Citation Nr: 21008517 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 12-11 437 DATE: February 17, 2021 ORDER Service connection for spleen condition, to include as secondary to service-connected sarcoidosis, is denied. Prior to January 7, 2013, entitlement to a rating in excess of 50 percent for sarcoidosis and sleep apnea is denied. From January 7, 2013 to October 31, 2018, a 60 percent, but no higher, rating for sarcoidosis and sleep apnea is granted, subject to regulations governing the payment of monetary awards. From November 1, 2018, entitlement to a rating in excess of 50 percent for sarcoidosis and sleep apnea is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s spleen condition is not caused or aggravated by his service-connected sarcoidosis and is not related to an in-service injury or disease 2. Prior to January 7, 2013, the Veteran’s sarcoidosis and sleep apnea did not result in pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control; FEV-1 of 40- to 55-percent predicted, FEV-1/FVC of 40 to 55 percent, DLCO (SB) of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit); and was without chronic respiratory failure with carbon dioxide retention or cor pulmonale, and did not require tracheostomy. 3. From January 7, 2013 to October 31, 2018, the Veteran’s sarcoidosis and sleep apnea was characterized by DLCO (SB) in excess of 40 percent but 55 percent or less, without chronic respiratory failure with carbon dioxide retention or cor pulmonale, and did not require tracheostomy. 4. From November 1, 2018, the Veteran’s sarcoidosis and sleep apnea did not result in pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control; FEV-1 of 40- to 55-percent predicted, FEV-1/FVC of 40 to 55 percent, DLCO (SB) of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit); and was without chronic respiratory failure with carbon dioxide retention or cor pulmonale, and did not require tracheostomy. CONCLUSIONS OF LAW 1. The criteria for service connection for spleen condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303(b), 3.310 (2020). 2. Prior to January 7, 2013, the criteria for a rating in excess of 50 percent for sarcoidosis and sleep apnea are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.97, Diagnostic Codes 6600, 6846, 6847 (2020). 3. From January 7, 2013 to October 31, 2018, the criteria for a 60 percent, but no higher, rating for sarcoidosis and sleep apnea are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.97, Diagnostic Codes 6600, 6846, 6847 (2020). 4. From November 1, 2018, the criteria for a rating in excess of 50 percent for sarcoidosis and sleep apnea are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.97, Diagnostic Codes 6600, 6846, 6847 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from August 1974 to August 1996. These matters are before the Board of Veterans’ Appeals (Board) on appeal from November 2009, September 2011, and March 2017 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in July 2015 when the Board remanded the case to afford the Veteran an opportunity to have a hearing before the Board. The Veteran appeared at a hearing before the Board in January 2018. A transcript of the hearing is of record. Subsequently, the case was before the Board in May 2018, June 2019, and July 2020 when it was remanded for further development. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020). The Veteran has not raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board”). Regarding the duty to assist, following the July 2020 Board remand, the Veteran submitted a VA Form 21-4142 (Authorization to Disclose Information to the Department of Veterans Affairs (VA)) for records from Dr. R.B. Per VA regulations, VA must notify the Veteran of any records that VA is unable to obtain, an explanation of the efforts made to obtain the records, a description of any further action VA will take regarding the claim, and that the Veteran is ultimately responsible for providing the evidence. See 38 C.F.R. § 3.159(e). In addition, for private records, per 38 C.F.R. § 3.159(c)(1), for records in the possession of a private facility, “[s]uch reasonable efforts will generally consist of an initial request for the records and, if the records are not received, at least one follow-up request.” Further, “[i]f VA receives information showing that subsequent requests to this or another custodian could result in obtaining the records sought, then reasonable efforts will include an initial request and, if the records are not received, at least... an additional request to the original source.” 38 C.F.R. § 3.159(c)(1). Regarding the records from Dr. R.B., VA informed the Veteran of its inability to obtain the records on August 20, 2020 after the first attempt to obtain the records. VA then informed the Veteran of its inability to obtain the records on September 8, 2020 after the second attempt to obtain the records. In addition, a September 4, 2020 VA 21-0820, Report of General Information, illustrates that on August 3, 2020, VA spoke with the medical records department at the office of Dr. R.B., and VA confirmed the fax number, provider name, and address of Dr. R.B. VA then sent faxes on August 3, 2020 and August 15, 2020 to the office of Dr. R.B. to request the records. The Board concludes that VA has met its duty to assist. VA made two attempts to obtain the records from the facility and received no response from the office of Dr. R.B. The office of Dr. R.B. did not send the records and further attempts for VA to obtain them would be futile given the numerous unsuccessful attempts made to obtain them. As the Veteran has been afforded VA examinations for all of his claims currently before the Board and given that the examinations are adequate for evaluation purposes, they provide all the information necessary to adjudicate the claims at issue. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Martinak v. Nicholson, 21 Vet. App. 447 (2007). In addition, VA has obtained, to the extent possible, all relevant evidence identified by the Veteran and necessary for an equitable resolution of the issues on appeal. Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claims. See Bernard v. Brown, 4 Vet. App. 384 (1993).   Service Connection – Spleen Condition The Veteran contends his spleen condition is due to his service-connected sarcoidosis. See Board Hearing Transcript, dated January 5, 2018. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The questions for the Board are whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease; or whether the Veteran has a current disability that is proximately due to or the result of or is aggravated beyond its natural progress by his service-connected his service-connected sarcoidosis. Regarding the theory of direct service connection, the Board concludes that, while the Veteran has a current diagnosis of accessory splenic tissue, the preponderance of the evidence weighs against finding that such diagnosis began during service or is otherwise related to an in-service injury, event, or disease. Following a November 2018 VA examination, the examiner opined that the Veteran’s spleen condition was less likely than not incurred in or caused by the Veteran’s service. In support of the opinion, the VA examiner noted that the finding of a splenule on a February 2009 abdomen CT scan has not caused any pathophysiologic state based on the follow-up diagnostic testing in the record. Furthermore, the VA examiner noted that the accessory tissue was first noted in 2009, so it did not occur during service. Therefore, given that the November 2018 VA examiner provided a thorough review of the record, examined the Veteran, that he took into consideration the Veteran’s prior medical history and lay statements, and provided a sufficient rationale for the Board to evaluate the claim, the Board gives much probative weight to the examiner’s opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). As such, the weight of the evidence is against a finding that service connection on a direct basis for the Veteran’s spleen condition is warranted. Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran’s current spleen condition, diagnosed as accessory splenic tissue, is proximately due to or the result of or was aggravated beyond its natural progress by his service-connected sarcoidosis. As to this question, the November 2018 VA examiner opined that it is less likely than not that the Veteran’s spleen condition was caused or aggravated by sarcoidosis. In support of the opinion, the VA examiner stated that the medical literature illustrates that splenic enlargement and/or splenic granulomata are entities known to be related to sarcoidosis, but accessory splenic tissue is not related to sarcoidosis. The Board acknowledges that in a February 2010 written statement, Dr. T.C., a private physician, opined that the Veteran has an acute spleen problem that is secondary to sarcoidosis. In support of the opinion, Dr. T.C. stated that a 1984 Gallium showed that the Veteran’s sarcoidosis affected his spleen. Dr. T.C. provided no further rationale for this statement, including no explanation as to what specific type of spleen condition was impacted by the Veteran’s sarcoidosis or how his sarcoidosis affected his spleen condition. The Board places the most weight of probative value on the November 2018 VA examiner’s opinion. The opinion includes a detailed discussion of the Veteran’s medical history, a discussion of the causes of the Veteran’s accessory splenic tissue and addresses both causation and aggravation theories of entitlement. In addition, the rationale in the opinion is consistent with the record. The Board acknowledges that the Veteran believes his spleen condition is proximately due to or aggravated by his service-connected sarcoidosis. However, the Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships and disease processes. Therefore, it is outside the competence of the Veteran in this case because the record does not show that the Veteran has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA medical opinion. Accordingly, the preponderance of the evidence is against a finding that the Veteran’s spleen condition is caused or aggravated by his service-connected sarcoidosis. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating – Sarcoidosis The Veteran generally contends he is entitled to an increased rating for his service-connected sarcoidosis. See Board Hearing Transcript, dated January 5, 2018. The AOJ has assigned the Veteran’s sarcoidosis and obstructive sleep apnea a single 50 percent rating throughout the appeal period under hyphenated Diagnostic Code 6846-6847. 38 C.F.R. § 4.97. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic codes indicate that the Veteran’s respiratory disabilities are rated under the criteria for sarcoidosis (Diagnostic Code 6846) and sleep apnea (Diagnostic Code 6847). Under 38 C.F.R. § 4.97, a single rating is assigned for coexisting respiratory conditions that reflect the predominant disability. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under Diagnostic Code 6847 for sleep apnea, a 50 percent rating is assigned for sleep apnea that requires the use of a breathing assistance device such as continuous airway pressure (CPAP) machine. A 100 percent rating is assigned for sleep apnea that manifests in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy. 38 C.F.R. § 4.97, Diagnostic Code 6847. Under Diagnostic Code 6846, sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids is rated 30 percent disabling. Sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control is rated 60 percent disabling. Sarcoidosis with cor pulmonale, or; cardiac involvement with congestive heart failure, or; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment, is rated 100 percent disabling. 38 C.F.R. § 4.97. Alternatively, sarcoidosis may be rated pursuant to Diagnostic Code 6600 under the rating criteria for chronic bronchitis. 38 C.F.R. § 4.97, Diagnostic Code 6846 (“or rate active disease or residuals as chronic bronchitis (Diagnostic Code 6600) and extra-pulmonary involvement under specific body system involved”). Diagnostic Code 6600 provides ratings for chronic bronchitis based on the results of pulmonary function tests (PFTs). FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56- to 70-percent predicted or; DLCO (SB) of 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40- to 55-percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent predicted, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy is rated 100 percent disabling. 38 C.F.R. § 4.97. In this regard, PFTs are required to rate respiratory conditions except in certain situations, such as when the PFTs are inconsistent with the other clinical evidence of record and the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Further, post-bronchodilator PFT studies are required except when the results of pre-bronchodilator tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating a disability based on PFTs, post-bronchodilator results should be used unless such results are poorer than the pre-bronchodilator results, in which case the latter should be applied. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs (FEV-1, FVC, etc.) so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). Prior to January 7, 2013 Prior to January 7, 2013, the AOJ has assigned a 50 percent rating for the Veteran’s respiratory disability. Based on a review of the relevant evidence and the applicable law and regulations, a preponderance of the evidence is against a finding that a rating in excess of 50 percent is warranted prior to January 7, 2013. Turning to the medical evidence of record during this period, a July 2009 chest X-ray showed that the prominence of the hilar areas is felt most likely secondary to high position of the hemidiaphragms or expiratory phase of respiration. Furthermore, the medical evidence of record illustrates that the Veteran used a CPAP machine throughout this period. A July 2009 VA examination report reflects that the Veteran reported receiving daily steroid therapy at 40 milligrams per day. He reported losing 15 pounds in the 3 months preceding the examination, having a persistent fever, a cough with sputum, night sweats, pain and discomfort over the chest area on exertion. He reported the symptoms occur at work, at home, and when walking every day. The Veteran reported his sarcoidosis causes functional impact in the form of limited movement due to shortness of breath. The PFT showed the Veteran had FEV-1 of 69 percent pre-bronchodilator and 68 percent post-bronchodilator and FEV-1/FVC of 92.0 pre-bronchodilator and 92.9 post-bronchodilator. DLCO was not done as the examiner noted that PFT results were sufficient to evaluate the Veteran. The examiner indicated that he did not have complications of cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, or chronic respiratory failure with carbon dioxide retention. Following a review of the medical and lay evidence during this period, the Board concludes that a preponderance of the evidence is against a finding that a rating in excess of 50 percent is warranted during this period. Regarding Diagnostic Code 6600, the PFT results during this period would result in a 30 percent rating based on the FEV-1 value between 56 to 70 percent predicted. Regarding Diagnostic Code 6846, the Veteran was noted to be receiving daily steroid therapy at 40 milligrams per day at the July 2009 VA examination; however, there is no evidence of high dose therapeutic corticosteroids for control during this period. Regarding Diagnostic Code 6847, there is no evidence of chronic respiratory failure with carbon dioxide retention, cor pulmonale, or that the Veteran’s sleep apnea required tracheostomy. Thus, even when considering the Veteran’s symptoms of weight loss, persistent fever, cough with sputum, night sweats, pain and discomfort over the chest area on exertion, the preponderance of evidence is against a finding of a rating in excess of 50 percent prior to January 7, 2013. January 7, 2013 to October 31, 2018 Based on a review of the relevant evidence and the applicable law and regulations, it is the Board’s conclusion that a 60 percent, but no higher, rating for the Veteran’s respiratory disability is warranted from January 7, 2013 to October 31, 2018. The Veteran attended a VA examination on January 7, 2013 for an evaluation of his respiratory condition. The examination report reflects that the Veteran was not taking oral or parenteral corticosteroid medications, inhaled medications, oral bronchodilators, antibiotics, or using outpatient oxygen therapy. The examination report reflects