis of gout of the left ankle with onset in 2015. The examiner's medical opinion was that the Veteran's gout was not incurred in or caused by service. The preponderance of the evidence is against the Veteran's claim for an arthritis condition manifested by arthritis (gout) of the left ankle. Simply put the Veteran was diagnosed with gout in 2015, over four and a half decades after he separated from service. Service treatment records do not show any diagnosis of gout or arthritis during service; there is no evidence that arthritis or gout became manifest within the first year after separation from service. He provided not explanation of how he thought this was related to service. The competent medical opinion of record indicates that the Veteran's left ankle gout was not related to service, and there is no evidence of record to link it to service. Accordingly, service connection is denied. INCREASED RATING CLAIMS The Board notes that a November 2020 rating decision granted entitlement to a total disability rating based on individual unemployability (TDIU) effective June 2015; despite the current appeals, the Veteran would have been paid at a 100 percent disability rate. Disability ratings 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 (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. This appeal being from the initial ratings assigned to disabilities upon awarding service connection, the entire body of evidence is for equal consideration. Consistent with the facts found, the ratings may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999). The evidentiary record does not reasonably raise the prospect that the Veteran's disabilities cannot be adequately rated under the Rating Schedule. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). 5. Bilateral Hearing Loss Ratings of impaired hearing 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 as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85. Under 38 C.F.R. § 4.85, Table VI, Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination, is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination and the pure tone threshold average. The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by 4. Table VII, Percentage Evaluation for Hearing Impairment, is used to determine the rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The disability rating is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Exceptional patterns of hearing impairment can also be rated with consideration under 38 C.F.R. § 4.86. When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000 and 4000 Hertz is 55 decibels or more, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Table VIA can also be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc. 38 C.F.R. § 4.85(c). The evidence of record does not show that the Veteran had an exceptional pattern of hearing impairment. The Veteran's service-connected bilateral hearing loss is rated as noncompensable under 38 C.F.R. § 4.85, Diagnostic Code 6100. He disagreed with the initial disability rating assigned. In October 2015, a VA audiology Compensation and Pension examination of the Veteran was conducted. The pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 30 60 55 41.25 LEFT 20 25 45 55 36.25 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 94 percent in the left ear. These audiometric results translate into level I for the right ear and level I for the left ear. Level I hearing in both ears warrants the assignment of a noncompensable (0%) disability rating. 38 C.F.R. § 4.85. Table VII. The Veteran indicated that the functional impact of his hearing loss was that he has to ask people to repeat a lot. VA medical treatment records have been obtained and reveal he has received regular treatment at a VA audiology clinic from 2014 to the present and that he has been prescribed and issued hearing aids. These treatment records do not provide any audiometric data which is suitable for rating. The Board acknowledges that the Veteran had bilateral hearing loss. However, the evidence of record reveals that, at worst, the Veteran's hearing was manifested by Level I hearing in both ear, which only warrants the assignment of a noncompensable (0%) disability rating. 38 C.F.R. § 4.85, Table VII. Accordingly, the competent evidence of record does not reflect that the Veteran's bilateral hearing loss warranted a compensable rating during the rating period. To the extent that the Veteran contends that his bilateral hearing loss is more severe than reflected by his current disability rating, the Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge and understanding as a lay person such as difficulty understanding conversation. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to state that his hearing acuity is of a severity sufficient to warrant a higher rating under VA's tables for rating hearing loss disability because such an opinion requires medical expertise and knowledge that he has not been shown to possess. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the Board attaches more probative weight to the medical records and clinical findings from the skilled medical professionals who conducted the VA audiological testing than to the Veteran's lay testimony. Moreover, the assignment of disability ratings for hearing loss is primarily based upon a mechanical application of the rating criteria, as explained and applied in this decision. In this case, the clinical evidence of record, when mechanically applied to the rating criteria, simply does not show that a compensable disability rating is warranted. Neither the appellant or her attorney have raised any other issues with regard to the rating for the service-connected bilateral hearing loss, nor have any other such issues been reasonably raised by the record. