Citation Nr: 21008575 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 16-24 511A DATE: February 17, 2021 ORDER Entitlement to a total disability evaluation based upon individual unemployability (TDIU) has been withdrawn. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for a peptic ulcer disease is denied. Entitlement to a compensable evaluation for service-connected headaches is denied. Entitlement to an evaluation in excess of 10 percent disabling for service-connected right lower extremity radiculopathy (previously evaluated as right-sided sciatica) is granted; in part is granted. Entitlement to a compensable evaluation for erectile dysfunction is denied. Entitlement to an evaluation in excess of 20 percent disabling for service-connected lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 prior to November 27, 2019 and in excess of 40 percent disabling, thereafter is denied. Entitlement to an evaluation in excess of 10 percent disabling for service-connected gastroesophageal reflux disease (GERD), gastritis, and hiatal hernia is granted; in part. Entitlement to a compensable evaluation for service-connected allergic rhinitis is denied. Entitlement to compensable evaluation for sinusitis prior to February 13, 2015 and in excess of 50 percent disabling, thereafter is denied. Entitlement to a compensable disability rating for left ear hearing loss is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress syndrome (PTSD) excluding an adjustment disorder is remanded. FINDINGS OF FACT 1. On October 1, 2020, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he wished to withdraw the claim of entitlement to a TDIU. 2. The preponderance of the evidence weighs against finding that the Veteran’s cervical spine condition manifested in service or for many years thereafter and is not otherwise related to any incident during active service. 3. The preponderance of the evidence weighs against finding that the Veteran has peptic ulcer disease or had any such diagnosis at any time during the appeal period. 4. Throughout the appeal period, the Veteran experienced frequent headaches, with no evidence of prostrating attacks. 5. Prior to November 27, 2019, the Veteran’s service-connected right lower extremity radiculopathy was manifested by symptoms that were, at most, mild in severity, to include numbness and pain. 6. From November 27, 2019 forward, the Veteran’s service-connected right lower extremity radiculopathy has been manifested by symptoms that are, at most, moderate to severe in nature. Other symptoms include numbness and pain. 7. Throughout the appeal period, the Veteran’s service-connected erectile dysfunction has not been manifested by a deformity of the penis. 8. Prior to November 27, 2019, the Veteran’s service-connected lumbar strain, L5-S1 grade I spondylolisthesis, was manifested by no worse than, forward flexion of the lumbar spine greater than 30 degrees with muscle spasms or guarding not severe enough to result in an abnormal gait or spinal contour. 9. From November 27, 2019 forward, the Veteran’s service-connected lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 has not been manifested unfavorable ankylosis of the entire lumbar spine, or IVDS with incapacitating episodes. 10. Throughout the appeal period, the Veteran’s service-connected GERD, gastritis, with hiatal hernia has been manifested by no worse than, persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. 11. Throughout the appeal period, the Veteran’s service-connected allergic rhinitis has not been manifested by nasal polyps, 50 percent obstruction of both nasal passages; or a complete obstruction of one side. 12. Prior to February 13, 2015, the Veteran’s service-connected sinusitis was manifested by, no worse than, chronic sinusitis confirmed by radiological imaging. 13. From February 13, 2015 forward, the Veteran’s service-connected sinusitis was manifested by chronic sinusitis confirmed by radiological imaging and near constant sinusitis characterized by headaches, pain and tenderness affecting the sinuses. 14. Throughout the appeal period, the medical evidence has shown no worse than Level I-hearing acuity in the Veteran’s left ear. CONCLUSIONS OF LAW 1. The criteria for withdrawal of entitlement to a total disability evaluation based upon individual unemployability by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105 (2014); 38 C.F.R. § 20.205 (2018). 2. The criteria for establishing entitlement to service connection for a cervical spine condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for establishing entitlement to service connection for a peptic ulcer disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2018). 4. The criteria for establishing entitlement to a compensable evaluation for service-connected headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100 (2018). 5. The criteria for establishing entitlement to an evaluation in excess of 10 percent disabling for service-connected right lower extremity radiculopathy (previously evaluated as right-sided sciatica) prior to November 27, 2019, have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2018). 6. The criteria for establishing entitlement to an evaluation of 40 percent disabling, but no higher, for service-connected right lower extremity radiculopathy (previously evaluated as right-sided sciatica) from November 27, 2019, forward, have been shown. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2018). 7. The criteria for establishing entitlement to a compensable evaluation for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107(b) (2014); 38 C.F.R. §§ 4.3, 4.115b, Diagnostic Code 7599-7522 (2018). 8. The criteria for establishing entitlement to an evaluation in excess of 20 percent disabling for service-connected lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 prior to November 27, 2019 and in excess of 40 percent disabling, thereafter have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242-5239 (2018). 9. The criteria for establishing entitlement to an evaluation of 30 percent disabling, but no higher, for service-connected gastroesophageal reflux disease (GERD), gastritis, with hiatal hernia have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7307-7346 (2018). 10. The criteria for establishing entitlement to a compensable evaluation for service-connected allergic rhinitis have not been met. 38 U.S.C. § 1155 (2014); 38 C.F.R. § 3.102, 3.159, Diagnostic Code 6522 (2018). 11. The criteria for establishing entitlement to compensable evaluation for sinusitis prior to February 13, 2015 and in excess of 50 percent disabling, thereafter have not been met. 38 U.S.C. § 1155 (2014); 38 C.F.R. § 3.102, 3.159, Diagnostic Code 6513 (2018). 12. The criteria for establishing entitlement to a compensable evaluation for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from February 2006 to July 2010. Pursuant to an August 2018 Board decision, this matter was remanded for additional development to include scheduling the Veteran for new VA examinations. Regrettably, an additional remand is necessary as to the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress syndrome (PTSD) excluding an adjustment disorder in order to ensure that due process is followed and that there is a complete record upon which to decide the appellant’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2014); 38 C.F.R. § 3.159 (2018). The remaining issues have been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2018). Copies of compliant VCAA notices were located in the claim’s file. VA’s duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 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.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). 