that the Veteran’s sarcoidosis caused no physiologic impairment, but he had a restrictive PFT. The examiner noted that the FEV-1 PFT test result most accurately reflected the Veteran’s pulmonary function. The PFT showed the Veteran had FEV-1 of 30 percent pre-bronchodilator and 42 percent post-bronchodilator. FEV-1/FVC was 88 percent pre-bronchodilator and 96 percent post-bronchodilator. The examiner indicated that FEV-1 results most accurately reflected the Veteran’s current pulmonary function. The examiner indicated that DLCO testing was not indicated for the Veteran’s condition. The examiner noted that the Veteran’s sarcoidosis was stage one based on the X-ray findings. Furthermore, the examiner noted that the Veteran had no ophthalmologic, renal, cardiac, neurologic, or other organ system involvement due to his sarcoidosis. The examiner noted the Veteran’s condition did not result in cardiopulmonary complications, such as cor pulmonale, right ventricular hypertrophy, or pulmonary hypertension. The examiner noted that the Veteran’s sarcoidosis caused no functional impact. The Veteran submitted a private disability benefits questionnaire for his sleep apnea dated December 2017. The questionnaire reflects that the Veteran used a CPAP machine and that the Veteran experienced persistent daytime hypersomnolence, but the Veteran’s sleep apnea caused no chronic respiratory failure with carbon dioxide retention, cor pulmonale, or that the Veteran’s sleep apnea required tracheostomy. Following a review of the medical and lay evidence during this period, the Board concludes that the evidence most nearly approximates a 60 percent, but no higher, rating during this period. Regarding Diagnostic Code 6600, the Veteran’s post-bronchodilator FEV-1 value of 42 percent results in a 60 a percent rating. A rating in excess of 60 percent during this period is not warranted under Diagnostic Code 6600 as there is no evidence of FEV-1 less than 40 percent of predicted value; FEV-1/FVC less than 40 percent predicted; DLCO (SB) less than 40 percent predicted; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); cor pulmonale (right heart failure); right ventricular hypertrophy; pulmonary hypertension (shown by Echo or cardiac catheterization); episode(s) of acute respiratory failure, or; outpatient oxygen therapy. Regarding Diagnostic Code 6846, the evidence during this period does not reflect that the Veteran was taking oral or parenteral corticosteroid medications for control during this period. Regarding Diagnostic Code 6847, there is no evidence of chronic respiratory failure with carbon dioxide retention, cor pulmonale, or that the Veteran’s sleep apnea required tracheostomy. Thus, the evidence most nearly approximates a 60 percent, but no higher, rating from January 7, 2013 to October 31, 2018 under Diagnostic Code 6600. From November 1, 2018 Based on a review of the relevant evidence and the applicable law and regulations, a preponderance of the evidence is against a finding that a rating in excess of 50 percent is warranted from November 1, 2018. The Veteran attended a VA examination on November 1, 2018 for an evaluation of his sarcoidosis. The examination report reflects that the Veteran was not taking oral or parenteral corticosteroid medications. The examination report reflects that the Veteran was taking inhaled medications, described by the Veteran as home nebulizer treatments. The examination report reflects that the Veteran was not using bronchodilators, antibiotics, or oxygen therapy for his sarcoidosis. The symptoms of his sarcoidosis were characterized as productive cough, dyspnea on exertion, fatigue, and tiredness. The examiner classified the Veteran’s sarcoidosis as stage three based on the X-ray findings, but the examination report also reflects that the chest X-ray performed at the examination was a stable, negative chest X-ray, as the cardiomediastinal silhouette remained stable in size. The PFT showed the Veteran had FEV-1 of 88 percent, FEV-1/FVC of 107 percent, and a DLCO of 76 percent predicted pre-bronchodilator. The examiner noted that the DLCO PFT test result most accurately reflected the Veteran’s pulmonary function. Post-bronchodilator testing was not performed because the pre-bronchodilator results were normal. The examiner noted that the Veteran’s sarcoidosis caused functional impact in the form of sedentary work in unfavorable climates (e.g. refrigerated or humid/warm rooms) and moderate and heavy physical work may be contraindicated. The Veteran reported at the examination that since the January 2013 VA examination he feels groggy, has no energy, and is tired and sleepy. Further, he reported that since his sarcoidosis in the 1980s, he has had a chronic cough with production of thick white mucous without blood. He reported he uses a nebulizer as needed. He reported the pulmonary sarcoidosis affects his ability to perform physical tasks due to dyspnea on exertion. The Veteran also attended a VA examination on November 1, 2018 for an evaluation of his sleep apnea. The examination report reflects that the Veteran required use of a CPAP machine and that the Veteran’s sleep apnea resulted in persistent daytime hypersomnolence, but the Veteran’s sleep apnea caused no chronic respiratory failure with carbon dioxide retention, cor pulmonale, or that the Veteran’s sleep apnea required tracheostomy. The VA examiner noted that the functional impact of the Veteran’s sleep apnea is that work involving lone and/or quietness, operation of equipment of public conveyance, operation of hazardous