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017). Specifically, the Veteran has described the functional impact from his bilateral hearing loss as difficulty hearing. The provisions of 38 C.F.R. §§ 4.85 and 4.86 contemplate, and thus compensate for, the functional effects of hearing loss, namely difficulty understanding speech and the inability to hear sounds in various contexts. Doucette, 28 Vet. App. at 369. The situations noted by the Veteran in this case amount to decreased hearing and difficulty understanding speech in an everyday environment and are not exceptional or unusual for someone with hearing loss. The Board therefore finds that the criteria for a compensable disability rating for the Veteran's service-connected bilateral hearing loss have not been met at any time during the relevant rating period. As the preponderance of the evidence is against the assignment of a compensable disability rating the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Tinnitus The Veteran is currently assigned a 10 percent disability rating for tinnitus pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6260. The Veteran was awarded service connection for tinnitus in an October 2015 rating decision and a 10 percent evaluation was assigned. The Veteran's attorney checked the box on the Notice of Disagreement indicated that he disagreed with the disability rating assigned and therefore asserting that the service-connected tinnitus disability warranted a higher rating. As will be discussed below, the claim must be denied as a matter of law as the Veteran is in receipt of the maximum rating. The Veteran's tinnitus is rated as 10 percent disabling under Diagnostic Code 6260. Under 38 C.F.R. § 4.87, Diagnostic Code 6260, there is no provision for assignment of a rating in excess of 10 percent for tinnitus. Only a single evaluation may be assigned, whether the sound is perceived in one ear, both ears, or in the head. Id. at Note (2). In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit concluded that 38 C.F.R. § 4.25(b) and 38 C.F.R. § 4.87, Diagnostic Code 6260, limit a Veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. A higher evaluation for tinnitus is not available. The Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for that disability. 38 C.F.R. § 4.87, Diagnostic Code 6260. As there is no legal basis upon which to award a higher evaluation, to include separate schedular ratings for tinnitus in each ear, the Veteran's claim for an increased disability rating must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). 7. Coronary Artery Disease. The Veteran's service-connected coronary artery disease is assigned an initial 10 percent disability rating under 38 C.F.R. § 4.104, Diagnostic Code 7005. He disagreed with the initial disability rating assigned. During the pendency of the appeal, the rating criteria for evaluating diseases of the heart under 38 C.F.R. § 4.104, including Diagnostic Code 7005, were amended effective September 2021. 86 Fed. Reg. 54093 (Sept. 30, 2021). As the Veteran in this case died in February 2019, the Board will only consider the old version of the diagnostic code only. Prior to the regulatory change, the Veteran has been assigned a rating under Diagnostic Code 7005 for Arteriosclerotic heart disease (coronary artery disease). Under Diagnostic Code 7005, a 10 percent rating was warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent rating was warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating was warranted for more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating was warranted for chronic congestive heart failure, or workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. In October 2015 a VA Compensation and Pension examination of the Veteran was conducted. The Veteran reported having an abnormal stress test so had angiogram in 2012 and was told he had a blocked artery in back rear of heart and no stent indicated. He also reported a 25 year history of hypertension but no chest pain or any other symptoms related to his heart. The diagnosis was coronary artery disease. He was noted to be on medication for his heart disease but there was no evidence of myocardial infarction or congestive heart failure. The Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. VA medical treatment records note the Veteran's diagnosis of coronary artery disease and that he is prescribed medication, but otherwise indicate that the disability is asymptomatic. The preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the Veteran's service-connected coronary artery disease for any period covered by the appeal. The Veteran required medication to treat his coronary artery disease. However, there is no evidence that the disability was otherwise symptomatic or caused any functional impairment or restriction of activity. Accordingly, a disability rating in excess of 10 percent is denied. 