1. Entitlement to a total disability evaluation based upon individual unemployability (TDIU) The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55 (2018). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55 (2018). In the present case, the appellant submitted written correspondence, dated October 2020, indicating that he did not wish to continue his claim of entitlement to a TDIU. Therefore, no allegations of errors of fact or law remain for appellate consideration as to this issue. Accordingly, the Board does not have jurisdiction to review the claim and it is dismissed. Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (a), 3.304 (2018). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2018). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2018). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). 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) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 2. Entitlement to service connection for a cervical spine disability is denied. The Veteran asserts entitlement to service connection for a cervical spine condition as causally related to active service. As discussed in more detail below, the preponderance of the evidence is against his claim. In analyzing the Veteran’s claim, the threshold inquiry before the Board is 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. The Board concludes that, while the Veteran has been diagnosed with degenerative changes of the cervical spine, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. Service treatment records are silent for complaints, treatment, or diagnosis of a cervical spine condition. Post-service treatment records show that the Veteran reported generalized neck pain during a primary care visit in January 2014. Similar symptoms were reported in July 2015. In November 2015, magnetic resonance imaging (MRI) documented degenerative changes in the cervical spine. Additional complaints of neck pain were reported in March 2020. Radiological imaging (X-rays) revealed mild spondylotic changes. Prescribed treatments included physical therapy. The Veteran rated pain as a 5 or 6 on a 10-point scale. In a February 2015, a private medical opinion was associated with the claims file. There in, the internal medicine physician identified neck and upper back pain with stiffness, numbness, tingling, sensorial loss, cramps and weakness of paracervical spine muscles. Pain radiated from the cervical spine to the shoulders, arms, elbows, and wrists. He also reported an inability to lift weights or perform routine physical activities. Participation in physical therapy treatments were unable to resolve his symptoms. Considering the above, the physician opined that the Veteran’s cervical spine condition was causally related to active service. No rationale was provided to support the asserted opinion. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a VA examination. On examination in November 2019, a current diagnosis of degenerative changes in the cervical spine was indicated. During the clinical interview, the Veteran reported constant pain in the cervical spine. Pain was rated as a 6 on a 10-point scale. After onset, flare-ups of pain persisted for an entire day. Pain impaired range of motion. Range of motion testing revealed forward flexion limited to 40 degrees, extension limited to 30 degrees, right and left lateral flexion limited to 30 degrees, right lateral rotation limited to 40 degrees, and left lateral rotation limited to 45 degrees. Range of motion itself does not contribute functional loss. Pain was noted on examination with all ranges of motion however, it did not result in functional loss. There was no evidence of pain with weight bearing. Localized tenderness was observed over the trapezius muscles in the upper back and shoulders. Repetitive use testing did not result in additional functional loss or range of motion. Neither pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability over time. Muscle spasms were observed, with no change to the Veteran’s gait or spinal contour. Deep tendon reflexes and muscle strength testing revealed normal findings. There is no evidence of muscle atrophy or ankylosis. Favorable findings of radiculopathy were noted in the left cervical spine at the C8-T1 nerve roots. The Veteran denied use of assistive devices. As to the Correia factors, favorable findings of pain were observed with passive motion. There was no evidence of pain with non-weight bearing. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s cervical spine condition is causally related to active service. In support of the stated conclusion, the examiner noted that service treatment records were silent for any evidence of a cervical spine condition during active service or within one year of separation. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of his current symptoms, their impact on daily living and employment, and such reporting is deemed credible. However, in the absence of specialized training or medical experience, he is not competent to provide complex medical opinions or render related diagnoses. Moreover, the Board recognizes the recent ruling by the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) in Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018), that found “pain alone can serve as a functional impairment and therefore, qualify as a disability.” In this case, service treatment records were silent for complaints of neck pain or any evidence of a cervical spine condition or. Post-service treatment records show an initial reference to neck pain in January 2014. A favorable private medical opinion which lacked diagnostic testing or evidential support was rendered in February 2015. Evidence of degenerative changes in the cervical spine were confirmed by MRI in November 2015. Cervical spondylosis was shown on radiological imaging in March 2020. In November 2019, a VA examiner found no “nexus” between the Veteran’s cervical spine condition and active service, to include any in-service injury or event. While the Board recognizes the Veteran’s subjective belief that he suffers from pain and degenerative changes in the cervical spine as casually related to active service, the evidence does not support his contention. In fact, the evidence is silent for a confirmed diagnosis of a cervical spine condition or complaints of symptoms until 2014; several years after separation. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for a cervical spine condition must be denied. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.10 (2018). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness which causes additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40 (2018); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2018). Additionally, evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2018). However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Id.; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a peptic ulcer disease is denied. The Veteran contends that he suffers from a peptic ulcer disease as causally related to active service. As discussed in more detail below, the preponderance of the evidence is against the claim. The threshold inquiry before the Board is whether the Veteran has a current disability that began during or is otherwise casually related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a peptic seizure and has not had one at any time during the pendency of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service treatment records are largely silent for any evidence of a stomach ulcer or complaints of an intestinal condition. In December 2005, no complaints of frequent indigestion heartburn, stomach, or intestinal trouble were endorsed in a report of medical history. The comments section referenced treatment for appendicitis in 