Citation Nr: 21013657 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-67 178 DATE: March 10, 2021 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for a headache condition is granted. Entitlement to service connection for bilateral carpal tunnel syndrome is denied. Entitlement to service connection for a right knee condition is denied. Entitlement to service connection for a left knee condition is denied. Entitlement to service connection for a right foot condition is denied. Entitlement to service connection for a left foot condition is denied. Entitlement to service connection for a gastrointestinal condition manifested by ulcers is denied. Entitlement to service connection for a hiatal hernia condition is denied. Entitlement to a 70 percent initial rating, but no more, is warranted for post-traumatic stress disorder (PTSD) for the entirety of the appeal period. Entitlement to an initial rating in excess of 20 percent for bilateral sensorineural hearing loss (SNHL) is denied. Entitlement to a rating in excess of 10 percent for lumbosacral degenerative disc disease is denied. Entitlement to an effective date prior to February 24, 2015 for the grant of service connection for PTSD is denied. Entitlement to an effective date prior to February 24, 2015 for the grant of service connection for lumbosacral degenerative disc disease is denied. Entitlement to an effective date prior to August 19, 2016 for the grant of a 20 percent rating for bilateral SNHL is denied. REMANDED Entitlement to service connection for pancreatitis is remanded. Entitlement to a total disability rating based on individual unemployability as due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the currently diagnosed hypertension was incurred in or is otherwise attributable to service, to include as secondary to a service-connected disability. 2. The evidence is at least in equipoise as to whether the currently diagnosed obstructive sleep apnea was incurred in or is otherwise attributable to service, to include as secondary to a service-connected disability. 3. The evidence is at least in equipoise as to whether the currently diagnosed headache condition was incurred in or is otherwise attributable to service, to include as secondary to a service-connected disability. 4. The competent medical evidence does not demonstrate that the Veteran has bilateral carpal tunnel syndrome that was incurred in service or is otherwise attributable to his service. 5. The competent medical evidence does not demonstrate that the Veteran has a right knee condition that was incurred in service or is otherwise attributable to his service. 6. The competent evidence does not demonstrate that the Veteran currently has a diagnosable left knee condition, nor has he experienced such a condition during the pendency of the appeal or recent to the filing of the claim. 7. The competent evidence does not demonstrate that the Veteran currently experiences a diagnosed right foot condition, nor has he experienced one during the pendency of the appeal or recent to the filing of the claim; his documented pain is fully attributable to his right ankle sprain. 8. The competent evidence does not demonstrate that the Veteran currently has a diagnosable left foot condition, nor has he experienced such a condition during the pendency of the appeal or recent to the filing of the claim. 9. The competent medical evidence does not demonstrate that the Veteran has a gastrointestinal disorder manifested by ulcers that was incurred in service or is otherwise attributable to his service. 10. The competent medical evidence does not demonstrate that the Veteran has a hiatal hernia condition that was incurred in service or is otherwise attributable to his service. 11. For the entire period of the appeal, the Veteran’s PTSD was shown to be productive of a disability picture that equated to occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; intermittent visual and auditory hallucinations; difficulty in adapting to stressful circumstances, sleep disturbances; disturbances of motivation and mood; and difficulty in establishing and maintaining effective relationships. 12. For the entire period of the appeal, the Veteran’s service-connected lumbosacral degenerative disc disease was not manifested by forward flexion limited to 60 degrees or less, a combined range of motion of 120 degrees or less, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 13. During the entire pendency of the appeal, the Veteran’s bilateral SNHL was not manifested by more than Level V hearing loss in either ear. 14. The Veteran submitted an informal claim seeking entitlement to service connection for PTSD on February 24, 2015; this was the earliest statement received by VA expressing a desire or intention to seek such benefit. 15. The Veteran submitted an informal claim seeking entitlement to service connection for lumbosacral degenerative disc disease on February 24, 2015; this was the earliest statement received by VA expressing a desire or intention to seek such benefit. 16. The Veteran submitted his claim seeking entitlement to an increased rating of his service-connected bilateral SNHL on August 19, 2016; this was the earliest statement received by VA expressing a desire or intention to seek such benefit; moreover, a factually ascertainable increased in disability was not shown to have occurred within one year prior to August 19, 2016 for bilateral SNHL. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 2. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 3. The criteria for entitlement to service connection for a headache condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 4. The criteria for service connection for bilateral carpal tunnel syndrome have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for a right knee condition have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 6. The criteria for service connection for a left knee condition have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 7. The criteria for service connection for a right foot condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 8. The criteria for service connection for a left foot condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 9. The criteria for service connection for a gastrointestinal disorder manifested by ulcers have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 10. The criteria for service connection for a hiatal hernia condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 11. For the entire period of the appeal, the criteria for an initial disability rating of 70 percent, but no more, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.130, Diagnostic Codes 9411. 12. The criteria for entitlement to an initial rating in excess of 10 percent for lumbosacral degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5242. 13. The criteria for a rating in excess of 20 percent for bilateral SNHL have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.85, Diagnostic Code 6100. 14. The criteria for an effective date earlier than February 24, 2015 for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5108, 5110, 7104; 38 C.F.R. §§ 3.156, 3.400. 15. The criteria for an effective date earlier than February 24, 2015 for the grant of service connection for lumbosacral degenerative disc disease have not been met. 38 U.S.C. §§ 5108, 5110, 7104; 38 C.F.R. §§ 3.156, 3.400. 