Citation Nr: 21009072 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 18-03 507 DATE: February 18, 2021 ORDER The claim to reopen the issue of service connection for a left leg disability is granted. The claim for service connection for obstructive sleep apnea (OSA) is denied. The claim for service connection for right leg disability, other than weakness, abnormal gait, or a skin disorder, is denied. The claim for service connection for an eye disability to include defective vision, presbyopia, glaucoma, cataracts, pseudophakia, and dry eyes is denied. The claim for an increased disability rating in excess of 10 percent for low back strain is denied. The claim for an increased disability rating in excess of 10 percent prior to August 4, 2014, for cervical spine degenerative disc disease (cervical spine disability) is denied. The claim for an increased disability rating in excess of 20 percent beginning August 4, 2014, for cervical spine degenerative disc disease (cervical spine disability) is denied. The claim for a higher initial disability rating in excess of 40 percent for right upper extremity radiculopathy is denied. The claim for a higher initial disability rating in excess of 20 percent for left upper extremity radiculopathy is denied. The claim for a compensable disability rating for erectile dysfunction (ED) is denied. The claim for an increased disability rating in excess of 20 percent prior to January 12, 2016, for status post prostatectomy, prostate adenocarcinoma (herein prostate cancer residuals) is denied. The claim for an increased disability rating in excess of 40 percent beginning January 12, 2016, for prostate cancer residuals is denied. The claim for a higher initial disability rating in excess of 30 percent prior to August 20, 2015, for coronary artery disease (CAD) is denied. The claim for a higher initial disability rating in excess of 60 percent from August 20, 2015, to January 31, 2019, for CAD is denied. The claim for a higher initial disability rating in excess of 30 percent from February 1, 2019, to March 12, 2020, for CAD is denied. The claim for a higher initial disability rating in excess of 60 percent beginning March 12, 2020, for CAD is denied. REMANDED The claim for service connection for an acquired psychiatric disability other than major depressive disorder, to include posttraumatic stress disorder (PTSD) and alcohol dependence, is remanded. The claim for service connection for a right leg skin disorder is remanded. The claim for service connection for a left leg skin disorder is remanded. The claim for service connection for hypertension is remanded. FINDINGS OF FACT 1. In a July 1989 rating decision, service connection for a left leg disability was denied; a notice of disagreement and/or new and material evidence was not received within one year of notice of that decision. 2. Evidence received more than one year after the July 1989 rating decision is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for a left leg disability. 3. The preponderance of the evidence is against finding that OSA began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence of record is against finding that the Veteran has had a right lower extremity disability, other than weakness, abnormal gait, or skin disorder at any time during or approximate to the pendency of the claim. 5. The preponderance of the evidence is against finding that a current eye disability began during active service or is otherwise related to an in-service injury or disease. 6. The Veteran's lumbar spine disability is manifested, at worst, by forward flexion to 75 degrees and combined range of motion of 185 degrees without guarding or muscle spasm, ankylosis of the spine, or intervertebral disc syndrome (IVDS) with doctor prescribed bedrest for incapacitating episodes. 7. Prior to August 4, 2014, the Veteran’s cervical spine disability manifested, at worst, by degenerative disc and joint disease with painful motion and without demonstration of the loss of range of motion, guarding or muscle spasm, ankylosis of the spine, or IVDS with doctor prescribed bedrest for incapacitating episodes required for a higher rating. 8. Beginning August 4, 2014, the Veteran’s cervical spine disability manifested, at worst, by forward flexion of 25 degrees without ankylosis or IVDS with doctor prescribed bedrest for incapacitating episodes. 9. The Veteran’s right upper extremity fifth and sixth radicular group radiculopathy is manifest, at worst, by moderate, incomplete paralysis. 10. The Veteran’s left upper extremity fifth and sixth radicular group radiculopathy is manifest, at worst, by mild, incomplete paralysis. 11. Throughout the appeal period, service-connected ED has not manifested by a deformity of the penis. 12. Prior to January 13, 2016, the Veteran's prostate cancer residuals manifested in urinary incontinence without the use of absorbent materials or appliances, daytime voiding intervals of two to three hours, and nighttime awakening to void twice per night. 13. Beginning January 13, 2016, the Veteran’s prostate cancer residuals manifested in urinary incontinence requiring the wearing of absorbent materials which must be changed two to four times per day, but not by wearing of absorbent material which must be changed more than four times per day or the use of appliances. 14. Prior to August 20, 2015, coronary artery disease (CAD) manifested by left ventricular dysfunction with an ejection fraction between 50 and 55 percent, which is the most accurate measure of the Veteran’s CAD for this period, without chronic congestive heart failure, or a workload of 5 METs or less. 15. During the period from August 20, 2015, to January 31, 2019, CAD manifested by left ventricular dysfunction with an ejection fraction of 59 percent, which is the most accurate measure of the Veteran’s CAD for this period, without chronic congestive heart failure, or a workload of 3 METs or less. 16. During the period from February 1, 2019, to March 12, 2020, CAD manifested by left ventricular dysfunction with an ejection fraction between 50 and 55 percent, which is the most accurate measure of the Veteran’s CAD for this period, without chronic congestive heart failure, or a workload of 5 METs or less. 17. Beginning March 12, 2020, CAD manifested by left ventricular dysfunction with an ejection fraction of 45 percent without chronic congestive heart failure, or a workload of 3 METs or less. CONCLUSIONS OF LAW 1. The July 1989 rating decision that denied service connection for left leg disability is final. 38 U.S.C. §§ 7104 (b), 7105(c); 38 C.F.R. §§ 3.104, 20.201, 20.302, 20.1103. 2. Evidence received more than one year since the July 1989 rating decision is new and material to the claim for service connection for left leg disability and the claim to reopen the issue is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for right lower extremity disability other than weakness, abnormal gait, or skin disorder, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for an eye disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.9. 