1992. No complications or residuals were reported. In July 2006, the Veteran reported a sore throat. A follow-up examination revealed a small lesion located in the back of the throat. It was described as an erythematous ulcer. In an August 2006 health record, an aphthous ulcer was listed as a current problem. Prescribed medication included Triamcinolone Acetonide and Rabeprazole. The later was used to treat heartburn. Two years later, a report of medical history made no reference to frequent indigestion heartburn, stomach, or intestinal trouble in May 2008. Post-service treatment records show gastrointestinal complaints to include heartburn. An upper GI series found no evidence of peptic ulcer disease in December 2010. An endoscopy in April 2016 confirmed findings of gastritis, however, no stomach ulcers were identified. In a February 2015, a private medical opinion was associated with the claims file. There in, an internal medicine physician identified current symptoms as nausea, vomiting, flatulence, fatty food intolerance, and epigastric burning. The Veteran’s symptoms were deemed consistent with a diagnosis of gastroesophageal reflux disease and peptic ulcer disease. Prescribed treatments included oral medications and dietary recommendations. Considering the above, the physician opined that the Veteran’s digestive disorders were likely secondary to active service. No rationale was provided in support the asserted opinion. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a VA examination. On examination in November 2019, a current diagnosis of gastritis was indicated. During the clinical evaluation, the Veteran reported experiencing heartburn, regurgitation, acid reflux, abdominal pain, nausea, and bloating over many years. Worsening symptoms were reported in the morning and after eating. Recurrent episodes of mild symptoms occurred 4 or more times per year. Abdominal pain was pronounced and recurred monthly. Transient nausea occurred 4 or more times per year. No other conditions were identified. In December 2010, an upper GI radiologic study found no evidence of an upper GI abnormality. An upper endoscopy in April 2019 showed non-erosive antritis and a small hiatal hernia. No functional impact was reported. Following the clinical evaluation, no diagnosis of a peptic ulcer disease was indicated. While the examiner acknowledged the favorable private medical opinion, dated February 2015, other treatment records and diagnostic findings dispute that diagnosis. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. However, as to the etiology of a particular disability, the issue of causation requires specialized training and medical expertise that is typically outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, there is no evidence that Veteran possesses the required skillset. To the extent that his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. Review of the record is largely silent for any evidence of a stomach ulcer, either in service or within one year of separation. In fact, post-service treatment records show only a single favorable medical opinion. That opinion was offered in the absence of evidential support or diagnostic testing. Accordingly, the Board accords greater probative weight to the upper GI series and endoscopy which failed to document a current diagnosis of peptic ulcer disease. While the Board recognizes the Veteran’s subjective belief that he suffers from peptic ulcer disease as casually related to active service, the evidence does not support his contention. In fact, the evidence is silent for a confirmed diagnosis of peptic ulcer disease. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for peptic ulcer disease must be denied. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.10 (2018). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness which causes additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40 (2018); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2018). Additionally, evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2018). However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Id.; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a compensable evaluation for service-connected headaches The Veteran contends that his service-connected headaches are worse that currently evaluated. As discussed in more detail below, the preponderance of the evidence is against his claim. The Veteran’s headache disability has been assigned a noncompensable evaluation under Diagnostic Code 8100, which pertains to migraine headaches. 38 C.F.R. § 4.124a (2018). Under Diagnostic Code 8100, a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one episode in 2 months over the last several months. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. The maximum schedular disability rating of 50 percent is warranted for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define “prostrating,” nor has the Court. Fenderson v. West, 12 Vet. App. 119 (1999). (Diagnostic Code 8100 is quoted verbatim, but the Court does not specifically address the matter of what is a prostrating attack.). According to DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32nd Ed. 2012), “prostration” is defined as “extreme exhaustion or powerlessness.” In analyzing the Veteran’s claim, the Board has fully reviewed the evidence of record, to include the VA examination reports, VA and private treatment records, and all lay statements. Considering the above, it concludes that the Veteran is not entitled to a compensable rating for his headache disorder at any point during the appeal period. In this case, the Veteran has been afforded multiple VA examinations. On examination in May 2015, the previous diagnosis of chronic headaches was confirmed. During the clinical interview, the Veteran reported ongoing headache episodes localized at his temples and forehead since hie previous evaluation in December 2010. Headaches recur once per week and improve with use of analgesic medication. The Veteran denied any experience with prostrating attacks or aura. Photophobia within concomitant symptoms was also reported. To treat his symptoms, the Veteran reported use of Tramadol and Acetaminophen as needed. Current symptoms include pain impacting both sides of the head, with sensitivity to light and sound. After onset, pain persisted for 1 day. No diagnostic testing was indicated. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in August 2020, the previous diagnosis of chronic headaches was confirmed. During the clinical interview, the Veteran reported headache pain localized at the temples and forehead. Symptoms occur 5 times per week. Tramadol and Gabapentin were used to treat pain. After onset, pain persisted for less than 24 hours. Other symptoms included photophobia with concomitant symptoms. The Veteran denied any experience with prostrating attacks or aura. Current symptoms included pain impacting both sides of the head, with sensitivity to light and sound. After onset, pain persisted for less than 1 day. No diagnostic testing was indicated. The Veteran was deemed capable of functioning within an occupational setting. Avoiding job-related stressors, loud noises, or other factors that trigger headache pain was recommended. In analyzing the Veteran’s claim, the Board has fully considered the medical evidence and lay assertions of record. It also recognizes the Veteran’s subjective belief the current severity of his headaches warrants a higher evaluation. Generally, the Veteran is competent to report on his current symptoms and their worsening, and such reporting is deemed credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, the Board observes that the medical evidence fails to show any evidence of prostrating attacks. Accordingly, the Board finds that the Veteran’s symptomology continues to approximate the diagnostic criteria for a non-compensable evaluation. While the Board is sympathetic to the Veteran’s complaints of worsening symptoms, the medical evidence fails to show headaches with characteristic prostrating attacks averaging one episode in 2 months over the last several months. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2018). Therefore, the Board finds that the evidence of record fails to show worsening symptoms sufficient to warrant a higher evaluation of 10 percent disabling for any point during the appeal period. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to compensable evaluation for his service-connected headaches must be denied. 5. Entitlement to an evaluation in excess of 10 percent disabling for service-connected right lower extremity radiculopathy (previously evaluated as right-sided sciatica) is granted; in part The Veteran contends that the current severity of his right lower extremity radiculopathy is worse than currently evaluated. The Veteran’s right lower extremity radiculopathy has been evaluated as 10 percent disabling under Diagnostic Code 8520. 38 C.F.R. § 4.124a (2018). Under Diagnostic Code 8520, which pertains to paralysis of the sciatic nerve, mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating; moderate incomplete paralysis of the sciatic nerve warrants a 20 percent rating; moderately severe incomplete paralysis of the sciatic nerve warrants a 40 percent rating; severe incomplete paralysis of the sciatic nerve with marked muscular atrophy warrants a 60 percent rating; and, complete paralysis of the sciatic nerve warrants an 80 percent rating. Id. Terms such as “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6 (2018). The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the typical picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Review of the record indicates that the Veteran has been afforded multiple VA examinations. On examination in May 2015, current diagnosis included a lumbosacral strain, lumbar spondylolisthesis, and right-sided sciatica. During the clinical interview, the Veteran reported worsening pain. Flare-ups of pain recur weekly and lasts for hours after onset. Functional loss was described as difficulty with prolonged walking, standing, and stooping. Range of motion testing revealed forward flexion limited to 35 degrees, extension limited to 20 degrees, right and left lateral flexion limited to 15 degrees, and right and left lateral rotation limited to 15 degrees. Pain was reported with forward flexion and it caused functional loss. Evidence of pain was reported with weight-bearing. Localized tenderness was observed over the paravertebral muscles. No additional loss of function or range of motion was reported with repetitive use testing. Guarding and muscle spasms were endorsed with no evidence of an abnormal gait or spinal contour. No additional factors contributed to functional loss. Muscle strength testing yielded normal findings. There was no evidence of muscle atrophy or ankylosis. Deep tendon reflexes were normal. Decreased sensation was observed in the right lower leg and foot. Straight leg raising was negative. Mild radiculopathy was described as intermittent pain, paresthesias and/or dysesthesias on the right side. Moderate numbness was also reported on the right side. Involvement of the sciatic nerve roots was observed on the right side only. There was no evidence of intervertebral disc syndrome (IVDS). The Veteran endorsed constant use of a cane. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in November 2019, current diagnoses included a lumbosacral strain, lumbar spondylolisthesis with a herniated disc at L5-S1, and right-sided sciatica. During the clinical interview, the Veteran reported worsening pain. Flare-ups of pain recur weekly and persisted for an entire day after onset. Functional loss was described as difficulty with prolonged walking and standing. Range of motion testing revealed forward flexion limited to 25 degrees, extension limited to 10 degrees, right and left lateral flexion limited to 10 degrees, and right and left lateral rotation limited to 15 degrees. Pain was reported with all ranges of motion and it caused functional loss. Evidence of pain was reported with weight-bearing. Localized tenderness or pain to palpation was observed over the paraspinal muscles. No additional loss of function or range of motion was reported with repetitive use testing. Pain limits functional ability over time and results in a loss of range of motion of 10-15 degrees in all directions. Guarding and muscle spasms resulted in an abnormal gait or spinal contour. Additional factors contributing to functional loss included interference with standing and sitting. Muscle strength testing yielded substantially normal findings. There was no evidence of muscle atrophy or ankylosis. Deep tendon reflexes were hyperactive in the bilateral ankles. Decreased sensation was observed in the bilateral legs and feet. Straight leg raise testing was positive, bilaterally. Moderate to severe radiculopathy impacted the bilateral lower extremities. Involvement of the sciatic nerve roots was observed, bilaterally. Favorable findings of IVDS was noted, with no evidence of incapacitating episodes. The Veteran endorsed constant use of a crutch and occasional use of a wheelchair. A functional impact was described as difficulty with twisting, bending, heavy lifting, carrying, pushing/pulling, prolonged standing or ambulation activities. As to the Correia factors, pain was reported with passive range of motion. On review of the evidence of record, the Board finds that an evaluation of 40 percent disabling was warranted for the Veteran’s service-connected right lower extremity radiculopathy from November 2019, forward. The Board recognizes that worsening symptoms were reported throughout the rating period, however, the medical evidence failed to show worsening symptoms prior to November 2019. In fact, on examination in May 2015, the Veteran’s condition was characterized as mild. During the most recent VA examination, evidence of moderate to severe radiculopathy was indicated. Considering the above, the Board finds that the Veteran’s disability picture more nearly approximates an evaluation of 40 percent disabling from November 2019, forward. To meet the diagnostic criteria for an evaluation of 40 percent disabling, the Board observes that the evidence must reveal moderately severe incomplete paralysis of the sciatic nerve. In this case, the required showing has not been met prior to November 27, 2019. Similarly, to meet the diagnostic criteria for an evaluation of 20 percent disabling, the medical evidence must reveal moderate incomplete paralysis of the sciatic nerve of the sciatic nerve. Prior to November 2019, the Veteran’s symptoms were described as no worse than mild in severity. Accordingly, the Board finds that the medical evidence supports a finding of 40 percent disabling, but no higher, from November 27, 2019 forward. Alternatively, the preponderance of the evidence weighs against an evaluation in excess of 10 percent disabling for his right lower extremity radiculopathy prior to November 27, 2019. Therefore, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable and the claim must be denied. see also Gilbert, 1 Vet. App. 49. 6. Entitlement to a compensable evaluation for erectile dysfunction The Veteran contends that he is entitled to a compensable rating for erectile dysfunction. As discussed in more detail below, the preponderance of the evidence is against his claim. The Veteran’s erectile dysfunction has been assigned a 0 percent rating under Diagnostic Code 7599-7522 as a residual of prostate cancer. 