8. PTSD. The Veteran's service-connected PTSD with depression and alcoholism is rated at a 50 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. He disagreed with the initial disability rating assigned. The Veteran's service-connected PTSD is rated under Diagnostic Code 9411, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In October 2015, a VA Compensation and Pension examination of the Veteran was conducted. The diagnosis was PTSD with depressive disorder which resulted in occupational and social impairment with reduced reliability and productivity. Symptoms noted to be present were depressed mood, suspiciousness, chronic sleep impairment, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships. There was no evidence of delusions, perceptual abnormalities; his mood was even and congruent with affect. In December 2017, another, a VA Compensation and Pension examination of the Veteran was conducted. The diagnosis was PTSD with depressive disorder and alcohol use disorder which resulted in occupational and social impairment with reduced reliability and productivity. Symptoms noted to be present were depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships. He was alert and oriented with no evidence of delusions. He specifically indicated that he had never received any mental health treatment. VA medical treatment records covering the appeal period have been obtained and reviewed. They show notations of the diagnosis of PTSD, but do not indicate any treatment. In November 2019, a private psychologist submitted an assessment, primarily in relation to the Veteran's substituted claim for TDIU. This assessment was conducted after the Veteran's death and concluded that the Veteran's PTSD and alcohol use impacted his employability while living and made him unable to sustain gainful employment. The Board notes that TDIU was granted based in part on this assessment. The Board finds the assigned 50 percent rating appropriately compensated the Veteran for his symptoms. The evidence indicates the Veteran his difficulty with depression, alcohol use, and difficulty in establishing and maintaining relationships. All the mental health evidence of record reveals he is oriented, had good hygiene, with few reported symptoms other than his self-isolation from relationships and irritable mood. Suicidal or homicidal ideation was never noted to be present. He never sought treatment for his PTSD. As such, the evidence does not indicate the Veteran's PTSD manifested by symptoms that more nearly approximate a 70 percent rating, such as speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene or inability to establish and maintain effective relationships. Additionally, the Board does not find that a 100 percent evaluation is warranted at any time during the appeal period. As noted, to warrant a 100 percent rating, the Veteran's symptoms must meet or more nearly approximate total occupational and social impairment. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list but are examples of the type and severity of symptoms that indicate a certain level of disability. Examining the Veteran's PTSD symptoms however, the Board concludes that the Veteran's symptomatology more nearly approximated the criteria for the currently assigned 50 percent rating. The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim for a higher rating. As such, that doctrine is not applicable in the instant appeal, and his increased rating claim must be denied. Knee Disability Ratings The October 2015 rating decision granted service connection for arthritis of the right knee at a 10 percent rating and arthritis of the left knee at a 10 percent rating. Subsequently, a September 2017 rating decision granted separate disability ratings for instability of the right knee at a 10 percent rating and instability of the left knee at a 20 percent rating. The Board will address all four ratings assigned for the Veteran's knee disabilities. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can be assigned when a knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. In this case the evidence does not reflect, and the Veteran did not allege that he had any meniscal disability. As such, these diagnostic codes are not for application. Ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis of the knee, including possible functional ankylosis during a flare-up. As such, those diagnostic codes are not for application. Specifically, on both VA examination reports of record, the examiner indicated that the Veteran had range of motion of both knees, and that ankylosis was not present. The Veteran's assertions of pain on flare-up do not indicate an absence of knee motion that would approximate functional ankylosis during a flare-up. Ratings can be assigned for knee instability or subluxation under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Since the Veteran died in February 2019, the Board need consider only old version of the diagnostic code. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). "Slight," as relevant to a physical condition, is defined as "small of its kind or in amount." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to "mild," which is defined as "not severe" or temperate; with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. Range of motion testing was performed during VA examinations in October 2015 and March 2018 and was at worst 110 degrees of flexion and 0 degrees of extension for the right knee and 115 degrees of flexion and 0 degrees of extension for the left knee. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiners, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. At the October 2015 examination, the Veteran reported flare-ups consisting of increased pain with walking, standing or using the stairs at times as well as reporting the left knee gives out at times. At the March 2018 examination he reported flare-ups of increased knee pain with prolonged walking or standing. While given the opportunity to describe functional limitation related to the disability, the Veteran's statements do not show the requisite limitation of motion necessary for a higher or separate rating. Treatment records do not show greater limitation of motion than the examination findings. Given the above, a higher or separate rating is not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. Regarding instability and subluxation of the knee, in at the October 2015 examination the Veteran reported his left knee gave out at times; however physical examination and stability testing did not reveal any instability of either knee at that time. A June 2016 VA treatment record indicated that the Veteran stated that he had instability of the right knee with it occasionally giving way and that he used a knee brace. An August 2016 VA treatment record shows that the Veteran reported left knee instability with use of a brace. During the March 2018 VA examination, testing revealed slight lateral instability of the right knee but none on the left. Given the tests performed are generally recognized in the medical community as diagnostic for instability, the results are afforded high probative value. In addition, the testing results are given more probative weight than the Veteran's lay statements. While the Veteran may experience a feeling that his knee may give way or is unstable, if subluxation or instability were present, as required for a separate compensable rating, the Board would expect that this would have been identified at least once during the multiple tests that were performed. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257 (2020). 9. Right Knee Arthritis. The Veteran is assigned a 10 percent disability rating for his right knee arthritis based on limitation of flexion, with his worst right flexion being to 110 degrees. Again, limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). The Veteran's right knee arthritis is manifest by limitation of flexion to 110 degrees with pain on motion, which warrants the assignment of a 10 percent rating. See, 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5260. There is no evidence showing that the Veteran's right knee arthritis resulted in any limitation of extension, or limitation of flexion to 30 degrees or less. Accordingly, a disability rating in excess of 10 percent is not warranted and the appeal is denied. 10. Left Knee Arthritis. The Veteran is assigned a 10 percent disability rating for his left knee arthritis based on limitation of flexion, with his worst right flexion being to 110 degrees. Again, limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). The Veteran's left knee arthritis is manifest by limitation of flexion to 105 degrees with pain on motion, which warrants the assignment of a 10 percent rating. See, 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5260. There is no evidence showing that the Veteran's left knee arthritis resulted in any limitation of extension, or limitation of flexion to 30 degrees or less. Accordingly, a disability rating in excess of 10 percent is not warranted and the appeal is denied. 11. Right Knee Instability. The Veteran's right knee instability is assigned a 10 percent disability rating for slight lateral instability under the version of Diagnostic Code 5257 in effect prior to February 7, 2021. During the appeal period the evidence only shows the presence of slight lateral instability as documented by testing at the 2018 VA examination upon objective testing. A higher rating is not warranted as the evidence is against a finding of the presence of moderate or severe lateral instability or recurrent subluxation. As such, a disability rating in excess of 10 percent is not warranted and the appeal is denied. 12. Left Knee Instability. The Veteran's left knee instability is assigned a 20 percent disability rating for moderate lateral instability under the version of Diagnostic Code 5257 in effect prior to February 7, 2021. During the appeal period the evidence only shows the Veteran reported that his left knee gave out at times prior to 2017 and that he used a knee brace at that time. The presence of left knee lateral instability was not documented by objective testing at either VA examination of record. A higher rating is not warranted as the evidence is against a finding of the presence of severe lateral instability or recurrent subluxation of the left knee. As such, a disability rating in excess of 10 percent is not warranted and the appeal is denied. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded. The Veteran was never afforded a VA examination with respect to his claim of service connection for hypertension. As he was service connected for coronary artery disease remand for a medical opinion is warranted. The matter is REMANDED for the following action: The claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension had onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether the hypertension is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) any service-connected disability, to include as a result of his service-connected coronary artery disease. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Havelka, 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.