16. The criteria for an effective date earlier than August 19, 2016 for the grant of an increased 20 percent rating for bilateral SNHL have not been met. 38 U.S.C. §§ 5108, 5110, 7104; 38 C.F.R. §§ 3.156, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1987 to September 1989. These matters were last before the Board in May 2019, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of two separate supplemental statements of the case, both issued in June 2020, these matters were certified to the Board for its adjudication. In view of the facts found, and to provide broader consideration on appeal, the Board has recharacterized the claim of entitlement to service connection for ulcers as one for a gastrointestinal disorder manifested by ulcers. The Board notes that it referred to the AOJ the issues of entitlement to earlier effective dates for the grant of service connection for PTSD and lumbosacral degenerative disc disease as well as entitlement to an earlier effective date for the grant of a 20 percent rating for bilateral SNHL. The AOJ promulgated a June 2019 statement of the case continuing the denial of all three claims. While the Veteran did not submit a formal appeal of this statement of the case subsequent to its issuance, the Board notes that the issue of entitlement to earlier effective dates is part and parcel to the extant claims seeking increased ratings for all three service-connected disabilities. As such, the Board finds that it has jurisdiction to address the effective date claims that were the subject of the June 2019 statement of the case. The Board also notes that it has considered whether a claim for TDIU has been raised by the Veteran during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that VA must address the issue of entitlement to TDIU with increased rating claims when the issue of unemployability either is raised expressly or by the record. Here, the Board confirms that the issue of entitlement to TDIU is presently before it, given the Veteran’s October 2020 TDIU application. Accordingly, this issue has been added to the appeal and is addressed below. The Board additionally notes that, pursuant to its prior May 2019 remand instructions, the Veteran underwent an August 2019 VA foot examination to determine the proper diagnosis to account for his documented right foot symptomatology. The chosen VA examiner dismissed a right foot condition diagnosis and instead endorsed a diagnosis of a right ankle sprain. While the Board is denying the right foot condition service connection claim for a lack of diagnosis, the diagnosis of a right ankle condition manifested by the right foot pain for which the Veteran is currently seeking service connection raises an inferred claim of service connection for a right ankle condition. This claim must be addressed by the AOJ in the first instance prior to being adjudicated by the Board. The claim for entitlement to service connection for a right ankle condition is REFERRED to the Regional Office. Service Connection Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  Secondary service connection is permitted based on aggravation, such that compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). Consequently, there exist two potential theories of entitlement to secondary service connection namely, causation under § 3.310(a) and aggravation under § 3.310(b). 1. Hypertension The Veteran contends that he has hypertension that is secondary to his service-connected disabilities. He seeks service connection for the condition on this basis. At the outset, the Board notes that the Veteran’s diagnosed hypertension is well documented in the available medical records, and so the first element of the service connection claim is established. The question that remains is whether service connection is warranted on either a direct or secondary basis. After a review of the claims file, the Board finds that there is sufficient evidence to support a determination that service connection is warranted on a secondary basis. The Veteran has submitted a March 2018 correspondence from a Dr. H.S. who indicated that he reviewed the claims file. He opined that it was at least as likely as not that the Veteran’s hypertension was aggravated by his PTSD with alcohol abuse disorder as well as the chronic pain from his lumbosacral degenerative disc disease, right distal radius fracture, and tinnitus. In support thereof, Dr. H.S. referred to several medical research articles tending to suggest that there was a connection between chronic anxiety and depression and the development of hypertension, as well as prescription medication used for the treatment of depression and the development of hypertension; furthermore, other research articles referenced by Dr. H.S. suggested a connection between chronic pain and the development of comorbid hypertension. In light of Dr. H.S.’s indication that he reviewed the entirety of the claims file prior to issuing his positive nexus opinion, and his reference to multiple research articles in support of his determination, the Board finds that Dr. H.S.’s opinion is highly probative as to the ultimate issue of whether the hypertension is secondary to the Veteran’s service-connected disabilities. Sklar v. Brown, 5 Vet. App. 140 (1993). After further review of the claims file, the Board does not find that there is any evidence tending to discount Dr. H.S.’s determination that the hypertension is secondary to his service-connected disabilities. To date, the Veteran has not been afforded a VA examination to evaluate the nature and etiology of his claimed hypertension. The only relevant objective evidence of record is Dr. H.S.’s positive and probative etiology opinion. Resolving all doubt in favor of the Veteran, the Board concludes that the evidence is at least in equipoise as to the question of whether the hypertension is secondary to the Veteran’s service-connected disabilities. Consequently, service connection is warranted. 2. Obstructive Sleep Apnea The Veteran contends that he has obstructive sleep apnea that is secondary to his service-connected disabilities. He seeks service connection for the condition on this basis. At the outset, the Board notes that the Veteran was diagnosed with obstructive sleep apnea on the basis of a November 2016 sleep study, and so the first element of the service connection claim is established. The question that remains is whether service connection is warranted on either a direct or secondary basis. After a review of the claims file, the Board finds that there is sufficient evidence to support a determination that service connection is warranted on a secondary basis. The Veteran has submitted a March 2018 sleep apnea disability benefits questionnaire (DBQ) prepared by Dr. H.S., as well as a corresponding March 2018 evaluation. After noting that he reviewed the claims file and interviewed the Veteran, Dr. H.S. confirmed the diagnosis of obstructive sleep apnea and then opined that it was at least as likely as not that the obstructive sleep apnea was aggravated by the Veteran’s PTSD. In support thereof, Dr. H.S. noted that the Veteran was unable to utilize his continuous positive airway pressure (CPAP) machine, as it increased his PTSD symptomatology at night. Furthermore, Dr. H.S. referred to several medical research articles tending to suggest that there was a connection between PTSD symptomatology and the development of obstructive sleep apnea. In light of Dr. H.S.’s indication that he reviewed the entirety of the claims file and interviewed the Veteran prior to issuing his positive nexus opinion, and his reference to multiple research articles in support of his determination, the Board finds that Dr. H.S.’s opinion is highly probative as to the ultimate issue of whether the obstructive sleep apnea is secondary to PTSD. Sklar, supra. After further review of the claims file, the Board does not find that there is any evidence tending to discount Dr. H.S.’s determination that the obstructive sleep apnea is secondary to his service-connected PTSD. To date, the Veteran has not been afforded a VA examination to evaluate the nature and etiology of his claimed obstructive sleep apnea. The only relevant objective evidence of record is Dr. H.S.’s positive and probative etiology opinion. Resolving all doubt in favor of the Veteran, the Board concludes that the evidence is at least in equipoise as to the question of whether the obstructive sleep apnea is secondary to the Veteran’s service-connected disabilities. Consequently, service connection is warranted. 