equipment, heights, all may have restrictions and/or be contraindicated. A review of VA treatment records during this period illustrate that the Veteran walks two to three miles daily on a treadmill, and he reported having no flares of his sarcoidosis. Following a review of the medical and lay evidence during this period, the Board concludes that a preponderance of the evidence is against a finding that a rating in excess of 50 percent is warranted from November 1, 2018. Regarding Diagnostic Code 6600, the PFT results during this period would result in a 10 percent rating based on the DLCO value, the PFT result that the August 2018 VA examiner found most accurately reflects the Veteran’s pulmonary function. Thus, with there being no DLCO value between 40 to 50 percent predicted since November 1, 2018, a rating in excess of 50 percent under Diagnostic Code 6600 is not warranted. In reaching this conclusion, the Board acknowledges that the November 2018 examiner classified the Veteran’s sarcoidosis as stage three based on the X-ray findings, whereas the Veteran’s sarcoidosis was classified as stage one based on the X-ray at the January 2013 VA examination, suggesting a worsening of the Veteran’s condition. However, the PFT results from January 2013 to November 2018 show improvement in the Veteran’s pulmonary functioning from January 2013 to August 2018. In addition, the VA treatment records during this period reflect no flare-ups of the Veteran’s sarcoidosis. As such, based on the objective findings from the November 2018 VA examination, a rating in excess 50 percent is not warranted from November 1, 2018. Regarding Diagnostic Code 6846, the Veteran was noted to be using a nebulizer as much as daily during this period; however, there is no evidence of high dose therapeutic corticosteroids for control during this period. Regarding Diagnostic Code 6847, there is no evidence of chronic respiratory failure with carbon dioxide retention, cor pulmonale, or that the Veteran’s sleep apnea requires tracheostomy. Thus, even when considering the Veteran’s symptoms of tiredness, chronic cough with production of thick white mucous without blood, and dyspnea upon exertion, the preponderance of evidence is against a finding of a rating in excess of 50 percent from November 1, 2018. The Board notes that the Veteran is competent to provide evidence of such symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in determining the actual degree of disability, objective examinations and diagnostic testing are more probative of the severity of his respiratory disability. As such, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected sarcoidosis and sleep apnea. In summary, the Board finds that the Veteran is entitled to a 50 percent rating prior to January 7, 2013, a 60 percent rating from January 7, 2013 to October 31, 2018, and a 50 percent rating from November 1, 2018. REASONS FOR REMAND Entitlement to TDIU is remanded. The Board regrets the additional delay and acknowledges that there has been substantial compliance with the July 2020 Board remand regarding taking all appropriate action to obtain a VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192), for the Veteran’s employment as a pastor. However, given the conflicting evidence regarding the Veteran’s employment as a pastor, the Board is unable to render a decision on the Veteran’s claim for TDIU at this time. Following the July 2020 Board remand, the Veteran submitted an undated VA Form 21-4192 in August 2020 in which he indicated he last worked in November 2013. The Veteran also submitted a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940), in August 2020 in which he indicated he was presently employed as a pastor and earned 6,000 dollars in the past 12 months. However, he also indicated that his monthly earnings are 2,000 dollars per month. In August 19, 2020 and September 21, 2020 letters to the Veteran and his employer, the AOJ requested the employer to complete the attached VA Form 21-4192 for the Veteran’s employment as a pastor. A review of the record illustrates that the Veteran’s employer has not completed a VA Form 21-4192 for his employment as a pastor. Given the discrepancy in the VA Form 21-4192 and VA Form 21-8940 regarding the earnings and current status of employment, the Board is unable to make a determination as to whether the Veteran’s employment as a pastor constitutes substantially gainful employment based on the current record. As such, a remand is necessary to obtain a VA Form 21-4192 from the Veteran’s employment as a pastor. If the VA Form 21-4192 cannot be obtained, such should be documented in the record. The matters are REMANDED for the following actions: 1. Take all appropriate actions to obtain a VA Form 21-4192 from the employer for his employment as a pastor as noted in the August 2020 VA Form 21-8940 to adjudicate the Veteran’s claim for TDIU. Inform the Veteran that a VA Form 21-4192 completed by his employer, including the current number of hours worked and earnings, is necessary to make a determination on the Veteran’s claim for TDIU. If a VA Form 21-4192 cannot be obtained from the employer noted in the August 2020 VA Form 21-8940, document in the claims file as to why such cannot be obtained. 2. Seek clarification from the Veteran regarding his current employment and earnings as a pastor, noting the conflicts between the VA Form 21-4192 and VA Form 21-8940 received by VA on August 8, 2020. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, Associate 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.