Citation Nr: 21011294 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 18-51 159 DATE: March 1, 2021 ORDER Entitlement to an effective date earlier than March 14, 2017, for service connection of headaches as a residual of non-Hodgkin’s Lymphoma (NHL), is denied. Entitlement to an effective date earlier than March 14, 2017, for service connection for Wolff-Parkinson-White Syndrome associated with NHL is denied. Entitlement to an effective date earlier than March 14, 2017 for service connection for major depressive disorder associated with NHL is denied. Entitlement to an effective date earlier than March 14, 2017 for service connection chronic bronchitis associated with NHL is denied. Entitlement to an initial evaluation in excess of 60 percent for Wolff-Parkinson-White syndrome associated with NHL prior to March 4, 2020 is denied. Entitlement to an initial evaluation in excess of 50 percent for depressive disorder, associated with NHL is denied. Entitlement to an initial compensable evaluation for headaches as a residual of NHL is denied. Entitlement to an increased evaluation in excess of 20 percent for left lower extremity sensory deficit associated with lumbosacral strain is denied. Entitlement to service connection for sleep apnea is denied. REMANDED Entitlement to an effective date earlier than March 14, 2017, for service connection for right lower extremity neuropathy is remanded. Entitlement to a separate evaluation for NHL as an active disease is remanded. Entitlement to initial evaluation in excess of 20 percent for right lower extremity neuropathy associated with NHL is remanded. Entitlement to an initial compensable evaluation for chronic bronchitis, associated with NHL is remanded. Entitlement to increased evaluation in excess of 20 percent for lumbosacral strain is remanded. Entitlement to an effective date earlier than March 14, 2017, for a total disability rating because of individual unemployability due to service-connected disabilities is remanded. Entitlement to an effective date earlier than March 14, 2017, for eligibility to Dependents’ Educational Assistance under 38 U.S.C. Chapter 35 is remanded. FINDINGS OF FACT 1. The earliest effective date for the award of service connection for NHL is March 14, 2017, the date the laws and regulations authorized presumptive service connection for non-Hodgkins lymphoma due to exposure to contaminated water at Camp Lejeune. 2. The earliest effective date for the awards of service connection for Wolff-Parkinson-White Syndrome, major depressive disorder, chronic bronchitis, each as secondary to non-Hodgkins lymphoma, is March 14, 2017, the effective date for the award of service-connection for non-Hodgkins lymphoma. 3. Prior to March 4, 2020, the Veteran’s Wolff-Parkinson-White Syndrome, associated with non-Hodgkin’s lymphoma, manifested as no more than left ventricular dysfunction with an ejection fraction of 40 percent. 4. Throughout the period on appeal, the Veteran’s depressive disorder, associated with non-Hodgkin’s lymphoma, manifested by no more than occupational and social impairment with reduced reliability and productivity. 5. Throughout the period on appeal, the Veteran experiences infrequent, non-prostrating headaches with pain and light sensitivity, of short duration. 6. Throughout the period on appeal, the Veteran’s left lower extremity sensory deficit, associated with lumbosacral strain has manifested by no more than moderate incomplete paralysis of the sciatic nerve. 7. There is no evidence of record showing the Veteran has sleep apnea that had its onset during active service or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for an earlier effective dated earlier than March 14, 2017 for the grants of service connection for non-Hodgkin’s lymphoma, Wolff-Parkinson-White Syndrome, major depressive disorder, and chronic bronchitis each as secondary to non-Hodgkins lymphoma are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 2. The criteria for an initial evaluation in excess of 60 percent for Wolff-Parkinson-White syndrome, associated with NHL, prior to March 4, 2020 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.104, Diagnostic Code 7011. 3. The criteria for an initial evaluation in excess of 50 percent for depressive disorder, associated with NHL are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 – 4.7, 4.130, Diagnostic Code 9435. 4. The criteria for an initial compensable evaluation for headaches as a residual of NHL are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 – 4.7, 4.124a, Diagnostic Code 8100. 5. The criteria for an increased evaluation in excess of 20 percent for left lower extremity sensory deficit, associated with lumbosacral strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 6. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1987 to May 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2015 and October 2018 rating decisions by the Louisville, Kentucky Regional Office (RO) of the United States Department of Veterans Affairs. The October 2018 decision arose from a February 2015 rating decision denying service connection for NHL, and assigned initial ratings for that condition, based on residuals. During the pendency of the appeal, in a July 2020 rating decision, entitlement to special monthly compensation based on housebound criteria being met was granted, which constitutes a full grant of the benefits sought and the issue is no longer on appeal. Additionally, in the same decision, entitlement to an increased rating of 100 percent for Wolff-Parkinson-White Syndrome was granted effective March 4, 2020. As that represents the maximum schedular rating, it is a full grant as to the issue of entitlement to an increased rating for Wolff-Parkinson-White Syndrome from March 4, 2020, forward. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in the Fully Developed Claim Forms filed by the Veteran in September 2015. The RO associated the Veteran’s service and VA private outpatient treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Effective Date Effective March 14, 2017, 38 C.F.R. §§ 3.307 and 3.309 were amended to add eight diseases to the list of diseases associated with contaminants present in the water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina, from August 1, 1953, to December 31, 1987. The amendments apply to claims received by VA on or after January 13, 2017, and claims pending before VA on that date. 82 Fed. Reg. 4173 (Jan. 13, 2017). Non-Hodgkin’s lymphoma (NHL) was one of the diseases that was added to this list. The Veteran is currently seeking entitlement to an effective date earlier than March 14, 2017, for his service-connected for NHL, and for Wolff-Parkinson-White Syndrome, major depressive disorder, and chronic bronchitis; each as secondary to NHL. The RO awarded the effective date of March 14, 2017, because this is the date the law was changed to add non-Hodgkin’s lymphoma as a condition presumed to be associated with exposure to chemicals at Camp Lejeune. Generally, the effective date for an award of service connection and disability compensation is the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, for an award based on an original claim, a claim reopened after a final allowance, or a claim for an increase, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. However, retroactive effective dates are allowed, to a certain extent, in cases where an award or increase of compensation is granted pursuant to a liberalizing law. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114(a). To be eligible for a retroactive payment under these provisions, the evidence must show that the claimant met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue and that such eligibility existed continuously from that date to the date of claim or administrative determination of entitlement. These provisions apply to original and reopened claims, as well as claims for increase. Id.; see also McCay v. Brown, 9 Vet. App. 183, (1996), aff’d, 106 F.3d 1577 (Fed. Cir. 1997). In such cases, the effective date of the award or increase shall be fixed in accordance with the facts found but shall not be earlier than the effective date of the liberalizing law or VA issue. 38 C.F.R. § 3.114(a). The Veteran filed his claim for entitlement to service connection for NHL due to exposure to contaminated water at Camp Lejeune on September 19, 2013. Treatment records indicate that the Veteran was diagnosed with NHL in July 2002. Based on this evidence, the Veteran met all eligibility criteria for service connection for mantle cell lymphoma on the effective date of the liberalizing law that allows presumptive service connection for NHL based on exposure to chemicals at Camp Lejeune, March 14, 2017. Although the Veteran has argued for an earlier effective date, an effective date prior to March 14, 2017, is legally precluded. The controlling statute and regulation provide that the effective date for a grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Even though the Veteran’s NHL was diagnosed in 2002 and the original claim was filed in September 2013, entitlement did not arise until March 14, 2017, when non-Hodgkin’s lymphoma was added to the list of presumptive conditions associated with Camp Lejeune. Therefore, March 14, 2017 is the appropriate effective date in this case for the grants of service-connection for NHL, and for Wolff-Parkinson-White Syndrome, major depressive disorder, and chronic bronchitis, each as secondary to NHL. The Veteran argues that the evidence of record justifies a finding of actual causation, as opposed to presumptive causation, and if service connection is granted on such basis, the date of receipt of claim is the later date, as diagnosis was established far earlier. This argument is, however, circular. The Veteran’s argument involves using the current conclusions on causation to effectively backdate the presumption, saying essentially that now that all the evidence is in, service connection could have been established without the presumption. It was not, however. The evidence produced prior to the effective date of the presumption was not sufficient, and the presumption was necessary to establish entitlement as of March 14, 2017. Hindsight relying on evidence developed after the event cannot justify an effective date prior to the current one. Effective dates prior to March 14, 2017 for service connection for NHL, and for Wolff-Parkinson-White Syndrome, major depressive disorder, and chronic bronchitis, each as secondary to service-connected NHL, are not warranted. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 – 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). Wolff-Parkinson-White Syndrome The Veteran is seeking an increased evaluation in excess of 60 percent for Wolff-Parkinson-White Syndrome (WPWS), associated with NHL prior to March 4, 2020. The Board notes the Veteran has been assigned a 100 percent disability rating for WPWS, associated with NHL as of March 4, 2020 which represents a full grant of benefits as of that date. The Veteran’s WPWS, associated with NHL has been assigned a rating under 38 C.F.R. § 4.104, Diagnostic Code 7011 for ventricular arrhythmias. Diagnostic Code 7011, for ventricular arrhythmias, provides a 10 percent evaluation for a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent evaluation is assigned for a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is assigned for more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is assigned for chronic congestive heart failure, or; workload of greater than 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. A 100 percent evaluation is also assigned for indefinite period from date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia, or; for indefinite period from date of hospital admission for ventricular aneurysmectomy, or; with an automatic implantable Cardioverter-Defibrillator (AICD) in place. A note indicates that a rating of 100 percent shall be assigned from the date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia or for ventricular aneurysmectomy. Six months following discharge, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. The Veteran underwent a VA contract hematologic and lymphatic conditions examination in January 2018. The VA contract examiner noted the Veteran had not been treated for NHL since 2009 and that he was in remission. Symptoms including weakness, easy fatigability, light-headedness, shortness of breath, headaches, dyspnea on mild exertion, dyspnea at rest, tachycardia, and syncope were noted. The Veteran underwent a VA contract heart examination in May 2018. The VA contract examiner noted the Veteran’s diagnosis of WPWS. Continuous medication was not required for control of the Veteran’s heart condition. The VA contract examiner noted the Veteran had an echocardiogram in May 2016 which revealed a left ventricular ejection fraction of 40 percent. The Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. VA treatment records dated September 2019 reflected new onset dyspnea. After a thorough review of the evidence of record the Board finds that the medical evidence does not support a higher initial evaluation of 100 percent for the Veteran’s WPWS. The medical evidence of record indicated the Veteran experienced dyspnea and had a left ventricular ejection fraction of 40 percent. The Board finds that the Veteran’s disability picture prior to March 4, 2020 most closely approximates the criteria associated with a 60 percent disability evaluation. Accordingly, based on the above, entitlement to an initial rating in excess of 60 percent for WPWS prior to March 4, 2020 is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Depressive Disorder The Veteran’s service-connected major depressive disorder, associated with NHL has been assigned an initial disability rating of 50 percent under 38 C.F.R. § 4.130, Diagnostic Code 9435. The Veteran contends that a higher disability evaluation is warranted for his major depressive disorder, associated with NHL. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Pursuant to 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders (“General Rating Formula”). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 426, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d at 118. Having carefully considered all the evidence of record, the Board finds that based on the overall disability, an initial rating in excess of 50 percent is not warranted. VA treatment records dated May and July 2017 reflect treatment for depression. In July 2017, the Veteran reported experiencing increased depression and anxiety symptoms over the past 6 to 8 months. He stated he had been battling cancer off and on for many years. The Veteran underwent a VA contract mental disorders examination in January 2018. The contract examiner noted the Veteran’s diagnosis of moderate depressive disorder with anxious distress. The contract examiner summarized the Veteran’s occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported that he had been married to his wife for 33 years and have two daughters. He stated that while in the military his social life was normal, his wife moved to Camp Lejeune shortly after boot camp. He stated that he is very close to his kids. His oldest daughter is going through a break-up and she and her children are living with the Veteran and his wife. His friends are drinkers and he doesn’t drink anymore so he stays away from them but does talk to them on the phone. He stated that he started feeling depressed after his third cancer, he couldn’t work and became depressed. He had noticed more irritability as of late. Symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, impairment of short- and long-term memory, and disturbances of motivation and mood. He was cooperative and interacted appropriately, was well-groomed and appropriately dressed. His speech was normal, and mood was appropriate for the situation. The contract examiner noted that, based upon the examination, the Veteran needed to seek follow up treatment and required psychotherapy and/or psychotropic intervention for treatment of depression. The contract examiner noted that the Veteran did not appear to pose any threat of injury to self or others. The Veteran underwent a VA contract mental disorders examination in March 2020. The contract examiner noted the Veteran’s diagnosis of major depressive disorder, recurrent, with unspecified anxious distress. The