Citation Nr: 21013782 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-03 787 DATE: March 10, 2021 ORDER Entitlement to a compensable initial rating for bilateral hearing loss is denied. Entitlement to a disability rating of 10 percent, and no higher, for hypertension is granted prior to November 21, 2019. Entitlement ta disability rating in excess of 10 percent, from November 21, 2019, for hypertension is denied. Entitlement to a compensable disability rating, prior to November 21, 2019, for sinusitis, is denied. Entitlement to a disability rating in excess of 30 percent, from November 21, 2019, for sinusitis, is denied. Entitlement to a disability rating of 30 percent, and no higher, prior to August 16, 2018, for acute renal failure, is granted. Entitlement to a disability rating in excess of 60 percent, from August 16, 2018, for acute renal failure, is denied. Entitlement to an initial disability rating in excess of 10 percent for gout, great metacarpal toe of the left foot, is denied. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder, not otherwise specified, is denied. REMANDED The issue of entitlement to service connection or sleep apnea, to include as due to service-connected disability, is remanded. The issue of entitlement to service connection for diverticulosis is remanded. The issue of entitlement to service connection for a right knee disability is remanded. The issue of entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s service-connected bilateral hearing loss is manifested by no worse than Level III hearing in his right ear and no worse than Level III hearing in his left ear. 2. The objective clinical findings reflect that, prior to November 21, 2019, the Veteran had been on continuous medication for control of hypertension, without objective demonstration of a history of diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. 3. From November 21, 2019, the Veteran’s service-connected hypertension has not been manifested by diastolic pressure that is predominantly 110 or more or by systolic pressure that is predominantly 200 or more. 4. Prior to November 21, 2019, the most probative evidence of record does not demonstrate the Veteran’s sinusitis manifested in one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 5. From November 21, 2019, the most probative evidence of record does not demonstrate the Veteran’s sinusitis has manifested in radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 6. Prior to August 16, 2018, the Veteran’s service-connected hypertension is rated as 10 percent disabling under Diagnostic Code 7101. 7. From August 16, 2018, the record shows that the Veteran’s acute renal failure has been manifested, at worst, by definite decrease in kidney function. 8. Throughout the entire period on appeal, the Veteran’s gout, great metacarpal toe of the left foot, has not manifested in moderately severe symptoms. 9. The severity, frequency, and duration of the Veteran’s PTSD with depressive disorder, not otherwise specified, symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a compensable initial rating for the Veteran’s service-connected bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100, and Tables VI, VIA, and VII. 2. The criteria for a 10 percent rating, from November 21, 2019, for hypertension have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code 7101. 3. The criteria for a disability rating in excess of 10 percent, from November 21, 2019 for the service-connected hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.104, Diagnostic Codes 7101. 4. The criteria for a compensable disability rating, prior to November 21, 2019, for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6513. 5. The criteria for a disability rating in excess of 30 percent, from November 21, 2019, for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6513. 6. The criteria for a disability rating of 30 percent, but no higher, prior to August 16, 2018, for acute renal failure have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.115, 4.115a Diagnostic Code 7502. 7. The criteria for a disability rating in excess of 60 percent from August 16, 2018, for acute renal failure have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.115, 4.115a Diagnostic Code 7502. 8. The criteria for entitlement to an initial disability rating in excess of 10 percent for gout, great metacarpal toe of the left foot, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5002-5280. 9. The criteria for entitlement to a rating in excess of 50 percent for PTSD with depressive disorder, not otherwise specified, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1966 to January 1970 and from April 1971 to December 1984. These matters come before the Board of Veterans’ Appeals (Board) on appeal of March 2011 and October 2011 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in November 2017 and July 2020. A review of the claims file shows that there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board for review. In March 2017, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board observes that the Veteran has perfected an appeal of the issues of entitlement to increased initial ratings for right lower extremity, left lower extremity, and left upper extremity diabetic neuropathy. Pursuant to his appeal, he has requested a hearing before the Board on these issues. As such, the appeal is being processed on a separate docket from the instant appeal and is awaiting scheduling of the Veteran’s requested hearing. Under these circumstances, the issues of entitlement to increased ratings for diabetic neuropathy will not be addressed herein, and instead will be the subject of a future Board decision, if otherwise in order. Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 1. Entitlement to a compensable initial rating for bilateral hearing loss is denied. The Veteran seeks a compensable initial rating for his service-connected bilateral hearing loss. The Veteran’s service-connected bilateral hearing loss is rated as noncompensable under 38 C.F.R. § 4.85, Diagnostic Code 6100. The applicable rating period is from July 19, 2010, the effective date for the award of service connection for bilateral hearing loss, through the present. See 38 C.F.R. § 3.400. Ratings for hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average puretone threshold levels as measured by puretone audiometry tests at the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability for hearing loss, the Schedule has established eleven auditory acuity levels, designated from level I, for essentially normal acuity, through level XI, for profound deafness. 38 C.F.R. § 4.85 (h), Table VI. To establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average puretone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use the results of puretone audiometry tests together with the results of controlled speech discrimination tests, using the Maryland CNC test. Results of those tests are charted on Table VI and Table VII as set out in the Schedule. Table VIA, which allows for rating based only on puretone threshold averages, is used instead of Table VI when an examiner certifies that the use of speech discrimination testing is not appropriate or when there is an exceptional pattern of hearing impairment. 38 C.F.R. § 4.85 (c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, 4000 Hertz) is 55 decibels or more, it is appropriate to use the Roman numeral designation for hearing impairment from either Table VI or Table Via, whichever results in the higher numeral. Each ear will be evaluated separately. When the puretone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz, it is appropriate to use the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear is evaluated separately. 38 C.F.R. § 4.86 (b). Turning to the relevant evidence of record, the Board notes that the Veteran was provided a VA audiological examination in June 2011. The pertinent audiometric results, measured in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 45 55 60 60 55 LEFT 45 55 55 70 56.25 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 88 percent in the left ear. The results of the June 2011 audiological testing do not reflect an exceptional pattern of hearing impairment. 38 C.F.R. § 4.86. Under Table VI, the right ear is assigned a Level I impairment and the left ear is assigned a Level II impairment. When applied to Table VII, a noncompensable rating is warranted. The Veteran was also provided a VA audiological examination in June 2019. The pertinent audiometric results, measured in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 50 70 70 80 68 LEFT 50 55 75 75 64 Speech audiometry revealed speech recognition ability of 90 percent in the right ear and 88 percent in the left ear. The results of the June 2019 audiological testing do not reflect an exceptional pattern of hearing impairment. 38 C.F.R. § 4.86. Under Table VI, the right ear is assigned a Level III impairment and the left ear is assigned a Level III impairment. When applied to Table VII, a noncompensable rating is warranted. Accordingly, the competent evidence of record does not reflect that the Veteran’s bilateral hearing loss warranted a compensable initial rating during the rating period. To the extent that the Veteran contends that his bilateral hearing loss is more severe than reflected by his current disability rating, the Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge and understanding as a lay person such as difficulty understanding conversation. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to state that his hearing acuity is of a severity sufficient to warrant a higher rating under VA’s tables for rating hearing loss disability because such an opinion requires medical expertise and knowledge that he has not been shown to possess. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the Board attaches more probative weight to the medical records and clinical findings from the skilled medical professionals who conducted the VA audiological testing than to the Veteran’s lay witness statements. Moreover, the assignment of disability ratings for hearing loss is primarily based upon a mechanical application of the rating criteria, as explained and applied in this decision. In this case, the clinical evidence of record, when mechanically applied to the rating criteria, simply does not show that a compensable initial rating is warranted. Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected bilateral hearing loss, nor have any other such issues been reasonably raised by the record. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017). Specifically, the Veteran has described the functional impact from his bilateral hearing loss as difficulty hearing. The provisions of 38 C.F.R. §§ 4.85 and 4.86 contemplate, and thus compensate for, the functional effects of hearing loss, namely difficulty understanding speech and the inability to hear sounds in various contexts. Doucette, 28 Vet. App. at 369. The situations noted by the Veteran in this case amount to decreased hearing and difficulty understanding speech in an everyday environment, and are not exceptional or unusual for someone with hearing loss. The Board therefore finds that the criteria for a compensable initial rating for the Veteran’s service-connected bilateral hearing loss have not been met at any time during the relevant rating period. As the preponderance of the evidence is against the assignment of a compensable initial rating the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an increased rating for service-connected hypertension. The Veteran seeks higher ratings for his service-connected hypertension. The Veteran’s service-connected hypertension is rated as noncompensable prior to November 21, 2019 and 10 percent disabling, from November 21, 2019 under 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran’s increased rating claim was received on October 7, 2010. Therefore, the relevant rating period is from October 8, 2009, one year prior to receipt of the claim, through the present. See, 38 C.F.R. § 3.400 (o) (2). Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more; or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A maximum 60 percent rating is warranted for diastolic pressure predominantly 130 or more. The Veteran was provided a VA examination in February 2011. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran takes medication for his hypertension. Upon examination, the Veteran demonstrated blood pressure readings of 141/79, 132/77, and 130/77. The Veteran was provided a VA examination in November 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran takes medication for his hypertension. Upon examination, the Veteran demonstrated blood pressure readings of 123/68, 133/62, and 126/66. Prior to November 21, 2019, the evidence of record does not show any systolic pressure readings of 160 or more. Also, the Veteran’s diastolic pressure readings were predominantly lower than 100. That said, it is clear from the Veteran’s history that, prior to November 21, 2019, he was prescribed medication for hypertension, and there is insufficient documentation of record to suggest that his diastolic pressure would not have been predominantly 100 or more, or his systolic pressure predominantly 160 or more, but for the medication. The disability picture that emerges is one of a hypertension disability, prior to November 21, 2019, that medication kept below the threshold represented by the criteria for a 10 percent rating. Resolving reasonable doubt in the Veteran’s favor, the Board finds that, prior to November 21, 2019, a 10 percent evaluation, but not more, is warranted for the Veteran’s hypertension. To that extent, the appeal is granted. As to the period from November 21, 2019, the Board finds that the evidence does not support the criteria for a disability rating in excess of 10 percent for hypertension under Diagnostic Code 7101. The evidence shows no evidence of diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature and severity of his service-connected hypertension at issue. The Board notes that his lay testimony is competent to describe certain symptoms associated with this disability. His history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which he has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran’s statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for a rating in excess of 10 percent, from November 21, 2019, for the Veteran’s service-connected hypertension have not been met. Accordingly, there is no basis for staged ratings of the Veteran’s hypertension pursuant to Fenderson, 12 Vet. App. at 126-27, and a higher rating must be denied. As the preponderance of the evidence is against the grant of a higher rating, from November 21, 2019, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Ver. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to increased disability ratings for sinusitis. The Veteran seeks higher ratings for his service-connected sinusitis. The Veteran’s service-connected sinusitis is rated as noncompensable, prior to November 21, 2019, and 30 percent disabling, from November 21, 2019, under 38 C.F.R. § 4.97, Diagnostic Code 6513. The Veteran’s increased rating claim was received on July 19, 2010. Therefore, the relevant rating period is from July 20, 2009, one year prior to receipt of the claim, through the present. See 38 C.F.R. § 3.400 (o) (2). Under Diagnostic Code 6513, a 10 percent rating is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Turning to the relevant evidence of record, the Veteran was provided a VA examination in August 2010. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported severe, stable sinus trouble since a 1969 in-service injury and 1986 surgery to remove nasal polyps. He reported symptoms of headaches and sinus pain that occur two times per year and last one or two days. The Veteran did not report a history of incapacitating episodes. At the March 2017 Board hearing, the Veteran reported incapacitating episodes of sinusitis consisting of severe pain in the frontal area requiring him to lay down and use cold compresses to reduce the pain. The Veteran did not report purulent discharge related to his incapacitating episodes. The Veteran was provided a VA examination in November 2019. The VA examiner reviewed the record, interviewed the Veteran, and conducted an in-service examination. The Veteran reported headaches, pain of affected sinus and tenderness of affected sinus. The Veteran further reported non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting occurring seven or more times in the past twelve months. The Veteran did not report incapacitating episodes of sinusitis in the past twelve months. Prior to November 21, 2019, the Board finds that a compensable disability rating is not warranted. To warrant a compensable rating the evidence would need to show one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The record demonstrates that, prior to November 21, 2019, the Veteran did not have incapacitating episodes or non-incapacitating episodes resulting in purulent discharge or crusting. As such, a compensable rating prior to November 21, 2019 is not warranted. From November 21, 2019, the Board finds that a rating in excess of 30 percent is not warranted. To warrant a rating in excess of 30 percent the evidence would need to show radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. The record demonstrates that from November 21, 2019, the Veteran did not have purulent discharge or crusting. As such, a rating in excess of 30 percent from November 21, 2019 is not warranted. The Board therefore finds that the criteria for a compensable rating, prior to November 21, 2019, and a rating in excess of 30 percent, from November21, 2019, for the Veteran’s service-connected sinusitis have not been met. Accordingly, there is no basis for additional staged ratings of the Veteran’s sinusitis pursuant to Fenderson, 12 Vet. App. at 126-27, and higher ratings must be denied. As the preponderance of the evidence is against the grant of higher ratings the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Ver. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Entitlement to increased ratings for acute renal failure. The Veteran seeks higher ratings for his service-connected acute renal failure. The Veteran’s service-connected acute renal failure is rated as noncompensable prior to August 16, 2018 and 60 percent disabling from August 16, 2018 under 38 C.F.R. § 4.115b, Diagnostic Code 7502. The Veteran’s increased rating claim was received on July 19, 2010. Therefore, the relevant rating period is from July 20, 2009, one year prior to receipt of the claim, through the present. See, 38 C.F.R. § 3.400 (o) (2). Under the criteria for rating renal dysfunction, a noncompensable rating is warranted when there is albumin and casts with a history of acute nephritis, or hypertension is noncompensable under Diagnostic Code 7101. 38 C.F.R. § 4.115a. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is warranted where there is constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating requires persistent edema and albuminuria with BUN 40 to 80 mg percent, or, creatinine 4 to 8 mg percent, or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent evaluation is assigned for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria, or, BUN more than 80 mg percent, or, creatinine more than 8 mg percent, or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Initially, in the above decision, the Board granted a 10 percent disability rating for the Veteran’s service-connected hypertension, prior to November 21, 2019, under Diagnostic Code 7101. The Veteran was provided a VA examination in August 2010. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that his renal failure symptoms largely resolved aside from back pain. Upon examination, there was no evidence of edema and dialysis was not required. August 2018 VA treatment records reflect that the Veteran was hospitalized, due in part, to kidney failure. The Veteran was provided a VA examination in November 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran had acute kidney failure. Upon examination, the Veteran did not demonstrate renal dysfunction, urolithiasis, urinary tract/kidney infection, or tumors and neoplasms. The Veteran demonstrated normal BUN and abnormal EGFR at 43. As noted above, the Veteran is currently rated as 10 percent disabled for hypertension under Diagnostic Code 7101, prior to November 21, 2019. As such, a 30 percent rating is warranted prior to August 16, 2018, for the Veteran’s service-connected acute renal failure due to hypertension rated at least 10 percent disabling under Diagnostic Code 7101. A rating in excess of 30 percent is not warranted prior to August 16, 2018, since the Veteran did not demonstrate constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. As for the period from August 16, 2018, the Board finds a rating in excess of 60 percent is not warranted. At the November 2019 VA examination the Veteran demonstrated normal BUN and there was no evidence of generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. As such, a rating in excess of 60 percent is not warranted for the period from August 16, 2018. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 60 percent for the service-connected acute renal failure from August 16, 2018. However, the record supports a finding that he was entitled to a rating of 30 percent, and no higher, for the service-connected acute renal failure, prior to August 16, 2018. To the extent the Veteran seeks higher ratings than those previously assigned and those assigned in this decision, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 ; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to an increased disability rating for gout, great metacarpal toe of the left foot. The Veteran seeks a higher initial rating for his service-connected gout, great metacarpal toe of the left foot. The Veteran’s service-connected left foot disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5002-5280. The applicable rating period is from July 19, 2010, the effective date for the award of service connection for gout, great metacarpal toe of the left foot, through the present. See 38 C.F.R. § 3.400. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. In this case, the use of Diagnostic Code 5002-5280 reflects that the condition is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5280, which pertains to unilateral hallux valgus. Under Diagnostic Code 5002, rheumatoid arthritis is rated as an active process or based on chronic residuals. When rated as an active process, a 20 percent rating is provided when there are one or two exacerbations a year in a well-established diagnosis. A 40 percent rating is provided when there are symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent rating is provided when the evidence demonstrates symptomatology less than the criteria for a 100 percent rating, but there is weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year, or a lesser number over prolonged periods. A maximum 100 percent rating is provided when there are constitutional manifestations associated with active joint involvement and the condition is totally incapacitating. 