6. The criteria for an increased disability rating in excess of 10 percent for low back strain disability are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5243. 7. The criteria for an increased disability rating in excess of 10 percent prior to August 4, 2014, for a cervical spine disability are not met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243 8. The criteria for an increased disability rating in excess of 20 percent beginning August 4, 2014, for a cervical spine disability are not met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243. 9. The criteria for an initial rating in excess of 40 percent for right upper extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code 8510. 10. The criteria for an initial rating in excess of 20 percent for left upper extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code. 8510 11. The criteria for a compensable disability rating for ED are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.115b Diagnostic Code 7522. 12. Prior to January 13, 2016, the criteria for the assignment of a rating in excess of 20 percent for prostate cancer residuals are not. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512-7527. 13. Beginning January 13, 2016, the criteria for the assignment of a rating in excess of 40 percent for prostate cancer residuals are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512-7527. 14. Prior to August 20, 2015, the criteria for a disability rating in excess of 30 percent for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, Diagnostic Code 7005. 15. During the period between August 20, 2015, to January 31, 2019, the criteria for a disability rating in excess of 60 percent for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, Diagnostic Code 7005. 16. During the period between February 1, 2019, to March 12, 2020, the criteria for a disability rating in excess of 60 percent for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, Diagnostic Code 7005. 17. Beginning March 12, 2020, the criteria for a disability rating in excess of 60 percent for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1962 to July 1988. The claim was remanded by the Board in February 2019. The Board notes that the issue of service connection for a right leg disability has been adjudicated throughout the claim as a musculoskeletal or neurological issue. However, during a 2020 VA examination, the Veteran raised the issue of a right leg skin disability. Development is complete regarding the former, but development has not been completed regarding a reported skin issue on the right leg. In applying all reasonable doubt in the Veteran’s favor as to whether he intended for the skin symptoms to be included in the claim from the outset and so as to not delay the Veteran’s claim by requiring a separate claim to be filed, the Board will bifurcate the issue of service connected for a right leg skin disorder from the issue of service connection for a right leg disability, other than weakness, abnormal gait, or skin disorder, and adjudicate each issue accordingly. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA's discretion); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff'd, 631 F.3d 1380 (Fed. Cir. 2011) (holding that it is permissible to bifurcate a claim and to adjudicate the distinct theories of entitlement separately). The issue of service connection for a left leg disability was previously denied in an unappealed July 1989 rating decision. The Board finds that the disability claimed and denied in 1989 and the current claim are the same as the Veteran has used the same verbiage regarding the issue in each claim. The Board, therefore, does not construe the current claim as a claim for a “distinctly diagnosed disease” from the disabilities adjudicated in the prior final decisions. As such, his current claim is not a separate and distinct claim, but rather a claim to reopen his prior determination. See Velez v. Shinseki, 23 Vet. App. 199 (2009). Where the claim in question has been finally adjudicated at the RO level and not appealed, the statutes make clear that the Board has a jurisdictional responsibility to consider whether it is proper for a claim to be reopened, regardless of whether the previous action denying the claim was appealed to the Board. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Thus, despite the various characterizations of the issue throughout the appeal, the Board must make an independent determination as to whether new and material evidence has been presented to reopen the claim. Claim to Reopen Generally, a claim which has been finally denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. The issue of service connection for left leg disability was previously denied in a July 1989 rating decision on the basis that the evidence did not demonstrate a left leg disability. The Veteran did not submit new and material evidence or a notice of disagreement within one year of the 1989 decision which became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.202, 20.1103; see Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (holding that VA has a duty to consider in every case whether evidence received within one year of an RO decision is new and material so as to prevent the decision from becoming final under 38 C.F.R. § 3.156(c)). The evidence now includes VA treatment records demonstrating left leg skin symptoms and diagnoses and the Veteran’s reports that his skin issues on the lower extremities are due to Agent Orange exposure. This evidence is new and material to the reason for the prior denial, namely whether the Veteran has a left leg disability that is etiologically related to military service. As such, the claim for service connection for a left leg disability is reopened. The issue of service connection for a left leg skin disability is addressed in the remand section of this decision. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) 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 in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for obstructive sleep apnea (OSA) The Veteran contends that he incurred OSA during or as a result of military service. Unfortunately, the evidence does not support a finding of service connection. The question for 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 a current diagnosis of OSA, and evidence shows that he reported snoring during service to the VA examiner, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis OSA began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records are negative for any complaints, treatment, or diagnosis of OSA and the Veteran specifically denied sleep problems upon separation examination in 1988. VA and private treatment records show the Veteran was not diagnosed with OSA until 2013, more than 24 years post-separation from service. During a March 2020 VA examination, the Veteran reported that his wife experienced his snoring and episodes of “respiratory pause.” However, the examination report did not indicate that she provided the date of onset of such symptoms. Then, during the September 2020 VA examination, the Veteran reported that OSA had onset in the 1980s, after his wife reported that he was snoring loudly, but that he did not have apneic episodes. While the Veteran and his wife are competent to report having experienced or observed symptoms of snoring during or since service, neither are competent to provide a diagnosis in this case or determine that these symptoms were manifestations of OSA. The issue is medically complex, as it requires knowledge of anatomical relationships in the body and the conduct and interpretation of complicated diagnostic medical testing, which he has not been shown to possess. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Furthermore, the March 2020 VA examiner noted that the Veteran’s lay statements indicate that his sleep apnea began between 2012 and 2013. Given the lack of evidence of sleep apnea during service, including upon separation, the examiner concluded that it was less likely than not that the Veteran’s OSA is etiologically related to military service. The September 2020 VA examiner opined that the Veteran’s OSA is not at least as likely as not related to an in-service injury, event, or disease, including the lay report of in-service snoring. He explained that there was no evidence of symptoms confirming OSA during service and that the Veteran denied such sleep problems upon his separation examination. In addition, the examiner found significant that the Veteran denied apneic episodes in the 1980s and the more than two-decade gap between the Veteran’s separation in 1988 and the diagnosis of OSA in 2013. He concluded that he could not establish that the Veteran’s chronic OSA had onset during or as a result of military service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges that the Veteran certainly believes that his OSA is related to an in-service injury, event, or disease. However, in this case he is not competent to provide a nexus opinion regarding this issue. As noted above, the issue is medically complex, as it requires knowledge of anatomical relationships in the body and the conduct and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials 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 2020 VA opinions, which are against the claim. Given the lack of medical evidence in support of the claim, the evidence is against a finding of a nexus between the Veteran’s current OSA and military service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for right leg disability other than weakness, altered gait, or a skin disorder The Veteran contends that he incurred a right leg disability during military service. The Board concludes that the evidence does not support a finding of service connection. The Board notes that right lower extremity weakness and abnormal gait, a residual of a stroke, are currently service connected. In addition, the issue of a right leg skin disorder is addressed in the remand section of this decision. Therefore, the question for the Board is whether the Veteran has another current right leg disability other than weakness, abnormal gait, or skin disorder, 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 the Veteran does not have a current diagnosis of another right leg disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Upon VA examination in September 2020, the VA examiner noted the Veteran’s denial of any other nonservice-connected, non-skin related right leg symptoms. Specifically, the Veteran denied decreased range of motion, pain, numbness, tingling, cramping, or muscle spasms. The examiner noted the Veteran’s complaints during service of leg cramps in 1980 but found that a chronic disability was not present during this appeal. On physical examination, the examiner found full range of motion without neurological or musculoskeletal symptoms. As such, the examiner concluded that the Veteran did not have a disability of the right leg, but rather noted that his concerns involved his skin. In addition, despite consistent treatment records, VA and private treatment records do not contain a diagnosis of a right leg disability other than the symptoms which are a part of other issues on appeal. The Board notes that the Veteran has not described any musculoskeletal or neurologic symptoms or disability of the right leg beyond what is noted above. He is also not competent to provide a diagnosis in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, that of the VA examiner, which is against the claim. 3. Entitlement to service connection for defective vision, presbyopia The Veteran contends that he incurred a defective vision disability, to include presbyopia, as a result of military service. Unfortunately, the evidence does not support a finding of service connection in this case. The Board concludes that, while the Veteran has a diagnosis of multiple eye disabilities, the preponderance of the evidence is against finding that a current eye disability began during active service, or is otherwise related to an in-service injury, event, or disease. Service treatment records are negative for any complaints, treatment, or diagnosis of an eye disability. The Board acknowledges that the Veteran had vision within normal limits upon enlistment and decreased near vision to 20/30 upon separation. However, such refractive error is considered a congenital defect, which is not considered a disease for VA compensation purposes. See M21-1 Part III, Subpart iv, 4.B.1.d; 38 C.F.R. § 3.303 (c); see also 38 C.F.R. § 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996). In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects or refractive errors of the eyes, even if visual acuity decreased in service, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for either a congenital defect or a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury that created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (July 18, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Thus, in the absence of some event or trauma, a refractive error is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. §§ 3.303 (c), 4.9 (congenital or developmental defects, refractive error of the eye, personality disorders, and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); see also VAOPGCPREC 82-90. In this case, the Veteran has not reported, nor does the evidence demonstrate, an event or trauma during military service. Similarly, the medical and lay evidence does not demonstrate any evidence of in-service complaints, treatment, or diagnosis of the currently diagnosed eye disabilities during service or for many years after discharge. As such, there is no evidence that the Veteran’s refractive errors were aggravated or subject to a superimposed disease or injury during his military service that resulted in additional disability. Further, an August 2020 VA examiner opined that the Veteran’s currently diagnosed disabilities are not at least as likely as not related to an in-service injury, event, or disease, including the decreased vision noted upon service separation. The examiner also explained that presbyopia is a naturally occurring process of the aging eye and cannot be attributed to any of the Veteran’s ocular conditions. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report lay-observable symptoms such as dry eyes, he has not reported experiencing any such symptoms during military service or for many years thereafter. Moreover, he is not competent to provide a diagnosis in this case or determine that any symptoms were manifestations of a currently diagnosed disability. The issue is medically complex, as it requires knowledge of anatomical relationships in the body and the conduct and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials 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). Given the lack of medical evidence in support of the claim, the evidence is against finding that a current eye disability began during active service or is otherwise related to an in-service injury, event, or disease. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). 4. Entitlement to an increased disability rating in excess of 10 percent for low back strain The Veteran submitted a claim for an increased rating for service-connected low back strain in August 2014. Therefore, the relevant focus for adjudicating the Veteran's claim is the period beginning one year prior to the claim for increase, August 2013. Hart v. Mansfield, 21 Vet. App. 505 (2007); cf 38 C.F.R. § 3.156(b). The Veteran contends that he is entitled to a higher rating, although he has not specifically stated how his disability is worse than rated. His low back strain disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating, the next highest rating available, is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In order to be awarded a disability rating in excess of 10 percent, the evidence must demonstrate forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, a combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, ankylosis, or IVDS with doctor prescribed bedrest for incapacitating episodes having a total duration of at least two weeks during the past twelve months. The Board notes that throughout three VA examinations and thousands of pages of VA and private treatment records, forward flexion has been limited at most to 75 degrees and combined range of thoracolumbar motion has been limited at most to 185 degrees, following three repetitions. Functional factors such as pain, flare-ups, fatigue, weakness, and incoordination have not been shown to result in additional limitation of motion or compensable loss of function. Moreover, guarding and spasms were not found during any examination. The Board further notes that ankylosis has never been demonstrated. In fact, each VA examiner found that there was no ankylosis and found that the Veteran was able to bend his back in all ways. The evidence, including the lay evidence, shows no indication whatsoever that the spine has been fixed in extension or flexion at any time during this period, thus demonstrating the absence of ankylosis. The Board notes that the medical treatment records in the claims file do not include evidence contradicting the VA examiners or demonstrating that his low back strain disability is worse than currently rated. Therefore, an increased rating in excess of 10 percent is not warranted under Diagnostic Code 5237 or the general rating formula for spine disorders. Similarly, the evidence does not demonstrate that the Veteran has ever been diagnosed with IVDS or prescribed two weeks or more of bedrest by a doctor. Each VA examiner found that the Veteran did not have IVDS. The Veteran has also not described any period of such bedrest, certainly not lasting two weeks of any year. As such, a rating in excess of 10 percent is not warranted under the rating criteria for IVDS. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board notes that all possibly relevant diagnostic codes have been considered, but finds that no other codes are applicable As noted above, the Veteran. Moreover, the medical and lay evidence of record does not indicate a degree of functional loss severe enough to warrant a disability rating in excess of 10 percent. While the Veteran is competent to report symptomatology that he experiences, he has not reported how his low back strain is worse than currently rated. Moreover, he has not shown that he has the medical experience or training to assess the severity of his lumbar spine. The issue is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for low back strain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an increased disability rating in excess of 10 percent prior to August 4, 2014, for cervical spine disability The Veteran submitted a claim for an increased rating for service-connected cervical spine disability in July 2013. Therefore, the relevant focus for adjudicating the Veteran’s claim is the period beginning one year prior to the claim for increase, July 2012. Hart v. Mansfield, 21 Vet. App. 505 (2007); cf 38 C.F.R. § 3.156(b). The Veteran contends that he is entitled to a higher rating for his cervical spine disability although he has not specifically stated how his disability is worse than rated. His cervical spine disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Cervical spine disabilities are also rated under the General Rating Formula for Diseases and Injuries of the Spine, but there are a few differences specifically for cervical spine disabilities. Under the criteria, the next highest disability rating, a 20 percent rating, is warranted for forward flexion of the thoracolumbar spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar 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. A 30 percent rating is awarded for forward flexion of the cervical spine limited to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In order to be awarded a disability rating in excess of 10 percent for this period, the evidence must demonstrate forward flexion limited to 30 degrees or less, a combined range of motion of 170 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, some form of ankylosis, or IVDS with doctor prescribed bedrest for incapacitating episodes having a total duration of at least two weeks during the past twelve months. The Board notes that a VA examination was not provided during this period on appeal, and, in fact, the effective date for the next period on appeal is the date of a VA examination. The medical evidence from the time the claim was filed up until the first VA examination in August 2014 does not demonstrate any range of motion testing or any medical or lay description of the cervical spine range of motion. In addition, there is no evidence of muscle spasm or guarding resulting in abnormal gait or spinal contour, that his spine was fixed in any direction, or that he had IVDS requiring doctor-prescribed bedrest. Therefore, the Board concludes that the evidence prior to August 4, 2014, does not demonstrate that a higher disability rating is warranted during this period. 38 C.F.R. § 4.71a, Diagnostic Code 5242, 5243. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent prior to August 4, 2014, for cervical spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. Entitlement to an increased disability rating in excess of 20 percent beginning August 4, 2014, for cervical spine disability In order to be awarded a disability rating in excess of 20 percent for this period, the evidence must demonstrate forward flexion limited to 15 degrees or less, some form of ankylosis, or IVDS with doctor prescribed bedrest for incapacitating episodes having a total duration of at least four weeks during the past twelve months. The Board notes that throughout three VA examinations conducted in January 2015 and March and September 2020 and thousands of pages of VA and private treatment records, forward flexion has been limited at most to 25 degrees without any additional loss in range of motion following three repetitions. Functional factors such as pain, flare-ups, fatigue, weakness, and incoordination have not been shown to result in additional limitation of motion or compensable loss of function. The Board further notes that ankylosis has never been demonstrated. In fact, each VA examiner found that there was no ankylosis and found that the Veteran was able to bend his back in all ways. The evidence, including the lay evidence, shows no indication whatsoever that the spine has been fixed in extension or flexion at any time during this period, thus demonstrating the absence of ankylosis. The Board notes that the medical treatment records in the claims file do not include evidence contradicting the VA examiners or demonstrating that his cervical spine disability is worse than currently rated. Therefore, an increased rating in excess of 20 percent is not warranted under Diagnostic Code 5242 or the general rating formula for spine disorders. Similarly, the evidence does not demonstrate that the Veteran has ever been diagnosed with IVDS or prescribed four weeks or more of bedrest by a doctor. Each VA examiner found that the Veteran did not have IVDS. The Veteran has also not described any period of such bedrest, certainly not lasting four weeks of any year. As such, a rating in excess of 20 percent is not warranted under the rating criteria for IVDS. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board notes that all possibly relevant diagnostic codes have been considered, but finds that no other codes are applicable While the Veteran is competent to report symptomatology that he experiences, he has not reported how his cervical spine disability is worse than currently rated. Moreover, he has not shown that he has the medical experience or training to assess the severity of his cervical spine disability. The issue is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for cervical spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. Entitlement to an initial disability rating in excess of 40 percent for right upper extremity radiculopathy The Veteran contends that he is entitled to a higher initial rating for his right upper extremity radiculopathy, although he has not explained why his disability is more severe than rated. The Board finds that the evidence does not support the award of a higher initial rating. Paralysis of the fifth and sixth radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8510. Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis including all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected is rated as 70 and 60 percent, respectively. 38 C.F.R. § 4.124a, Diagnostic Code 8510. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The Veteran received a VA examination of his cervical spine and/or peripheral nerves in August 2002, June 2006, November 2007, May 2010, January 2015, March 2020, and September 2020. Regarding impairment of motor functions, the Veteran’s right upper extremity strength was noted to be 4/5 with active movement against some, but not all, resistance during the November 2007, May 2010, and March 2020 VA examinations and the same for the right elbow and wrist at the January 2015 examination. Regarding sensory disturbance, the Veteran reported to the 2006 examiner that he experienced occasional numbness of the hand and fingers three to four times per year. However, his sensory examinations were normal with the exception of the March 2020 examination where decreased shoulder, forearm, and hand/fingers sensation to light touch was noted. The Veteran’s reflexes were largely full, with the exception of the January 2015 examination where the right biceps and brachioradialis were absent and the right triceps were hypoactive. However, the March and September 2020 examiners again found full reflexes. The Veteran denied related pain at every examination and the November 2007 examiner noted that right wrist pain reported was not connected to the Veteran’s service-connected disabilities. There were no trophic changes, atrophy, or complete paralysis noted upon any VA examination. The May 2010 VA examiner concluded that the Veteran’s bilateral upper extremity radiculopathy had resolved. It was only the January 2015 VA examiner who found any evidence of radiculopathy. The examiner found upon examination no constant pain or paresthesias, mild intermittent pain, and severe numbness and concluded that the Veteran had moderate, incomplete paralysis of the fifth and sixth radicular groups. However, the 2020 VA examiners again found no evidence of radiculopathy upon examination. VA and private treatment records do not demonstrate symptomatology worse than that found upon examination or worse than currently rated. Based on the above, the Board finds that the disability is primarily manifest by impairment of motor functions and reflexes. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by consistent or chronic trophic changes, sensory loss, atrophy, or pain. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis at worst. The Board acknowledges the lay assertions that his right upper extremity radiculopathy is worse than rated but notes that he has not reported the symptoms that are more severe. Moreover, the Board finds the medical evidence of record to be more probative because the examiners possess the medical knowledge and training to evaluate his disability and the Veteran has not been shown to possess such knowledge or skills. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent for right upper extremity fifth and sixth radicular group impairment. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. Entitlement to an initial disability rating in excess of 20 percent for left upper extremity radiculopathy The Veteran contends that he is entitled to a higher initial rating for his left upper extremity radiculopathy, although he has not explained why his disability is more severe than rated. The Board finds that the evidence does not support the award of a higher initial rating. Paralysis of the fifth and sixth radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8510. Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis including all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected is rated as 70 and 60 percent, respectively. 