contract examiner summarized the Veteran’s occupational and social impairment as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he engages in therapy with a psychologist and is prescribed medication by his primary care provider. He reported that his anxiety and depression have increased as a result of his current physical condition; his cancer has returned, and he was diagnosed with heart failure. He denied and suicidal or homicidal ideation. Symptoms included depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The contract examiner noted that the Veteran did not appear to pose any threat of danger or injury to self or others. occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. After a thorough review of the evidence of record, the Board finds that the Veteran’s depressive disorder symptoms do not meet the criteria for an initial rating in excess of the 50 percent disability rating previously assigned. His symptoms are consistent with those productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran’s symptoms primarily consisted of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood anxiety, panic attacks more than once a week, and difficulty with relationships. The evidence does not support the criteria for a 70 percent or greater disability rating. The Veteran has denied suicidal ideation. He does not report or display obsessional rituals which interfere with routine activities. His speech and thought patterns are normal, and while he is often depressed, such is not near continuous and he functions independently, appropriately and effectively. He remains married to his wife of 36 years. As there is no indication in the medical records that his symptoms are severe enough to cause occupational and social impairment with deficiencies in most areas, a 70 percent rating, or higher, is not warranted. See Vazquez-Claudio, 713 F.3d at 114 (holding that a veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration”). Headaches The Veteran seeks a compensable evaluation for his residual headaches. Headaches of all types are rated under Diagnostic Code 8100, for migraines. The criteria provide a 10 percent rating for characteristic prostrating attacks averaging one every two months; a 0 percent rating is assigned for less frequent attacks. A 30 percent rating is assigned for characteristic prostrating attacks occurring once a month on average. When prostrating attacks are completely prostrating and occur very frequently, and cause severe economic inadaptability, a 50 percent rating is assigned. At a May 2018 VA examination, the Veteran was diagnosed with tension headaches; such had begun in 2014. He complained of pulsating, throbbing pain on both sides of his head, worse with physical activity. He also reported sensitivity to light. Episodes last less than one day, and were not prostrating. VA treatment records from 2001 to 2020 note that the Veteran is service-connected for headaches, but fail to reveal any complaints related to headaches. The Veteran in fact repeatedly denied current headaches or symptoms of such. Private treatment records reveal a February 2005 report “more frequent” headaches recently, related to NHL. Records also show headache complaints in December 2005 and again in March 2006. The second episode appears related to a cyst, which was then surgically removed, and elevated blood pressure. The records are otherwise silent for headache complaints, and the Veteran is in fact noted to repeatedly deny such. While it is clear that the Veteran does have recurrent headaches, the evidence of record indicates that they are not prostrating, are of short duration, and do not occur frequently. Treatment records throughout the appellate period show only rare complaints of active headaches, and the Veteran has not reported to the contrary. No compensable rating is warranted for residual headaches. Left Lower Extremity Sensory Deficit associated with Lumbosacral Strain The Veteran is seeking an increased evaluation in excess of 20 percent for left lower extremity sensory deficit associated with lumbosacral strain. This disability is evaluated pursuant to the criteria for diseases of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Code 8520 provides a 10 percent evaluation for mild incomplete paralysis of the sciatic nerve of the lower extremity. A 20 percent evaluation is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation for moderately severe incomplete paralysis of the sciatic nerve of the lower extremity. A 60 percent evaluation for severe incomplete paralysis, with marked muscular atrophy, of the sciatic nerve of the lower extremity. An 80 percent evaluation is warranted for complete paralysis of the sciatic nerve of the lower extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Neuralgia of a peripheral nerve characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Complete paralysis of the sciatic nerve is indicated where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § § 4.124a, Diagnostic Code 8520. The Veteran underwent a VA peripheral nerves examination in October 2015. The VA examiner noted the Veteran’s diagnosis of left peripheral neuropathy of the sciatic nerve. Symptoms included mild numbness of the left lower extremity. Muscle strength testing was normal in the left knee and ankle. No muscle atrophy was present, deep tendon reflexes were normal. Sensory examination was normal. The VA examiner determined that the Veteran had mild incomplete paralysis of the left