38 C.F.R. § 4.71a , Diagnostic Code 5002. Under Diagnostic Code 5002, when there are chronic residuals, such as limitation of motion or ankylosis, the disability is to be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under those diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under 38 C.F.R. § 4.71a , Diagnostic Code 5280, a maximum 10 percent rating is warranted either when the hallux valgus has been operated upon with resection of the metatarsal head or when the hallux valgus is severe, if equivalent to amputation of the great toe. Turing to the evidence of record, the Veteran was provided a VA examination in August 2010. The Veteran reported pain in his great left toe. The VA examiner noted gouty arthritis affecting the great toe. Additionally, the VA examiner noted that the great toe arthritis affected daily activities such as, exercise, sports, recreation, traveling, bathing and driving. The Veteran was provided a VA examination in November 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran does not have hammer toe or functional loss for the left lower extremity attributable to the claimed condition. Having reviewed the complete record, the Board finds that the evidence does not support the criteria for an initial disability rating in excess of 10 percent during the period on appeal for gout under Diagnostic Code 5002-5280. The evidence does not demonstrate one or two exacerbations a year in a well-established diagnosis. Additionally, the Veteran’s left toe disability does not manifest in a moderately severe foot injury. The Board has also considered other Diagnostic Codes to determine whether the Veteran might be entitled to a higher rating at any time during the rating period in relation to his service-connected gout, great metacarpal toe of the left foot. Diagnostic Codes 5276-5284 pertain to disabilities of the foot and toes, but are not for application in the present case because the record is absent for evidence of flatfoot, weak foot, claw foot, Morton’s disease, hallux rigidus, hammer toe, malunion or nonunion of the metatarsal bones or other foot injuries as required under those Diagnostic Codes. In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature and severity of his service-connected gout at issue, and notes that his lay testimony is competent to describe certain symptoms associated with this disability. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran’s statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for an initial rating in excess of 10 percent for the Veteran’s service-connected gout, great metacarpal toe of the left foot, have not been met at any time during the rating period. Accordingly, there is no basis for staged ratings of the Veteran’s gout, great metacarpal toe of the left foot, pursuant to Fenderson, 12 Vet. App. at 126-27, and a higher initial rating must be denied. As the preponderance of the evidence is against the assignment of a higher initial rating, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Ver. App. 49 (1990). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 6. Entitlement to a rating in excess of 50 percent for PTSD. The Veteran seeks a higher initial rating for his service-connected PTSD with depressive disorder, not otherwise specified. The Veteran’s service-connected PTSD is rated as 50 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9434-9411. The applicable rating period is from July 19, 2010, the effective date for the award of service connection for PTSD, through the present. See 38 C.F.R. § 3.400. The Veteran’s PTSD is rated as 50 percent disabling throughout the relevant period under 38 C.F.R. § 4.130, Diagnostic Code 9411, and the General Rating Formula for Mental Disorders (General Formula). When rating disabilities under the General Formula, the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). In relevant part, under the General Formula, a 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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 or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. The Veteran’s VA treatment records; January 2011, July 2012, and December 2019 VA examinations; and the Veteran’s lay statements show that his PTSD was manifested by symptoms associated with a 50 percent rating of flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He also had anxiety, depressed mood, chronic sleep impairment and mild memory loss, which are symptoms associated with a 30 percent rating. He additionally had symptoms that are not listed with a specific rating, such as hypervigilance, exaggerated startle response and problems with concentration. The Board finds that the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. The unlisted symptoms are similar to impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, which are symptoms listed under the 50 percent rating criteria, and to suspiciousness, which is a symptom listed under the 30 percent rating criteria. In that regard, the Board notes that the December 2019 VA examiner considered many of the unlisted symptoms and opined that the Veteran experienced no worse than occupational and social impairment with reduced reliability and productivity, which is consistent with the 50 percent rating criteria. Although the Veteran did experience difficulty in adapting to stressful circumstances, which is contemplated by the 70 percent rating criteria, such is only one of the Veteran’s psychiatric symptoms. As noted above, the Veteran’s other symptoms were either contemplated by or more consistent with the 30 percent and 50 percent rating criteria such that, on balance, he most closely approximated the 50 percent rating criteria overall. In view of the foregoing, the Board finds that the criteria for a rating in excess of 50 percent for PTSD have not been met at any time during the rating period. As the preponderance of the evidence is against the assignment of a higher rating, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that he has sleep apnea that is directly related to his active service or secondary to his service-connected PTSD with depressive disorder. The Veteran was provided a VA examination related to his sleep apnea in July 2019. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the July 2019 VA examination is inadequate for decision making purposes. The VA examiner noted the Veteran’s current diagnosis of obstructive sleep apnea and opined that the disability is less likely than not proximately due to or the result of his service-connected PTSD. As rationale, the VA examiner explained that obstructive sleep apnea is an anatomical condition and PTSD can cause sleeping problems secondary to nightmares but less likely to cause obstructive sleep apnea. As such, the VA examiner concluded that the Veteran’s sleep apnea is less likely than not proximately due to or the result of his PTSD. However, the July 2019 VA examiner did not provide an opinion as to whether the Veteran’s sleep apnea is aggravated by his service-connected PTSD. In that regard, the Board notes that an opinion to the effect that one disability is not at least as likely as not “caused by or a result of” another disability does not answer the question of whether it is at least as likely as not that one disability is aggravated by another. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). 2. Entitlement to service connection for diverticulosis is remanded. 3. Entitlement to service connection for a right knee disability is remanded. The Veteran contends that he has a diverticulosis and a right knee disability that are directly related to his active service. The Veteran was provided a VA examination related to his diverticulosis in July 2019. The VA examiner noted that the Veteran has a current diagnosis of diverticulosis and opined that the disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. As rationale, the VA examiner explained that diverticulosis describes the presence of diverticula and that most people with diverticulosis have no symptoms. The VA examiner further explained that the Veteran was not diagnosed with diverticulosis during his active service. However, the VA examiner did not address the Veteran’s diagnosis of gastroenteritis in September 1976, during his active service. As such, the July 2019 opinion is not adequate for decision making purposes. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As to the Veteran’s claim for entitlement to service connection for a right knee disability, he was provided a VA examination in November 2019. The VA examiner noted the Veteran’s diagnosis of right knee arthritis and opined that the condition is less likely than not related to his active service. As rationale, the VA examiner stated there was no documented injuries related to the Veteran’s right knee during his active service. However, a March 1976 service treatment record reflects that the Veteran was treated for trauma to his right knee. As such, the November 2019 opinion is not adequate for decision making purposes. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 4. Entitlement to a TDIU is remanded. The Veteran contends that he is unable to secure or maintain a substantial gainful employment due to his service-connected disabilities. However, the Veteran has not submitted a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. As such, the nature of the Veteran’s employment history is not part of the record. The matters are REMANDED for the following action: 1. Send the Veteran a notification letter with respect to his claim for entitlement to a TDIU. The letter should include a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, and a VA Form 21-4142, Authorization and Consent to Release Information to VA, for completion and return to VA. 2. Complete any necessary development in view of the Veteran’s response to the above notification letter, to include the scheduling of any additional VA examinations deemed warranted. 3. Forward the record and a copy of this remand to the examiner who conducted the July 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is related to his active service. Rationale must be provided for the opinion proffered. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is proximately due to or the result of his service-connected disabilities, specifically his service-connected PTSD. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the sleep apnea is shown to be “predominantly” due to or result of PTSD, but rather, whether there is any contributing degree of etiological relationship to PTSD. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is aggravated beyond natural progression by his service-connected PTSD. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the sleep apnea is shown to be aggravated beyond natural progression “predominantly” by PTSD, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected PTSD. 4. Forward the record and a copy of this remand to the examiner who conducted the July 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diverticulosis is related to his active service, to include the September 1976 treatment for gastroenteritis. Rationale must be provided for the opinion proffered. 5. Forward the record and a copy of this remand to the examiner who conducted the November 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right knee disability is related to his active service, to include the March 1976 treatment for right knee trauma. Rationale must be provided for the opinion proffered. 6. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for sleep apnea, a right knee disability, and diverticulitis may be granted and whether a TDIU may be granted. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. ANTHONY C. SCIRÉ, JR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine, 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.