38 C.F.R. § 4.115b (2018). To warrant a compensable 20 percent rating for erectile dysfunction, there must also be deformity of the penis. 38 C.F.R. § 4.115b, Diagnostic Code 7522. The VA Adjudication Procedure Manual confirms that two requirements must be met before a 20 percent evaluation can be assigned for deformity of the penis with loss of erectile power under Diagnostic Code 7522: (1) the deformity must be evident, and (2) the deformity must be accompanied by loss of erectile power. Simply stated, the condition is not compensable in the absence of penile deformity. See M21-1, Part III, Subpart iv, Chapter 4, Section I, Paragraph 3.b. (Updated August 17, 2016). Review of the record indicates that the Veteran has been afforded multiple VA examinations. On examination in May 2015, the Veteran’s prior diagnosis of erectile dysfunction was confirmed. Current symptoms include poor erections and use of a vacuum device. The Veteran denied use of Viagra out of fear of adverse consequences. There is no evidence of a current diagnosis of an orchiectomy, renal dysfunction, or voiding dysfunction. The Veteran acknowledged some ability to achieve an erection sufficient for penetration and ejaculation without medication. There is no evidence of retrograde ejaculation or history of chronic infections. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in August 2020, the Veteran’s prior diagnosis of erectile dysfunction was confirmed. Current symptoms include poor erections and inconsistent strength of erections. Difficulty achieving strong erections, penetration and ejaculation was indicated. The Veteran endorsed occasional of a vacuum device. He denied use of Viagra or Cialis. There is no evidence that the Veteran has an orchiectomy, renal dysfunction, or voiding dysfunction. He acknowledged some ability to achieve an erection sufficient for penetration and ejaculation without medication. There is no evidence of retrograde ejaculation or history of chronic infections. Considering the above the Board finds that the Veteran does not meet the criteria for a 20 percent rating under Diagnostic Code 7599-7522. Specifically, the evidence does not reveal any physical deformity of the Veteran’s penis or loss of erectile power. Alternatively, the Board has also considered the applicability of other diagnostic codes, and finds that the assignment of a higher rating is not warranted as the medical evidence has not revealed that the Veteran suffers from a renal or voiding dysfunction, a urinary tract infection, a removal of testes, prostate gland injuries, tumors, or neoplasms. Consequently, no other diagnostic codes under 38 C.F.R. §§ 5.115a -b, pertaining to dysfunctions and diagnoses of the genitourinary system, are applicable. Consequently, the Board places more probative weight on the medical evidence of record establishing that the Veteran does not suffer from a penile deformity with loss of erectile power. Therefore, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b). A compensable rating for the Veteran’s erectile dysfunction must be denied. 7. Entitlement to an evaluation in excess of 20 percent disabling for service-connected lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 prior to November 27, 2019 and in excess of 40 percent disabling, thereafter The Veteran contends that the current severity of his lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 is worse than currently evaluated. As discussed in more detail below, the Board finds that the preponderance of the evidence is against the claim. The Veteran’s lumbar spine disability has been evaluated as 20 percent disabling prior to November 27, 2019, and as 40 percent disabling thereafter pursuant to Diagnostic Codes 5242-5239, which pertain to spondylolisthesis or segmental instability. 38 C.F.R. § 4.71a. Under the General Rating Formula, a 10 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; combined range of motion of the cervical spine greater than 170 degrees, but not greater than 335 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is assigned for forward flexion of the cervical spine at 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; or, unfavorable ankylosis of the entire cervical spine. Id. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. Id. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See also Plate V, 38 C.F.R. § 4.71a. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4) provides that the rater is to round each range of motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disability of the thoracolumbar and cervical spine segments is to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. Alternatively, a spinal disability can be evaluated as IVDS with incapacitating episodes. Under the criteria listed in Diagnostic Code 5243, a 20 percent evaluation requires incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of less than six weeks but more than four weeks, and a 60 percent rating is warranted if incapacitating episodes have a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. In this case, the Board finds the evidence does not support an evaluation of 40 percent disabling prior to November 27, 2019, or in excess of 40 percent disabling thereafter. Review of the record indicates that the Veteran has been afforded multiple VA examinations. Participation in physical therapy treatments and use of oral prescription medications were also noted. As previously indicated, the Veteran underwent a VA examination in May 2015. Range of motion testing revealed forward flexion limited to 35 degrees, extension limited to 20 degrees, right and left lateral flexion limited to 15 degrees, and right and left lateral rotation limited to 15 degrees. Pain was reported with forward flexion and it caused functional loss. There was no evidence of IVDS. Guarding and muscle spasms with no evidence of an abnormal gait or spinal contour. Functional loss was described as difficulty with prolonged walking, standing, and stooping. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in November 2019, current diagnosis included a lumbosacral strain, lumbar spondylolisthesis with a herniated disc at L5-S1, and right-sided sciatica. Range of motion testing revealed forward flexion limited to 25 degrees, extension limited to 10 degrees, right and left lateral flexion limited to 10 degrees, and right and left lateral rotation limited to 15 degrees. Pain was reported with all ranges of motion and it caused functional loss. Evidence of pain was reported with weight-bearing. Localized tenderness or pain to palpation was observed over the paraspinal muscles. Pain limits functional ability over time and results in a loss of range of motion of 10-15 degrees in all directions. Guarding and muscle spasms caused an abnormal gait or spinal contour. Favorable findings of IVDS was noted, with no evidence of incapacitating episodes. The Veteran endorsed constant use of a crutch and occasional use of a wheelchair. A functional impact was described as difficulty with twisting, bending, heavy lifting, carrying, pushing/pulling, prolonged standing or ambulation activities. Considering the above, the Board concludes that the evidence does not support a higher evaluation for the period prior to November 2019, or at any point thereafter. Notably, VA examinations in May 2015 revealed forward flexion limited to 35 degrees, with muscle spasms and guarding not resulting in an abnormal gait or spinal contour. From November 2019 forward, flexion was limited to, no worse than, 25 degrees with favorable findings of IVDS and no evidence of incapacitating episodes. When assessing the severity of musculoskeletal disabilities that are, at least partly, rated on the basis of limitation of motion, VA also must consider the extent that a veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when a veteran’s symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination, assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran is competent to report on his experience of low back pain and its impact on his quality of life. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, that pain is adequately accounted for in the Veteran’s assigned evaluations. See DeLuca, 8 Vet. App. 202; 38 C.F.R. § 4.1. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a higher evaluation for any point during the appeal period. Therefore, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to an evaluation in excess of 20 percent disabling for service-connected lumbar strain, L5-S1 grade I spondylolisthesis, herniated L5-S1 prior to November 27, 2019 and in excess of 40 percent disabling, thereafter must be denied. 8. Entitlement to an evaluation in excess of 10 percent disabling for service-connected gastroesophageal reflux disease (GERD), gastritis, and hiatal hernia is granted; in part The Veteran contends that his service-connected GERD with hiatal hernia is worse than currently evaluated. As discussed in more detail below, the Board finds that an evaluation of 30 percent disabling is warranted throughout the appeal period. The Veteran’s service-connected GERD with gastritis and a hiatal hernia was been evaluated as 10 percent disabling, pursuant to Diagnostic Code 7307-7346. See 38 C.F.R. § 4.113, 4.114 (2018). A hyphenated code is used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation. See 38 C.F.R. § 4.27. The first of the hyphenated diagnostic codes indicates the system or bodily part being rated, and the second diagnostic code indicates the most closely analogous disease, injury or disability listed in the rating schedule. Archer v. Principi, 3 Vet. App. 433 (1992); see also 38 C.F.R. §§ 4.20, 4.27. Diagnostic Code 7307 provides ratings for hypertrophic gastritis. Chronic hypertrophic gastritis, with small nodular lesions, and symptoms is rated 10 percent disabling. Chronic hypertrophic gastritis, with multiple small eroded or ulcerated areas, and symptoms, is rated 30 percent disabling. Chronic hypertrophic gastritis, with severe hemorrhages, or large ulcerated or eroded areas, is rated 60 percent disabling. Atrophic gastritis, which is a complication of a number of diseases, including pernicious anemia, is to be rated on the underlying condition. 38 C.F.R. § 4.114. Diagnostic Code 7346 provides ratings for hiatal hernia. Hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity is rated 10 percent disabling. Hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, is rated 30 percent disabling. Hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health, is rated 60 percent disabling. 38 C.F.R. § 4.114. Hematemesis means vomiting of blood. See Dorland’s Illustrated Medical Dictionary 842 (31st ed. 2007). Melena means the passing of dark-colored feces stained with blood pigments or with altered blood. Id. at 1142. Pyrosis means heartburn. Id. at 1586. Dysphagia means difficulty swallowing. See Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, 2007. On examination in May 2015, the Veteran reported current symptoms including persistently recurrent epigastric distress, reflux, regurgitation. There was no evidence of esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. No functional impact was indicated. In September 2015, a primary care treatment record listed complaints of upper abdominal pain, back and left leg pain with weakness, upper extremity weakness, and migraine headaches. Stomach conditions noted include GERD. The Veteran endorsed use of Pantoprazole. In April 2016, the Veteran underwent an upper gastrointestinal tract endoscopy. The diagnoses indicated were GERD and Dyspepsia. Mild erythema was observed around antrum, with no evidence of ulcers, masses or erosions. Diagnoses including a non-erosive antritis and small hiatal hernia were indicated. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in November 2019, a current diagnosis of gastritis and hiatal hernia was indicated. During the clinical evaluation, the Veteran reported episodes of heartburn, regurgitation, acid reflux, abdominal pain, nausea, pyrosis, and bloating over many years. Worsening symptoms were reported in the morning and after eating. Recurrent episodes of mild symptoms occurred 4 or more times were year. Abdominal pain recurred monthly and was described as pronounced. Transient nausea was noted, 4 or more times per year. Bouts of nausea persisted for less than 1 day after onset. No other conditions were identified. An upper endoscopy in April 2019 showed non-erosive antritis and a small hiatal hernia. In December 2010, an upper GI radiologic study found no evidence of an upper GI abnormality. No incapacitating episodes were reported. No functional impact was reported. On review of the record, the Board finds that the Veteran’s gastrointestinal symptoms more nearly approximated the diagnostic criteria for an evaluation of 30 percent disabling throughout the appeal period. As a preliminary matter, the Board notes that the Veteran’s predominant disability is best represented by the diagnostic criteria under Diagnostic Code 7346 for hiatal hernia, as evidenced by complaints of persistent symptoms including recurrent epigastric distress, acid reflux, regurgitation, and nausea. Conversely, there is no evidence of severe hemorrhages, or large ulcerated or eroded areas due to gastritis. Therefore, an initial 30 percent rating, and no higher, under Diagnostic Code 7307-7346 utilizing the specific criteria in Diagnostic Code 7346 is warranted for the service-connected GERD. In denying a rating higher than 30 percent, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (2014); 38 C.F.R. §§ 4.3, 4.7 (2018). 9. Entitlement to a compensable evaluation for service-connected allergic rhinitis The Veteran contends that his service-connected allergic rhinitis warrants a compensable evaluation. As discussed in more detail below, the preponderance of the evidence is against his claim. The Veteran’s allergic or vasomotor rhinitis has been assigned a non-compensable evaluation pursuant to Diagnostic Code 6522. 38 C.F.R. § 4.97 (2018). Under Diagnostic Code 6522, allergic rhinitis warrants a 10 percent evaluation where there is no evidence of nasal polyps but favorable findings of greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. A maximum rating of 30 percent is warranted when polyps are present. 38 C.F.R. § 4.97 (2018). In this case, the Veteran has been afforded multiple VA examinations. On examination in May 2015, current diagnoses include chronic sinusitis and allergic rhinitis. During the current evaluation, symptoms of sinusitis were listed as ethmoid, maxillary, sphenoid, frontal, and pansinusitis. Diagnostic imaging revealed near constant sinusitis. Tenderness to palpation was noted over both maxillary sinuses. The Veteran denied any experience with non-incapacitating episodes over the prior 12-month period or incapacitating episodes of sinusitis requiring prolonged 4 to 6 weeks of antibiotics treatment in the past 12-month period. There is no evidence of greater than 50 percent obstruction of the nasal passage on both sides, or complete obstruction on the left or right side due to rhinitis. There was also no evidence of granulomatous condition. No functional limitations were reported. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On examination in August 2020, current diagnoses include chronic sinusitis and allergic rhinitis. During the current evaluation, the Veteran endorsed occasional bouts with sinusitis and allergic rhinitis. Current symptoms include a stuffy/itchy nose, frontal sinus pain and eye irritation with prolonged use of a computer. No chronic cough constant, nasal drip, or itchy/watery eyes was indicated. The Veteran endorsed use of nasal sprays. Other sinus symptoms included ethmoid, maxillary, sphenoid, frontal, and pansinusitis. Diagnostic imaging revealed near constant sinusitis, with weekly episodes lasting more than 2 days after onset. The Veteran has tenderness to palpation over both maxillary sinuses. He denied any experience with non-incapacitating episodes over the prior 12-month period or incapacitating episodes of sinusitis requiring prolonged 4 to 6 weeks of antibiotics treatment in the past 12-month period. No sinus surgeries were reported. There was no evidence of greater than 50 percent obstruction of the nasal passage on both sides, or complete obstruction on the left or right side due to rhinitis. There was also no evidence of granulomatous condition or nasal polyps. Prior X-ray films, dated November 2010, revealed acute right maxillary sinusitis, chronic ethmoid, frontal and sphenoid sinusitis. No functional limitations were reported. Considering the above, the Board finds that the medical evidence fails to show symptoms sufficient to warrant a compensable evaluation at any point to the appeal period. To establish an evaluation of 10 percent disabling, the medical evidence must reveal greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side, with no evidence of polyps. No such findings have been shown at any time during the appeal period. While the Board is sympathetic of the Veteran’s complaints of chronic sinus symptoms, to include pain, a runny nose and itchy/watery eyes, the noted symptoms are insufficient to warrant a higher evaluation. Accordingly, the Board finds that the preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b). Therefore, the Veteran’s claim for a compensable evaluation for service-connected allergic rhinitis must be denied. 10. Entitlement to compensable evaluation for sinusitis prior to February 13, 2015 and in excess of 50 percent disabling, thereafter The Veteran contends that his service-connected sinusitis warrants a compensable evaluation prior to February 13, 2015 and in excess of 50 percent disabling thereafter. As discussed in more detail below, the preponderance of the evidence is against his claim. The Veteran’s chronic sinusitis has been assigned a non-compensable evaluation prior to February 13, 2015 and 50 percent disabling from February 13, 2015 forward pursuant to Diagnostic Code 6513. 38 C.F.R. § 4.97 (2018). Under the General Rating Formula for sinusitis, a noncompensable evaluation is assigned for sinusitis that is detected by X-ray only. A 10 percent rating is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness affecting the sinuses, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula for Sinusitis provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Note following Diagnostic Code 6514. As previously indicated the Veteran has been afforded multiple VA examinations. On examination in May 2015, a current diagnosis of chronic sinusitis was confirmed. Diagnostic imaging revealed near constant sinusitis. No nasal passage obstructions were observed. Tenderness to palpation was noted over both maxillary sinuses. The Veteran’s speaking voice had a nasal pitch. No incapacitating or non-incapacitating episodes of sinusitis were reported over the prior 6-12 months. Radiological imaging (X-rays) of the paranasal sinuses, dated November 2010, revealed acute right maxillary sinusitis. Other findings included chronic ethmoid, frontal and sphenoid sinusitis. In November 2015, an MRI of the brain (with and without contrast) showed a mucosal opacification of the left frontal sinus, bilateral ethmoid sinuses with mild mucosal thickening of the maxillary and sphenoid sinuses. The nasal septum was observed as slightly deviated towards the right side. No enhancing lesions or masses were indicated. Chronic sinus mucosal thickening was also noted. Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On subsequent examination, dated August 2020, the prior sinus related diagnoses were confirmed. Diagnostic findings revealed near constant sinusitis, with weekly episodes lasting more than 2 days after onset. Tenderness to palpation was noted over both maxillary sinuses. Considering the above, the Board finds that a compensable evaluation is not warranted prior to February 2015. To establish an evaluation of 10 percent disabling, the medical evidence must reveal one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. In fact, the medical evidence shows diagnostic imaging referencing chronic mucus thickening and lay reporting of near constant sinusitis characterized by headaches, pain and tenderness affecting the sinuses beginning in 2015. In addition, the Board notes that Diagnostic Codes 6510 through 6514 provide a maximum evaluation of 50 percent disabling for sinusitis. See 38 C.F.R. § 4.97. Accordingly, a higher evaluation is not possible under Diagnostic Codes 6510 through 6514 for the Veteran’s chronic sinusitis from February 13, 2015 forward. As there exists no other diagnostic code applicable to disabilities of the sinuses, there is no basis for a higher evaluation. Accordingly, the claim of entitlement to a compensable evaluation for the Veteran’s service-connected sinusitis warrants a compensable evaluation prior to February 13, 2015 and in excess of 50 percent disabling, thereafter must be denied. 11. Entitlement to a compensable disability rating for left ear hearing loss The Veteran contends that the current severity of his service-connected left ear hearing loss warrants a higher evaluation. However, as discussed in more detail below, the preponderance of the evidence is against the claim. In this case, the Veteran’s left ear hearing loss has been evaluated as non-compensable pursuant to 38 C.F.R. § 4.85, Diagnostic Code 6100 (2018). Under applicable laws and regulations, the rating assigned for hearing loss is determined by a mechanical application of the rating schedule, which is grounded on numeric designations assigned to audiometric examination results. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Specifically, evaluations of hearing impairment range from 0 to 100 percent based on organic impairment of hearing acuity. Auditory acuity is gauged by examining the results of controlled speech discrimination tests, together with the results of pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hz). To evaluate the degree of disability, the rating schedule establishes 11 auditory acuity levels ranging from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85 Tables VI and VII, as set forth following 38 C.F.R. § 4.85, are used to calculate the rating to be assigned. 38 C.F.R. § 4.85 (2018). Under 38 C.F.R. § 4.86, when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hz) is 55 decibels (dB) or more, Table VI or Table Via is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86 (a) (2017). Additionally, when the pure tone threshold is 30 dB or less at 1000 Hz, and 70 dB or more at 2000 Hz, Table VI or Table VIa is to be used, whichever results in the higher numeral. Thereafter, that numeral will be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86 (b) (2018). During the appeal period, the Veteran has been afforded multiple VA examinations. On the authorized audiological evaluation in May 2015, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 20 25 LEFT 15 15 20 35 50 Pure tone threshold averages were 18 dB for the right ear and 30 dB for the left ear. Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. Due to left ear hearing loss, the Veteran reported a functional impact as difficulty hearing and understanding in conversations, with a need to request repetition from speakers. The Veteran’s hearing impairment levels correspond to Level I in the right ear and Level I in the left ear. Intersecting Levels I and I under Table VI results in a non-compensable disability rating. See 38 C.F.R. § 4.86 (2018). Pursuant to an August 2018 Board remand decision, the Veteran was afforded a new VA examination. On the authorized audiological evaluation in November 2019, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 15 35 LEFT 10 10 10 35 50 Pure tone threshold averages were 19 dB for the right ear and 26 dB for the left ear. Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. Due to left ear hearing loss, the Veteran reported difficulty hearing and understanding in conversations, particularly in the presence of background noise. The Veteran’s hearing impairment levels correspond to Level I in the right ear and Level I in the left ear. Intersecting Levels I and I under Table VI results in a non-compensable disability rating. See 38 C.F.R. § 4.86 (2018). Considering the above, the Board finds that a compensable evaluation is not warranted for any time during the appeal period. In making this determination, the Board recognizes the Veteran’s competence to report on observable symptoms, including his difficulty hearing and understanding speech in conversations, particularly in the presence of background noise. However, the Veteran is not competent to consider complex medical questions to include an assessment of the nature and severity of the symptoms for purposes of establishing an increased rating claim or render a complex medical opinion or diagnosis in the absence of proof of relevant training and expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. In this case, the evidence fails to show a change in symptom severity sufficient to warrant a higher evaluation. While the Board is sympathetic to the Veteran’s complaints of worsening symptoms, the evidence does not support his contentions. Under the rating criteria, a non-compensable evaluation contemplates some degree of impaired hearing, to include difficulty communicating. As there is no evidence of more significant functional loss, the Board finds that a compensable rating is not warranted at this time. The Board notes that this finding does not signify the absence of a disability associated with the Veteran’s hearing loss. However, the assignment of disability ratings for hearing impairment is derived from a mechanical formula. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable the benefit of the doubt are not applicable. The claim of entitlement to a compensable evaluation for left ear hearing loss must be denied. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress syndrome (PTSD) excluding an adjustment disorder. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran’s claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2018). In this case, the Veteran contends that he is entitled to service connection for an acquired psychiatric disorder other than an adjustment disorder, to include PTSD. Review of the record indicates that the Veteran received multiple psychiatric diagnoses, to include PTSD. VA examinations in November 2010 and May 2015, failed to confirm the diagnostic criteria for a current diagnosis of PTSD. Pursuant to an August 2018 Board Remand decision, the Veteran’s claim was remanded for a new VA examination. Specifically, the examiner was requested to identify any psychiatric diagnoses present and opine whether the Veteran’s psychiatric condition is at least as likely as not a result of active military service, including the Veteran’s exposure to combat. The Board notes that the Veteran has been granted service connection for major depressive disorder with anxiety symptoms, which is rated under the same rating criteria for rating PTSD. As the record shows an additional diagnosis of PTSD was provided by a private physician, a VA examination is required to determine the etiology of any additional psychiatric disorders, to include PTSD, and to determine if the symptoms associated with such disorders are distinguishable from those of the service-connected major depressive disorder with anxiety symptoms. In accordance therewith, the Veteran underwent an additional VA examination in August 2020. A current diagnosis of an adjustment disorder was confirmed. No additional diagnoses were rendered, to include PTSD. No etiological opinion was provided. Further, the VA examiner failed to specifically address the private opinion or opine as to whether any new and separate psychiatric diagnoses were deemed warranted, to include as causally related to active service The Board observes that a claimant has the right to substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the United States Court of Appeals for Veterans Claims Court (Court) or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see also D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required). As substantial compliance has not been established, the Board finds that an additional remand is required. On remand, relevant ongoing medical records should also be obtained. 38 U.S.C. § 5103A (c) (2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim). The matters are REMANDED for the following action: 1. Obtain updated VA and private treatment records and associate them with the claims file. 2. Schedule the Veteran for an examination before an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. The examiner should identify a diagnosis for a psychiatric disability is found and note the evidence in support thereof. With respect to PTSD, the examiner must confirm or rule out a diagnosis of PTSD. If it is determined that PTSD has not been present during the period of the claim, the examiner should explain why the diagnosis is not warranted. The examiner should reconcile the November 2010 and May 2015 VA examination reports, indicating that the Veteran did not meet the diagnostic criteria for PTSD, with the February 2015 private treatment record, which reflects a diagnosis of PTSD. The examiner is advised that the Veteran should be evaluated under the DSM-5 criteria. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine as to whether it is at least as likely as not (50 percent probability or greater) related to a verified in-service stressor. For any diagnosed acquired psychiatric disorders other than PTSD, the examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that each disorder was incurred in, was caused by, or is otherwise etiologically related to the Veteran’s military service. It is noted that the regulations pertaining to in-service stressors do not apply to psychiatric disabilities other than PTSD. The examiner should note that the Veteran is currently service connected for major depressive disorder with anxiety symptoms. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. The examining physician/specialist should provide information to demonstrate that he or she is qualified to offer the above requested opinion (such as a curriculum vitae or similar demonstrable documentation). This information is to be associated with the Veteran’s claims file. See Francway v. Wilkie, No. 2018-2136, 2019 U.S. App. LEXIS 30633 (Fed. Cir. Oct. 15, 2019). 3. Thereafter, re-adjudicate the Appellant’s claim. If any benefit sought remains denied, provide the Veteran with a supplemental statement of the case and an adequate opportunity to respond before returning the matter to the Board for further adjudication, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on the next page)   This claim must be afforded expeditious treatment. The law requires all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims to be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Whitaker, 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.