lower sciatic nerve. The Veteran underwent a VA contract peripheral nerves examination in March 2020. The contract examiner noted the Veteran’s diagnosis of left lower extremity neuropathy. Subjective complaints included severe pain and numbness in his leg. He stated that he could not walk long distances due to pain, numbness and weakness. The contract examiner noted left lower extremity symptoms including moderate constant pain, severe intermittent pain, moderate paresthesias/dysesthesias, and moderate numbness. Muscle strength test results were 4 out of 5 on left knee extension, and 4 out of 5 on left ankle plantar flexion and dorsiflexion. No muscle atrophy was present. Reflex testing revealed hypoactive reflexes in left knee and left ankle. Sensation to light touch was decreased in the left foot and toes. Trophic changes of loss of har and shiny skin on the Veteran’s bilateral shins were noted. Gait was normal. The Veteran walked with a cane. The contract examiner determined that the Veteran had mild, incomplete paralysis of the left sciatic nerve. After a careful review of the evidence of record, the Board finds that an initial disability evaluation in excess of 20 for left lower extremity sensory deficit is not warranted. At the October 2015 VA examination, the Veteran complained of experiencing mild numbness. At the March 2020 VA contract examination, the Veteran complained of experiencing moderate constant pain, severe intermittent pain, moderate paresthesias/dysesthesias, and moderate numbness. However, neither private medical records nor VA treatment records document treatment for symptoms of peripheral neuropathy of the left lower extremity. Rather, the medical records simply reflect that this condition is part of the Veteran’s medical history and is a current medical problem. There is no medical evidence associated with the file which establishes the Veteran has experienced moderately severe peripheral neuropathy of the left lower extremity at any time during the period on appeal. The Board has carefully considered all the evidence and potentially applicable diagnostic codes and finds the disability picture of the Veteran’s left lower extremity sensory deficit does not meet the criteria for an evaluation in excess of 20 percent. The findings of the October 2015 and March 2020 VA examinations revealed mild, incomplete paralysis of the left sciatic nerve, therefore a higher rating of 30 percent for moderately severe incomplete paralysis of the left sciatic nerve pursuant to Diagnostic Code 8520 is not warranted. Accordingly, entitlement to initial evaluations in excess of 20 percent for right and left upper extremity diabetic peripheral neuropathy are not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claims for higher ratings. 38 C.F.R. §§ 4.7, 4.21. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 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; 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, the benefit of the doubt is afforded the claimant. Sleep Apnea The Veteran is seeking service connection for obstructive sleep apnea which he contends is related to his active service. He has not, however, put forth, any specific theory, allegation, or evidence in support of his general claim of service connection for obstructive sleep apnea. The service treatment records (STRs) are negative for treatment for symptoms of obstructive sleep apnea in service. VA treatment records indicate a diagnosis of sleep apnea in January 2019 and a confirmed diagnosis is reported in a February 2019 VA sleep apnea progress note, approximately 31 years after the Veteran’s separation from active duty service. A private provider diagnosed the condition. The Veteran was provided a CPAP machine by VA. There is no documentation as to the etiology of the diagnosed apnea. No health care professional is on record as opining that the Veteran currently experiences obstructive sleep apnea as a result of his active duty service. Simply put, there is no evidence regarding the nexus element of service connection outside the Veteran’s bare assertion. In the absence of evidence, there cannot be even equipoise, and there can be no resolution of doubt. The Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006). As there is no evidence to support any finding of a nexus between service and currently diagnosed obstructive sleep apnea, entitlement to the benefit sought is not warranted. REASONS FOR REMAND The issues of entitlement to an earlier effective date for entitlement to service connection for right lower extremity neuropathy, entitlement to an increased initial evaluation for right lower extremity neuropathy, entitlement to a compensable evaluation for NHL manifested by headaches, entitlement to a compensable evaluation for chronic bronchitis associated with NHL, entitlement to an increased rating in excess of 20 percent for lumbar strain, entitlement to an earlier effective date for TDIU and entitlement to an earlier effective date for eligibility for DEA under 38 U.S.C. Chapter 35 are remanded for additional development. Right Lower Extremity Neuropathy The Veteran initially sought entitlement to service connection for right lower extremity neuropathy in October 2015. Service connection for right lower extremity neuropathy was granted effective March 14, 2017 as a disability secondary to NHL. However, a review of the file reveals that the etiology of this disability is unclear. As discussed above, the Veteran underwent a VA