3. Headache Condition The Veteran contends that he has a headache condition that is secondary to his service-connected disabilities. He seeks service connection for the condition on this basis. At the outset, the Board notes that a review of the available VA medical records reflects a history of intermittent complaints of frontal headaches throughout the appeal period. Furthermore, Dr. H.S. in the below-detailed March 2018 headache DBQ diagnosed the Veteran with a chronic headache condition. Accordingly, the Board finds that the first element of the service connection claim is established. The question that remains is whether service connection is warranted on either a direct or secondary basis. After a review of the claims file, the Board finds that there is sufficient evidence to support a determination that service connection is warranted on a secondary basis. The Veteran has submitted a March 2018 headache DBQ prepared by Dr. H.S., as well as a corresponding March 2018 evaluation. After noting that he reviewed the claims file and interviewed the Veteran, Dr. H.S. set forth a diagnosis of chronic tension headaches and then opined that it was at least as likely as not that the headache condition was aggravated by the Veteran’s service-connected disabilities. In support thereof, Dr. H.S. referred to several medical research articles tending to suggest that there was a connection between PTSD, lumbar, and tinnitus symptomatology and the development of chronic tension headaches. In light of Dr. H.S.’s indication that he reviewed the entirety of the claims file and interviewed the Veteran prior to issuing his positive nexus opinion, and his reference to multiple research articles in support of his determination, the Board finds that Dr. H.S.’s opinion is highly probative as to the ultimate issue of whether the headache condition is secondary to the Veteran’s service-connected disabilities. Sklar, supra. After further review of the claims file, the Board does not find that there is any evidence tending to discount Dr. H.S.’s determination that the Veteran has a diagnosable chronic headache condition that is secondary to his service-connected disabilities. To date, the Veteran has not been afforded a VA examination to evaluate the nature and etiology of his claimed headache condition. The only relevant objective evidence of record is Dr. H.S.’s positive and probative etiology opinion. Resolving all doubt in favor of the Veteran, the Board concludes that the evidence is at least in equipoise as to the question of whether the headache condition is secondary to the Veteran’s service-connected disabilities. Consequently, service connection is warranted. 4. Carpal Tunnel Syndrome The Veteran contends generally that his currently diagnosed carpal tunnel syndrome is attributable to service. Of note, the Veteran is already service connected for residuals of an in-service right wrist fracture; he seeks a separate evaluation for carpal tunnel syndrome independent of this right wrist fracture residual condition. The question for the Board is whether the Veteran has bilateral carpal tunnel syndrome 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 bilateral carpal tunnel syndrome, the preponderance of the evidence is against a finding that the condition began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records does not reflect that the Veteran ever complained of symptomatology indicative of carpal tunnel syndrome or that he was diagnosed with carpal tunnel syndrome during service. No upper extremity abnormality or carpal tunnel syndrome was noted on the October 1988 separation examination, and the Veteran did not report any history of carpal tunnel or bilateral wrist symptomatology on the corresponding October 1988 Report of Medical History. Accordingly, service connection for bilateral carpal tunnel syndrome on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. Post-service VA medical records show that the Veteran complained of numbness in his hands during an April 2015 neurology consultation at his local VA medical center; after diagnostic testing, the impression was probable bilateral carpal tunnel syndrome. Subsequent records reflect that bilateral carpal tunnel syndrome has continued to be listed as an active problem in the Veteran’s VA medical records. The Veteran underwent right wrist carpal tunnel release surgery in December 2017. The Veteran was afforded a wrist examination in July 2015 in support of his separately claimed right wrist fracture residual condition, during which he reported experiencing numbness of the radial aspect of the right forearm and right hand as well as right hand weakness. The examiner noted the diagnosis of probable bilateral carpal tunnel syndrome from the April 2015 testing, but did not endorse a formal diagnosis of the condition, as the Veteran’s noted symptomatology did not match the mild to moderate severity reflected by the testing. As the carpal tunnel syndrome was not on appeal at the time of the July 2015 examination, the examiner was not queried as to a specific opinion regarding the etiology of the condition. The Veteran has not been afforded an examination in connection with his claim seeking service connection for bilateral carpal tunnel syndrome, but VA does not have a duty to provide one here, as there is no indication that the condition may be associated with the Veteran’s service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). He has not presented any competent evidence or testimony in support of the claim, and there are no records of the Veteran receiving a diagnosis of or treatment for the condition until over 25 years after service. There is simply no competent evidence to support that the condition is related to service. Indeed, the Veteran asserted himself during the April 2015 neurology consultation that the wrist numbness began only five or six years prior, so about 20 years after service. His own lay opinion as to the onset and etiology of the right wrist symptomatology does not constitute competent evidence, as he lacks medical training or credentials. Jandreau, supra. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of the claimed bilateral carpal tunnel syndrome. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s bilateral carpal tunnel syndrome and an in-service injury, event or disease.  38 U.S.C. §§ 1110, 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b). 5. Right Knee Condition The Veteran contends generally that he has a right knee condition that is attributable to service. The question for the Board is whether the Veteran has a diagnosable right knee condition 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 history of treatment for right knee symptomatology, the preponderance of the evidence is against a finding that he has a diagnosable right knee condition that began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records does not reflect that the Veteran ever complained of right knee symptomatology or was diagnosed with a right knee condition during service. No right knee condition or lower extremity abnormality specifically impacting the right knee was noted on the October 1988 separation examination, and the Veteran did not report any history of right knee symptomatology on the corresponding October 1988 Report of Medical History. Accordingly, service connection for a right knee condition on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. Post-service medical records show that the Veteran began seeking treatment for right knee pain through his VA medical providers in May 2020 and has continued to receive treatment for right knee pain for the remainder of the appeal period. At no point has any VA medical professional associated any of the Veteran’s right knee pain with his service. The Veteran has not been afforded an examination in connection with his claim seeking service connection for a right knee condition, but VA does not have a duty to provide one here, as there is no indication that the condition may be associated with the Veteran’s service. McLendon, supra. He has not presented any competent evidence or testimony in support of the claim, and there are no records of the Veteran receiving a diagnosis of or treatment for the condition until over 30 years after service. There is simply no competent evidence to support that the condition is related to service. The Veteran’s own lay opinion as to the onset and etiology of the right knee symptomatology does not constitute competent evidence, as he lacks medical training or credentials. Jandreau, supra. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of the claimed right knee condition. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s right knee condition and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b). 6. Left Knee Condition The Veteran seeks service connection generally for a left knee condition. Without delving into the question of the potential etiology of this condition, the Board finds that the Veteran has never formally sought treatment for or been diagnosed with a left knee condition and there is no evidence to suggest that such a diagnosis is appropriate; as such, entitlement to service connection must be denied. A review of available post-service medical records does not reflect that the Veteran has ever been diagnosed with or treated for any left knee condition. To be clear, the Board acknowledges that the Veteran has been receiving treatment for right knee symptomatology through his VA medical providers. However, he has never been diagnosed with or treated for left knee symptomatology, and specifically denied experiencing any such symptomatology on repeated occasions while being treated for his right knee symptomatology. Ultimately, there is no competent evidence that the Veteran has a diagnosable left knee condition or symptomatology that suggests that a diagnosis of the condition would be appropriate. Accordingly, without supporting records, the Board concludes that the Veteran does not have a diagnosable left knee condition and has not had such a condition during the appeal period. The Veteran himself does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology. Jandreau, supra. In the absence of competent supporting evidence, a VA examination also is not required. Service connection is denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b). 7. Right Foot Condition The Veteran seeks service connection for a right foot condition, which he contends is a residual of a right foot sprain he incurred in April 1989 while playing basketball in service. Without delving into the question of the potential etiology of this condition, the Board finds that the Veteran has never formally sought treatment for or been diagnosed with a right foot condition, and there is no evidence to suggest that such a diagnosis is appropriate; instead, the evidence of record suggests that his reports of right foot pain are localized to his right ankle instead, a wholly distinct joint. As such, entitlement to service connection must be denied. A review of available post-service medical records does not reflect that the Veteran has ever been diagnosed with or treated for any right foot condition. The Veteran was first afforded a VA examination to evaluate the nature and likely etiology of the claimed right foot condition in September 2016, during which he reported that he experienced pain at the lateral aspect of the heel of the right foot as well as tingling with prolonged standing. The examiner noted that the Veteran had documented treatment for a right foot sprain in service in April 1989 that he incurred while playing basketball. After an in-person evaluation and a further review of the claims file, the examiner did not document any symptomatology other than right foot pain and did not set forth a clear diagnosis of a current right foot condition other than to list the history of right foot sprain from April 1989. The examiner also noted that a September 2016 radiographic examination revealed no right foot pathology. In summation, the examiner found that it was not possible to attribute the Veteran’s “present right foot condition” to the in-service right foot sprain which occurred in 1989 without “documented examinations” of the right foot from the time of the Veteran’s discharge to the present. This examination is contradictory and lacks significant probative value. As stated, the VA examiner did not set forth a formal diagnosis of a right foot condition yet referred to such a condition when setting forth his etiology opinion. In the Board’s estimation, the most probative aspects of this examination are the negative radiographic examination as well as the examiner’s findings regarding the lack of significant right foot symptomatology other than pain. While the etiology opinion is not dispositive here, the Board also cannot rely on it as the examiner failed to substantiate his opinion on the grounds that there was a lack of documented treatment; essentially, the examiner was unwilling to speculate as to the potential etiology of any diagnosable right foot condition. In recognition of the deficiencies in the September 2016 examination, and as directed by the Board, the Veteran was scheduled for a new VA foot examination in August 2019 in order to determine whether there was a diagnosable right foot condition and, if so, set forth an opinion as to the likely etiology of any such diagnosed condition. He reported experiencing pain over the dorsum of his right foot resulting in decreased ability to walk or stand. After an in-person evaluation and a review of the claims file, the examiner declined a diagnosis of a right foot condition and instead only found evidence of a right ankle sprain, specifically attributing any right foot pain to this right ankle sprain. As such, the examiner declined to set forth any opinion as to the likely etiology of the claimed right foot condition. The Board finds that this examination is highly probative, as the examiner thoroughly reviewed the claims file and set forth a diagnosis that fully accounted for the Veteran’s documented right foot symptomatology. Sklar, supra. The Board has considered this case in light of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In Saunders, the United States Court of Appeals for the Federal Circuit (Federal Circuit) concluded that “pain is an impairment because it diminishes the body’s ability to function, and that pain need not be diagnosed as connected to a current underlying condition to function as an impairment.” Id. at 1364. “[A] physician’s failure to provide a diagnosis for the immediate cause of a veteran’s pain does not indicate that the pain cannot be a functional impairment that affects a veteran’s earning capacity.” Id. at 1367. Ultimately, the Federal Circuit in Saunders held that, to establish the presence of a disability, a veteran will need to show that his or her pain reaches the level of functional impairment of earning capacity. Id. at 1368. That having been noted, the Board finds the present case to be readily distinguishable from Saunders. There is no documentation of a current right foot condition in the record, and although the Veteran described experiencing right foot pain on both the September 2016 and August 2019 VA foot examinations, the highly probative August 2019 VA examination attributed that right foot pain to the diagnosed right ankle sprain. The Board further notes that the Veteran himself does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology. Jandreau, supra. In light of the above evidence showing no current diagnosis of a right foot condition, and a right ankle condition that accounts for the Veteran’s documented symptomatology, the Board finds that the preponderance of the evidence is against a determination that, even in light of Saunders, the Veteran has the condition at issue or that it is attributable to service. Accordingly, service connection for a right foot condition must be denied. Brammer, supra. 