38 C.F.R. § 4.124a, Diagnostic Code 8510. The Veteran received a VA examination of his left upper extremity cervical spine and/or peripheral nerves in January 2015, March 2020, and September 2020. Regarding impairment of motor functions, the Veteran was noted with full left upper extremity strength, except when it was noted to be 4/5 with active movement against some, but not all, resistance during the November 2007 VA examination. His sensory examinations were found to be normal at each VA examination. Similarly, his reflexes were largely full, with the exception of hypoactive brachioradialis reflexes found during the January 2015 examination. The March and September 2020 examiners again found full reflexes. The Veteran denied related pain at every examination and there were no trophic changes, atrophy, or complete paralysis noted upon any VA examination. The May 2010 VA examiner concluded that the Veteran’s bilateral upper extremity radiculopathy had resolved. It was only the January 2015 VA examiner who found any evidence of radiculopathy. The examiner found no evidence of symptoms relating to peripheral neuropathy, but concluded that the Veteran had mild, incomplete paralysis of the fifth and sixth radicular groups. The 2020 VA examiners again found no evidence of radiculopathy upon examination. VA and private treatment records do not demonstrate symptomatology worse than that found upon examination or worse than currently rated. Based on the above, the Board finds that the disability has not manifested consistently by any notable impairment, which only occasional motor and reflex impairment. The Board, therefore, finds that the level of impairment is most analogous to mild incomplete paralysis at worst. The Board acknowledges the lay assertions that his left upper extremity radiculopathy is worse than rated but notes that he has not reported the symptoms that are more severe. Moreover, the Board finds the medical evidence of record to be more probative because the examiners possess the medical knowledge and training to evaluate his disability and the Veteran has not been shown to possess such knowledge or skills. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for left upper extremity fifth and sixth radicular group impairment. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to a compensable disability rating for erectile dysfunction (ED) The Veteran submitted a claim for an increased rating for service-connected ED in August 2015. Therefore, the relevant focus for adjudicating the Veteran's claim is the period beginning one year prior to the claim for increase, August 2014. Hart v. Mansfield, 21 Vet. App. 505 (2007); cf 38 C.F.R. § 3.156(b). Under Diagnostic Code 7522, a compensable rating requires a physical deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Here, the requirement under Diagnostic Code 7522 of deformity of the penis "with" loss of erectile power clearly means that both factors are required. 38 C.F.R. § 4.115b; see Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). In this case, while the Veteran has loss of erectile power, the medical evidence does not demonstrate, nor does the Veteran contend that he has any physical deformity of his penis. VA examiners in September 2015, June 2017, and March and September 2020 found the penis and testes were normal. VA and private treatment records also do not document a deformity of the penis during the appeal period. Thus, a compensable disability rating for ED is not warranted at any period on appeal. In sum, the preponderance of the evidence is against the assignment of a compensable disability rating for service-connected ED at any time during the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7 10. Entitlement to a higher disability rating in excess of 20 percent prior to January 12, 2016, for prostate cancer residuals The Veteran submitted a claim for an increased rating for service-connected prostate cancer residuals in August 2015. Therefore, the relevant focus for adjudicating the Veteran's claim is the period beginning one year prior to the claim for increase, August 2014. Hart v. Mansfield, 21 Vet. App. 505 (2007); cf 38 C.F.R. § 3.156(b). The Veteran's prostate cancer residuals are currently assigned a 20 percent disability rating prior to January 13, 2016, under 38 C.F.R. § 4.115b, Diagnostic Code 7528-7527. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 7528, which addresses prostate cancer, provides a 100 percent rating for malignant neoplasms of the genitourinary system. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, any residual disability will be rated as voiding dysfunction or renal dysfunction, whichever is predominant. Under Diagnostic Code 7527, prostate gland injuries, infections, hypertrophy, or postoperative residuals are rated as voiding dysfunction or urinary tract infection, whichever is predominant. The Board notes that multiple VA examiners have found no evidence of renal dysfunction or urinary tract infection and such symptoms have not been noted in the treatment records associated with the claim. Therefore, the question is whether a higher disability rating is warranted based on voiding dysfunction, the more predominant symptom related to his prostate cancer residuals. 38 C.F.R. § 4.115b, Diagnostic Code 7528-7527. Voiding dysfunction may be rated based on urine leakage, frequency, or obstructed voiding. For ratings based on urine leakage, due to continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, the next highest disability rating, a 40 percent rating, is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed two to four times per day. The next highest disability rating for urinary frequency, a 40 percent rating, is warranted for daytime voiding interval less than one hour or awakening to void five or more times per night. Finally, a higher rating for obstructed voiding requires marked obstructive symptomatology (hesitancy, slow or weak stream, decreased for of stream with either post void residuals greater than 150cc, uroflowmetry, recurrent urinary tract infections, or stricture disease requiring dilation every two to three months. The only VA examination during this period was conducted in September 2015. The examiner found that the urine leakage did not require the wearing of absorbent material or use of an appliance. The urinary frequency resulted in a daytime voiding interval between two to three hours and a nighttime awakening to void two times per night. The examiner stated that there was no evidence that the voiding dysfunction caused any signs or symptoms of obstructed voiding or any other obstructive symptoms. The medical treatment records during this time do not contradict the examiner’s findings or demonstrate that his voiding dysfunction was worse than demonstrated during his VA examination. At no time during this period has the Veteran reported or the evidence demonstrated that the Veteran met the criteria for a disability rating in excess of 20 percent. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of an increased disability rating in excess of 20 percent prior to January 2016 for residuals of prostate cancer and voiding dysfunction. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 11. Entitlement to a higher disability rating in excess of 40 percent beginning January 12, 2016, for prostate cancer residuals For ratings based on voiding dysfunction, the only option for a rating in excess of 40 percent, is to demonstrate urine leakage requiring the required use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. The ratings for voiding dysfunction based on urinary frequency and obstructed voiding do not provide a higher disability rating. The current 40 percent rating is assigned based upon a VA treatment record on that date demonstrating the use of absorbent materials which must be changed two to four times per day. The Veteran received three VA examinations during this period, in June 2017 and March and September 2020. The 2017 examiner found that the urine leakages required the changing of absorbent materials two times per day. The March 2020 examiner found that the Veteran did not wear absorbent materials or an appliance. The September 2020 VA examiner found that he needed to change his absorbent materials less than two times per day. At no time in this file, including during VA treatment, has the Veteran reported or the evidence demonstrated that the absorbent materials needed to be changed more than four times per day. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of an increased disability rating in excess of 40 percent beginning January 2016 for residuals of prostate cancer and voiding dysfunction. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 12. Entitlement to a higher initial disability rating in excess of 30 percent prior to August 20, 2015, for coronary artery disease The Veteran contends that his CAD is worse than currently rated throughout this appeal, although he has not explained his contention. A review of the evidence, including VA treatment and examinations, reveals that an initial disability rating in excess of 30 percent for this period is not warranted. As noted above, the CAD rating is currently split into four stages under Diagnostic Code 7005. Under this code, the next highest rating in excess of 30 percent, a 60 percent rating, contemplates more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs, but not greater than 5 METs, which results in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent rating contemplates documented coronary artery disease (Diagnostic Code 7005) or myocardial infarction (Diagnostic Code 7006) resulting in chronic congestive heart failure, or; workload of 3 METs or less, resulting in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104. During this period, the Veteran received two VA examinations in January 2014 and January 2015. During the exams, the Veteran reported shortness of breath with activity, including while doing yard work, which resolved after rest. Both examiners found that the Veteran’s estimated left ventricular ejection fraction (LVEF) was between 50 and 55 percent. The examiners explained that the estimated METs level was not based solely on the Veteran’s CAD and that given the condition of his CAD, the Veteran’s METs should properly be between 5 and 7. Further, the fact that his LVEF is slightly lower than expected accounts for the shortness of breath the Veteran reported. At no time during this period did the Veteran report or the evidence demonstrate more than one episode of acute congestive heart failure in the past year, a workload of 5 or less METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of 30 to 50 percent. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of a higher initial disability rating in excess of 30 percent prior to August 2015 for CAD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 13. Entitlement to a higher initial disability rating in excess of 60 percent from August 20, 2015, to January 31, 2019, for CAD The Veteran contends that his CAD is worse than currently rated throughout this appeal, although he has not explained his contention. A review of the evidence, including VA treatment and examination, reveals that an initial disability rating in excess of 60 percent for this period is not warranted. The Veteran reported during a September 2015 VA examination that he experienced shortness of breath while walking to his mailbox, about 100 feet from his door. He reported that he experienced dyspnea and fatigue between 1 and 3 METs, while doing activities such as eating, dressing, taking a shower, or taking a slow, short walk. The examiner explained, however, that the interview based METs were due to multiple medical conditions, not solely CAD. The examiner found that the Veteran’s estimated left ventricular ejection fraction (LVEF) was between 50 and 55 percent. The examiner explained that although the Veteran reported getting short of breath with mild exertion, his LVEF was on lower end of normal. For that reason, the examiner stated that the estimated LVEF testing renders a more accurate description of the cardiac manifestations alone. At no time during this period did the Veteran report or the evidence demonstrate chronic congestive heart failure, a workload, supported by the evidence, of 3 or less METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of a higher initial disability rating in excess of 30 percent between August 20, 2015, to January 31, 2019, for CAD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 14. Entitlement to a higher initial disability rating in excess of 30 percent from February 1, 2019, to March 12, 2020, for CAD The Veteran contends that his CAD is worse than currently rated throughout this appeal, although he has not explained his contention. A review of the evidence, including VA treatment records, reveals that an initial disability rating in excess of 30 percent for this period is not warranted. The RO reduced the Veteran’s CAD rating as the 60 percent disability rating previously assigned was not supported by the evidence. The effective date of this reduction was the first of the month following 60 days after the notice of the reduction, which was February 1, 2019. VA and private treatment records do not provide any evidence that a disability rating in excess of 30 percent for this warranted. The Veteran did not receive a VA examination during this period. At no time during this period did the Veteran report or the evidence demonstrate more than one episode of acute congestive heart failure in the past year, a workload of 5 or less METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of 30 to 50 percent. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of a higher initial disability rating in excess of 30 percent prior to August 2015 for CAD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 15. The claim for a higher initial disability rating in excess of 60 percent beginning March 12, 2020, for CAD The Veteran contends that his CAD is worse than currently rated throughout this appeal, although he has not explained his contention. A review of the evidence, including VA treatment and examinations, reveals that an initial disability rating in excess of 60 percent for this period is not warranted. The Veteran denied experiencing any symptoms related to his CAD during a March 2020 VA examination. He stated that he walks approximately one mile per day without fatigue and that he swims in his pool without getting short of breath. Therefore, the examiner found that the estimated LVEF of 45 percent found upon an echocardiogram was the most objective reflection of his cardiac status. During the September 2020 VA examination, the Veteran reported difficulty with walking and running for long periods as well as climbing and descending stairs, squatting, kneeling, and heavy lifting due to low endurance, easy fatiguability, and weakness. The Veteran’s interview based METs were estimated to be between 5 and 7 METs at which point he experienced dyspnea and fatigue. The examiner stated that the estimated METs were due solely to the Veteran’s CAD and noted the March 2020 echocardiogram which found LVEF of 45 percent. At no time during this period did the Veteran report or the evidence demonstrate chronic congestive heart failure, a workload, supported by the evidence, of 3 or less METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent. Based on the forgoing, the Board concludes that the preponderance of the evidence is against the award of a higher initial disability rating in excess of 60 percent beginning March 12, 2020, for CAD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to connection for an acquired psychiatric disability other than major depressive disorder, to include alcohol abuse and posttraumatic stress disorder (PTSD) The Board notes that the Veteran has carried a diagnosis of alcohol abuse disorder throughout the claim on appeal. However, while the February and July 2020 VA examinations noted that the Veteran reported beginning heavy alcohol abuse during military service and continuing until one year prior to the examination, and although an etiology opinion was provided for major depressive disorder, the examiner did not opine as to the etiology of the alcohol abuse disorder. Such an opinion is necessary to properly evaluate this claim. 2. Entitlement to service connection for a right leg skin disability 3. Entitlement to service connection for a left leg skin disability During VA treatment records and a 2020 VA examination, the Veteran has reported, and the evidence demonstrates hypo- and hyperpigmentation, itchiness, and scaling of the right and left leg. The Veteran has asserted that such symptoms are attributable to his exposure to Agent Orange. The Board finds that a VA examination is warranted in this claim to assess the nature and etiology of any right and left leg skin disability. 4. Entitlement to service connection for hypertension The question as to whether the Veteran’s hypertension is proximately related to a service-connected disability, to include coronary artery disease (CAD) or his service-connected stroke has not yet been addressed by a VA examiner, to include during the most recent examinations in March and September 2020. The issue is certainly raised by the evidence of record, and, therefore, must be remanded in order to obtain those opinions. In addition, the Veteran’s exposure to herbicides has been conceded in this claim. Although hypertension is not specifically listed under 38 C.F.R. § 3.309(e), and thus, a connection between the Veteran's hypertension and herbicide agent exposure cannot be presumed, service connection for hypertension can be established on a direct basis. In addition, the National Academies of Sciences, Engineering, and Medicine recently opined that there is sufficient evidence of an association between exposure to herbicide agents used during the Vietnam War and hypertension. See The National Academies of Sciences, Engineering, and Medicine, Committee Review the Health Effects in Vietnam Veterans Exposure to Herbicides (Eleventh Biennial Update) (2018), available at https://www.nap.edu/catalog/25137/veterans-and-agent-orange-update-11-2018. Hypertension was moved to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category. The research showed that there is enough epidemiologic evidence to conclude that there is a positive association between herbicide agent exposure and hypertension in Vietnam Veterans. Id. As such, in addition to an opinion regarding proximate service connection between hypertension and a service-connected disability, the examiner must also opine in light of this new evidence as to whether hypertension is causally related to his exposure to herbicides during service. All outstanding records of ongoing VA treatment should be obtained and associated with the claims file. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Obtain an addendum opinion from the September 2020 VA mental health examiner to address the etiology of alcohol abuse and dependence, which were diagnosed during the pendency of this appeal. If the same examiner is not available, provide a new examination with an appropriate mental health examiner. The examiner must opine as to whether the alcohol abuse and alcohol dependence disorders diagnosed during the pendency of this appeal, is at least as likely as not related to service. The examiner must as to whether the alcohol abuse and alcohol dependence disorders diagnosed during the pendency of this appeal are at least as likely as not proximately due to a service-connected disability, to include major depressive disorder or any other physical health disability currently service connected. The examiner must as to whether the alcohol abuse and alcohol dependence disorders diagnosed during the pendency of this appeal are at least as likely as not aggravated, i.e., worsened beyond their natural progression, by a service-connected disability. The examiner must include a rationale to support the opinion(s) provided, which take into account the Veteran’s reports. 3. Schedule the Veteran for a VA examination for to assess the nature and etiology of any right or left leg disability present during the pendency of this appeal. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to list all skin disorders diagnosed during the appeal or present upon examination. The examiner must then opine as to whether any listed skin disorder is at least as likely as not related to service, including exposure to herbicides. The examiner is advised that a negative opinion cannot be based solely on the fact that the disability is not on the list of diseases that are presumptively associated with exposure to herbicide agents. Provide a rationale to support the opinion(s). 4. Schedule the Veteran for a VA examination to assess the nature and etiology of his hypertension. The examiner must review the claims file. The examiner must then opine as to whether the Veteran’s hypertension is at least as likely as not related to service, including exposure to herbicides, in light of the new evidence described above. (Continued on the next page)   The examiner is advised that a negative opinion cannot be based solely on the fact that the disability is not on the list of diseases that are presumptively associated with exposure to herbicide agents and that he must specifically address the new findings addressed above regarding “sufficient” evidence demonstrating a link between hypertension and herbicide exposure. Provide a rationale to support the opinion(s). Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bordewyk, Alicia R. 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.