peripheral nerves examination in October 2015. The VA examiner noted that the Veteran was service connected for his left sciatic nerve and that the Veteran was “claiming his right leg is affected by the same neuropathy.” Symptoms included mild intermittent pain of the right lower extremity and moderate numbness of the right lower extremity. Sensory examination revealed decreased sensation in right thigh and right foot/toes. The VA examiner determined that the Veteran had moderate incomplete paralysis of the right sciatic nerve. The VA examiner noted that, “The provider at Ohio State reported that his neuropathy was secondary to his treatments for non-Hodgkin’s lymphoma. This is very possibly true since the onset of his right leg issue is subsequent to said treatment. There is also the possibility that his neuropathy has spread to the right side and his arthritis has increased.” The Board finds that this opinion is inadequate for adjudication purposes. On remand, an addendum opinion as to the nature and etiology of the Veteran’s right lower extremity neuropathy must be obtained to determine the proper effective date for entitlement to service connection. The Veteran’s claim for an increased initial evaluation for right lower extremity neuropathy is intertwined with the claim for an earlier effective date for entitlement to service connection for this disability which is being remanded for additional development. Harris v. Derwinski¸ 2 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). Therefore, the claim for an increased initial evaluation for right lower extremity neuropathy is remanded. NHL The current appeal arises from the Veteran’s disagreement with the initial evaluations assigned for NHL; at the time there was no active disease, and so ratings were based on residuals. The appeal, however, encompasses all aspects of NHL, including the possibility of recurrence of the condition. The Veteran underwent a VA contract hematologic and lymphatic conditions examination in March 2020. The Veteran stated that he had been diagnosed again with NHL and that he was waiting to find out next steps from Cleveland Clinic as to what his treatment would be. Records pertaining to this recurrence of NHL are not associated with the Veteran’s file. On remand, updated VA treatment records and records from the Cleveland Clinic should be obtained and associated with the file to ascertain the current status of the Veteran’s NHL. Chronic Bronchitis The Veteran underwent a VA contract respiratory examination in March 2020. The contract examiner noted the Veteran had recently been diagnosed with a recurrence of NHL with masses to the chest. No pulmonary function testing was performed in conjunction with this examination. These results are needed to determine the appropriate disability rating for the Veteran’s chronic bronchitis. On remand, the Veteran should be scheduled for a VA respiratory examination to ascertain the current nature and severity of his chronic bronchitis associated with NHL. Lumbosacral Strain VA treatment records dated January 2020 and March 2020 indicate the Veteran reported experiencing severe low back pain which limited his activities and required assistance of a cane for ambulation. On remand, the Veteran should be scheduled for a VA spine examination to ascertain the current nature and severity of his lumbar strain. TDIU The Veteran’s claims for an earlier effective date for entitlement to TDIU and for eligibility to DEA benefits are inextricably intertwined with the remanded issues of entitlement to increased disability evaluations for right lower extremity neuropathy, lumbosacral strain, and chronic bronchitis. Therefore, these issues are remanded. The matters are REMANDED for the following action: 1. Associate all outstanding VA treatment records with the file. 2. Contact the Veteran and request properly executed releases for all relevant private treatment records, including, but not limited to, records from the Cleveland Clinic. Upon receipt of such, VA must take appropriate action to contact the identified providers and request complete treatment records. The Veteran should be informed that in the alternative he may obtain and submit the records himself. 3. Return the file to the VA examiner who provided the October 2015 VA peripheral nerves examination, or, if not available, another equally qualified clinician. The claims file must be reviewed by the examiner. If the examiner is not available, another appropriate medical professional may be consulted. If the examiner determines another VA examination is necessary, one should be scheduled. The examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right lower extremity neuropathy is related to service, secondary to his service-connected lumbosacral strain, or is secondary to his non-Hodgkin’s lymphoma. A full and complete rationale for all opinions expressed is required. 4. Schedule the Veteran for a VA respiratory examination to ascertain the current level and severity of his chronic bronchitis. (Continued on the next page)   5. Schedule the Veteran for a VA spine examination to ascertain the current level and severity of his lumbosacral strain. 6. Upon completion of the above, and any additional development deemed appropriate (including any VA examinations and/or opinions), readjudicate the remanded issues. If the benefits sought remain denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Lunger, 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.