8. Left Foot Condition The Veteran seeks service connection generally for a left foot condition. Without delving into the question of the potential etiology of this condition, the Board finds that the Veteran has never formally sought treatment for or been diagnosed with a left foot condition, and there is no evidence to suggest that such a diagnosis is appropriate; as such, entitlement to service connection must be denied. A review of available post-service medical records does not reflect that the Veteran has ever been diagnosed with or treated for any left foot condition. He was afforded VA foot examinations in September 2016 and in August 2019 and denied experiencing any left foot symptomatology on both occasions. This fact distinguishes this case clearly from the scenario set forth in Saunders. Ultimately, there is no competent evidence that the Veteran has a diagnosable left foot condition or symptomatology that suggests that a diagnosis of the condition would be appropriate. Accordingly, without supporting records, the Board concludes that the Veteran does not have a diagnosable left foot condition and has not had such a condition during the appeal period. The Veteran himself does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology. Jandreau, supra. Service connection is denied. Brammer, supra. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b). 9. Gastrointestinal Condition Manifested by Ulcers The Veteran contends generally that he has a gastrointestinal disorder manifested by ulcers that is attributable to service. The question for the Board is whether the Veteran has such a gastrointestinal 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, while the Veteran has a history of complaints of experiencing ulcers, the preponderance of the evidence is against a finding that any gastrointestinal disorder manifested by ulcers began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records does not reflect that the Veteran ever complained of or was diagnosed with ulcers or a gastrointestinal disorder while in service. No such symptomatology was noted on the October 1988 separation examination, and the Veteran did not report any ulcers or gastrointestinal symptomatology on the corresponding October 1988 Report of Medical History. Accordingly, service connection for a gastrointestinal disorder manifested by ulcers on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. Post-service medical records show that the Veteran has a history of intermittent complaints of experiencing ulcers throughout the appeal period; however, he has never had ulcers listed as an active problem in his VA medical records, and he has never been diagnosed with a gastrointestinal disorder distinct from the hiatal hernias for which he is separately seeking service connection. The Veteran has not been afforded an examination in connection with his claim seeking service connection for a gastrointestinal disorder manifested by ulcers, but VA does not have a duty to provide one here, as there is no indication that the condition may be associated with the Veteran’s service. See McLendon, supra. He has not presented any competent evidence or testimony in support of the claim, and there are no records of the Veteran receiving a diagnosis of or treatment for the condition for over 30 years after service. There is simply no competent evidence to support that the condition is related to service. The Veteran’s own lay opinion as to the onset and etiology of the purported gastrointestinal disorder manifested by ulcers does not constitute competent evidence, as he lacks medical training or credentials. Jandreau, supra. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of any gastrointestinal disorder manifested by ulcers. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s gastrointestinal disorder manifested by ulcers and an in-service injury, event or disease.  38 U.S.C. §§ 1110, 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107 (b). 10. Hiatal Hernia The Veteran contends generally that he has a hiatal hernia condition that is attributable to service. The question for the Board is whether the Veteran has a hiatal hernia condition that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has been treated for a hiatal hernia condition since being diagnosed in November 2016, the preponderance of the evidence is against a finding that any hiatal hernia condition began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records does not reflect that the Veteran ever complained of or was diagnosed with hernias or a gastrointestinal condition while in service. No hernias were noted on the October 1988 separation examination, and the Veteran did not report any history of hernias on the corresponding October 1988 Report of Medical History. Accordingly, service connection for a hiatal hernia condition on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. Post-service medical records show that the Veteran was diagnosed with a hiatal hernia condition via a November 2016 endoscopy and has had hiatal hernias listed as an active problem for the remainder of the appeal period. At no point has any VA medical professional associated the hiatal hernia condition with the Veteran’s service. The Veteran has not been afforded an examination in connection with his claim seeking service connection for hiatal hernias, but VA does not have a duty to provide one here, as there is no indication that the condition may be associated with the Veteran’s service. See McLendon, supra. He has not presented any competent evidence or testimony in support of the claim, and there are no records of the Veteran receiving a diagnosis of or treatment for the condition until November 2016, nearly 30 years after service. There is simply no competent evidence to support that the condition is related to service. The Veteran’s own lay opinion as to the onset and etiology of the hiatal hernia condition does not constitute competent evidence, as he lacks medical training or credentials. Jandreau, supra. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of the claimed hiatal hernia condition. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s hiatal hernia condition and an in-service injury, event or disease.  38 U.S.C. §§ 1110, 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107 (b). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 1. PTSD The Veteran seeks an initial rating in excess of 50 percent for his service-connected PTSD for the entire period of the appeal. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign a rating 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for 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. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment due to 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. The use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. When determining the appropriate disability evaluation to assign for psychiatric disabilities, however, the Board’s “primary consideration” is the Veteran’s symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013.) Upon review of the evidence, the Board finds that an initial rating of 70 percent, but no more, is warranted for the acquired psychiatric condition for the entire period of the appeal. The Veteran has submitted a May 2018 private psychiatric disability benefits questionnaire from a Dr. H.H.G., who indicated that she had reviewed the claims file prior to setting forth her conclusions. After she confirmed a diagnosis of PTSD, Dr. H.H.G. found that the Veteran exhibited the following symptoms: depression, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, and persistent delusions and hallucinations. In summation, she found that the PTSD contributed to occupational and social impairment with deficiencies in most areas, such as work, school family relations, judgment, thinking and/or mood. In a corresponding May 2018 evaluation report, Dr. H.H.G. again noted that the Veteran experienced passive suicidal ideation as well as auditory and visual hallucinations that had been occurring for the entirety of the appeal period. According to the Veteran, he was not able to have meaningful occupational and social relationships due to issues with trust and paranoia. Dr. H.H.G. further commented that the Veteran’s significant sleep disturbances and chronic anxiety would also impact the Veteran’s ability to function in an occupational environment. It was Dr. H.H.G.’s impression that the Veteran’s PTSD alone precluded him from securing and maintaining substantially gainful employment. In support thereof, she highlighted the medical evidence of record demonstrating that the Veteran exhibited significant impairment in occupational functioning, including irritability, difficulty adapting to stressful situations, inability to concentrate, neglect of personal appearance/hygiene, confusion, and frequent panic attacks. In addition, she referred to medical literature suggesting a strong correlation between PTSD symptomatology and unemployability. As Dr. H.H.G. in both the May 2018 disability benefits questionnaire and corresponding evaluation report thoroughly reviewed the claims file and referred to the Veteran’s medical history as well as medical literature, the Board finds her determinations as to the severity of the Veteran’s PTSD and its impact on his employability to be highly probative. Sklar, supra. In addition to Dr. H.H.G.’s May 2018 report, the Veteran also submitted lay statements dated in March 2018 from his wife and other close family members, all of whom attested to the significant severity of his PTSD and its negative impact on his employability. Specifically, the Veteran’s spouse detailed his difficulties with memory and handling his anxiety and reported that the Veteran had been unable to maintain steady employment ever since leaving service. Similarly, the Veteran’s daughter and his son’s girlfriend also attested to his extreme anxiety, memory problems, and irritability. The Board acknowledges that the Veteran underwent a July 2015 VA psychiatric examination, during which he denied experiencing much of the symptomatology that would warrant a 70 percent rating, to include suicidal/homicidal ideation and hallucinations. With that being said, the Board does note that the July 2015 examiner detailed that the Veteran exhibited symptoms of chronic sleep impairment, gross impairment in thought processes or communication, and difficulty in establishing and maintaining effective work and social relationships. Moreover, the examiner specifically noted that the Veteran’s PTSD caused fatigue, irritability, and decreased socialization, all of which negatively impacted his social and occupational functioning. Despite this, the examiner determined that the PTSD contributed only to occupational and social impairment with reduced reliability and productivity. It was on this basis that the AOJ assigned the initial 50 percent rating for PTSD. The Board also finds that the July 2015 VA examination is highly probative as it was based on a thorough review of the claims file and consideration of the Veteran’s medical history. Sklar, supra. VA treatment records reflect a history of regular treatment for mental health symptomatology through the Veteran’s local VA medical center. Although these VA medical records show that the Veteran has continually denied experiencing suicidal or homicidal ideation as well as hallucinations, the records also indicate that the Veteran has a history of suicide attempts that predate his beginning treatment through VA. The available VA records also reflect that the Veteran has consistently reported experiencing difficulty sleeping, chronic anxiety, irritability, paranoia, memory problems, and difficulty establishing social and occupational relationships. His most contemporary available VA medical record documenting treatment for psychiatric issues dates from June 2020 and indicates that he reported experiencing significant anxiety and difficulty sleeping as well as intrusive memories, hypervigilance, and irritability. Ultimately, the Board finds that the evidence is at least in equipoise as to the question of whether the Veteran’s PTSD symptomatology has been commensurate with the 70 percent rating criteria for the entirety of the appeal period. Although the July 2015 VA examiner found that the symptoms of the condition contributed to no more than moderate impairment in social and occupational functioning, the Board has highlighted above those symptoms inherent in the 70 percent rating that were not fully considered by the VA examiners, to include passive suicidal ideation, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, and significant sleep impairment. Taken together with those symptoms already encompassed in the 50 percent rating, these newly recognized symptoms resulted in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is entitled to an evaluation of 70 percent. However, the Veteran’s symptomatology does not meet the criteria for a 100 percent rating at any time during the appeal period. While the evidence does show that the Veteran has reported experiencing hallucinations, there is no evidence that he has ever acted on those hallucinations or that they have resulted in spatial or temporal disorientation. Furthermore, although he was noted to exhibit gross impairment in thought process or communication on the July 2015 VA examination, he did not exhibit grossly inappropriate behavior, which is another component of a 100 percent evaluation. Moreover, while the Veteran has reported experiencing memory issues during the VA examination as well as during the May 2018 evaluation with Dr. H.H.G., there is no suggestion that he experienced memory loss for his own name or names of close relatives during the appeal period. Most significantly, there is no indication that he experienced total occupational and social impairment as due to his service-connected PTSD; rather, he has maintained a relationship with his family, to include his wife of several years. Accordingly, a 100 percent evaluation is not warranted. 2. Lumbosacral Degenerative Disc Disease The Veteran is currently service connected for lumbosacral degenerative disc disease, rated as 10 percent disabling effective February 24, 2015. He seeks a rating in excess of that 10 percent for the entire period of the appeal. The current rating was assigned pursuant to 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Code 5237, corresponding to strain of the lumbosacral spine. Spinal conditions are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Code 5237. The General Rating Formula provides for a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is for application with 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 assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula (for Diagnostic Codes 5235 to 5243). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note (2); see also 38 C.F.R. § 4.71a, Plate V. According to the Formula for Rating IVDS, a 10 percent rating is warranted for incapacitating episodes having a total during of at least one week but less than two weeks during the past 12 months; a 20 percent rating requires evidence of incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months; a 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. An “incapacitating episode” is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. at Note (2). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. The Veteran was afforded a VA examination in July 2015 to evaluate the nature and etiology of the claimed lumbosacral degenerative disc disease, the results of which were reported in a disability benefits questionnaire. He reported experiencing back pain with lifting, bending, prolonged immobility and during cold weather. He also detailed that the pain was located in the lower lumbar area, did not radiate, and improved with rest. The Veteran did not endorse experiencing flare-ups of additional pain. After an in-person evaluation and diagnostic testing, the examiner set forth a diagnosis of degenerative disc disease of the lumbar spine. Range of motion testing revealed forward flexion limited to 70 degrees, extension limited to 25 degrees, bilateral lateral flexion limited to 25 degrees, and bilateral lateral rotation limited to 25 degrees. There was no additional loss of range of motion following repetitive use testing nor was there any ankylosis, although the examiner did note pain in weight-bearing and in non-weight bearing. Functional loss was detailed as less movement than normal as well as pain on movement. In summation, the examiner did find that the degenerative disc disease of the lumbar spine contributed to mild limitations in prolonged pushing, pulling, lifting, bending, twisting and stooping, but her impression was that these limitations would not significantly restrict the Veteran in any type of occupational task. The Board notes that the July 2015 VA examiner did issue an addendum opinion to her opinion in October 2015, but this opinion only addressed the likely etiology of the low back condition and so is not relevant to the Board’s present evaluation. A review of post-service medical records reflects that the Veteran first reported experiencing back pain at his local VA medical center in November 2009. Subsequent treatment records indicate that low back pain has continued to be listed as an active problem in the Veteran’s VA medical records for the entirety of the appeal period. The Veteran’s treatment has consisted mainly of over-the-counter pain medication, although there are intermittent reports of the Veteran receiving massage therapy. A May 2019 outpatient record shows that the Veteran reported experiencing non-radiating low back pain at a level of 8 out of 10 following his construction work; however, an evaluation at that time showed full range of motion in his back. More recently, a May 2020 outpatient record also reflected that the Veteran had full range of motion in his back and was prescribed a back brace. At no point has any treating medical professional determined that the Veteran experienced any of the symptoms or loss of range of motion which would support a rating in excess of 10 percent. Upon consideration of the record, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s lumbosacral degenerative disc disease. At no point during the appeal period is there any documentation of the Veteran exhibiting forward flexion limited to 60 degrees or less, combined range of motion of 120 degrees or less, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. Furthermore, there is no documentation of ankylosis of the low back. The Board has taken into consideration the lay evidence of record. While this lay testimony does confirm what has been reflected by the objective medical evidence, namely, that the Veteran experienced significant back pain resulting in functional impairment, the lay evidence of record does not establish that the Veteran’s lumbar spine symptomatology is of such severity as to be commensurate with the criteria for a rating in excess of the 10 percent already assigned. Furthermore, the Veteran explicitly denied experiencing flare-ups of additional pain during the July 2015 examination, and there is no indication from subsequent treatment records that the Veteran has begun to experience flare-ups of additional symptomatology which would equate to an increase in limitation of motion, as would be necessary for a higher rating.  Sharp v. Shinseki, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). Therefore, the Board finds that the assigned 10 percent rating adequately contemplates the functional impairment resulting from the Veteran’s service-connected lumbosacral degenerative disc disease, and a higher initial rating must be denied. The Board notes that the evidence of record does not show additional objective neurological abnormalities associated with the Veteran’s lumbosacral degenerative disc disease. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Accordingly, in light of the fact that neither the Veteran nor his representative has raised any other issues that are associated with the lumbosacral degenerative disc disease increased rating claim, nor have any other issues been reasonably raised by the record, the Board will not proceed to consider any alternative form of entitlement to this particular benefit. Doucette v. Shulkin, 28 Vet. App. 366 (2017). 3. Bilateral SNHL The Veteran contends generally that he is entitled to a rating in excess of 20 percent for bilateral SNHL. The Rating Schedule establishes 11 auditory hearing acuity levels based upon average pure tone thresholds and speech discrimination. See 38 C.F.R. § 4.85. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of the 1000, 2000, 3000, and 4000 Hertz (cycles per second). The audiometric test results are then translated into a numeric designation ranging from Level I to Level XI, in order to evaluate the degree of disability from bilateral service-connected defective hearing. Id. In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. See Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Even if an audiologist’s description of the functional effects of a veteran’s hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Id. The Veteran was afforded a VA audiology examination in August 2016. Audiometric testing revealed the following pure tone thresholds: 1000 2000 3000 4000 RIGHT 50 60 60 65 LEFT 50 55 55 60 The average pure tone threshold in the right ear was 59 and in the left ear was 55. Speech audiometry using the Maryland CNC test revealed a speech recognition score of 72 percent in both ears. As for the functional impact of the hearing loss, the Veteran reported that he experienced difficulty understanding people in communication situations. Applying the results from the August 2016 examination to Table VI under the 38 C.F.R. § 4.85 criteria shows Level V hearing impairment in both ears. See 38 C.F.R. § 4.85 Table VI, Diagnostic Code 6100. Applying these findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a 20 percent evaluation for bilateral hearing loss under Diagnostic Code 6100. In addition to the medical evidence above, the Board has considered the lay evidence provided by the Veteran. He has been followed for bilateral hearing loss through his local VA medical center for the entirety of the appeal period and has consistently reported difficulty in understanding conversation. His treatment has included the prescription of hearing aids. A layperson’s testimony is competent evidence regarding the symptoms he experiences. Heuer v. Brown, 7 Vet. App. 379, 384 (1995). However, disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). As such, the medical evidence is considered the most probative evidence with regard to the level of severity of the Veteran’s service-connected hearing loss. Moreover, the September 2016 VA examiner considered the functional effects of the Veteran’s hearing loss during the examination and concluded that the condition did not contribute to any impairment of functioning. Martinak, 21 Vet. App. at 455. Based on the foregoing, the evidence of record shows that a rating in excess of 20 percent is not warranted for the bilateral SNHL at any point during the appeal period. The Board also notes that the Veteran has not specifically contended that the rating criteria are insufficient for evaluating the severity of his bilateral hearing loss disability. See Doucette, supra. Effective Date Generally, the effective date for an award of compensation or claim for increase is the date of receipt of the claim or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The date of entitlement is the date the claimant meets the basic eligibility criteria for the benefit. Additionally, 38 U.S.C. § 5101(a) provides that “[a] specific claim in the form prescribed by the Secretary... must be filed in order for benefits to be paid or furnished to any individual.” For VA compensation purposes, a “claim” is defined as “a written communication requesting a determination of entitlement or evidencing a belief in entitlement, to a specific benefit under the laws administered by the Department of Veterans Affairs submitted on an application form prescribed by the Secretary.” 38 C.F.R. § 3.1(p). An informal claim is “[a]ny communication or action indicating an intent to apply for one or more benefits.” 38 C.F.R. § 3.155(a). It must “identify the benefit sought.” Id. Thus, the essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim, both formal and informal, for benefits and is required to identify and act on informal claims for benefits. See Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). 1. Entitlement to an effective date prior to February 24, 2015 for service connection for PTSD. The Veteran contends that he is entitled to an effective date earlier than February 24, 2015 for the award of service connection for PTSD. Service connection was granted in a January 2016 rating decision, effective the date the Veteran submitted his informal claim for benefits. No communication that can be interpreted as a claim seeking service connection for PTSD was received by VA prior to this informal claim. Following a review of the claims file, the Board finds that there is no basis upon which to find that the Veteran is entitled to an effective date earlier than February 24, 2015 for the grant of service connection for PTSD. Accordingly, February 24, 2015, the date of the claim underlying the service connection grant at issue here, is the earliest date at which service connection may be effective; entitlement to an effective date earlier than that is not warranted, and the claim is denied. 2. Entitlement to an effective date prior to February 24, 2015 for service connection for lumbosacral degenerative disc disease. The Veteran contends that he is entitled to an effective date earlier than February 24, 2015 for the award of service connection for lumbosacral degenerative disc disease. Service connection was granted in a January 2016 rating decision effective, the date the Veteran submitted his informal claim for benefits. No communication that can be interpreted as a claim seeking service connection for lumbosacral degenerative disc disease was received by VA prior to this informal claim. Following a review of the claims file, the Board finds that there is no basis upon which to find that the Veteran is entitled to an effective date earlier than February 24, 2015 for the grant of service connection for lumbosacral degenerative disc disease. Accordingly, February 24, 2015, the date of the claim underlying the service connection grant at issue here, is the earliest date at which service connection may be effective; entitlement to an effective date earlier than that is not warranted, and the claim is denied. 3. Entitlement to an effective date prior to August 19, 2016 for the grant of a 20 percent rating for bilateral SNHL The Veteran is in receipt of a 20 percent evaluation for his bilateral SNHL, effective August 19, 2016, the date that he filed his claim seeking an increased evaluation for the condition. He seeks to have that 20 percent rating effective prior to the date of his claim. For claims for an increase in a service-connected disability, if an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o); VAOPGCPREC 12-98 (1998). Thus, although the Veteran is already in receipt of an effective date set at the date of his claim for an increased rating, he may also be entitled to that increased rating up to one year prior to the date of his claim if the evidence indicates that the increase in severity was factually ascertainable within that year. In reviewing the evidence already detailed above, the Board does not find that it was “factually ascertainable” in the year from August 19, 2015 to August 19, 2016 that the Veteran’s hearing acuity in his ears bilaterally had been reduced to the point that a compensable rating was warranted. The 20 percent rating was awarded on the basis of the pure tone threshold testing results that were recorded on the September 2016 VA examination administered in support of the increased rating claim. There are no prior audiological testing results in the claims file which reflect hearing acuity reduced to a sufficient degree to warrant a 20 percent rating or even a 10 percent rating at any point during the year prior to the date of the Veteran’s increased rating claim. Under these circumstances, the Board cannot extend the 20 percent rating back before the date of the claim, that is, August 19, 2016. Thus, the claim for an effective date prior to August 19, 2016 is denied. REASONS FOR REMAND Entitlement to service connection for pancreatitis is remanded. The Veteran seeks service connection for pancreatitis. A review of the available VA medical records shows that the Veteran has received treatment for pancreatitis as due to his alcohol abuse disorder throughout the appeal period. Although this is evidence tending to suggest that the pancreatitis may be secondary to the Veteran’s service-connected PTSD with alcohol abuse disorder, the Board cannot make this medical determination on its own and must rely on the finding of an objective medical professional. Accordingly, the claim of entitlement to service connection for pancreatitis is remanded in order to afford the Veteran a VA examination for the purpose of evaluating the nature and likely etiology of the claimed pancreatitis, to include consideration of whether the condition is secondary to the service-connected PTSD. See McLendon, supra. Entitlement to TDIU The Board finds this claim to be inextricably intertwined with the pancreatis claim, and accordingly must remand it. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Schedule the Veteran for a VA medical examination to evaluate the nature and etiology of the claimed pancreatitis.  The claims file, including a copy of this remand, must be made available to the examiner for review.  The VA examiner should confirm the claims file review.  All necessary diagnostic testing should be completed prior to setting forth any opinion.  The examiner is requested to opine whether it is at least as likely as not (a 50 percent probability or greater) that pancreatitis is directly related to active military service.  In addition, irrespective of the answer to the above, the examiner is also requested to provide an opinion as to whether it is at least as likely as not that pancreatitis was caused or aggravated by one or more service-connected disabilities (listed in an October 2016 rating decision), to specifically include PTSD with alcohol abuse disorder. In setting forth this opinion, the examiner should note that the term “aggravated by” refers to a chronic or permanent worsening of the underlying condition, as contrasted to mere temporary or intermittent flare-ups of symptoms that resolve and return to the baseline level of disability.  If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated the pancreatitis, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation.  A complete rationale is required for any opinion. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.