Citation Nr: 21017313 Decision Date: 03/24/21 Archive Date: 03/24/21 DOCKET NO. 10-33 257 DATE: March 24, 2021 ORDER As new and material evidence has not been received, the petition to reopen a claim for entitlement to service connection for bilateral hearing loss is denied. As new and material evidence has not been received, the petition to reopen a claim for entitlement to service connection for tinnitus is denied. As new and material evidence has not been received, the petition to reopen a claim for entitlement to service connection for chloracne, to include as due to herbicide exposure, is denied. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected Parkinson’s disease with RUE tremor and bradykinesia and/or migraine headaches, is granted. Entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from March 8, 2013 to January 28, 2018 is denied. Entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from January 29, 2018 is denied. Entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from March 8, 2013 to January 28, 2018 is denied. Entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from January 29, 2018 is denied. Entitlement to an initial evaluation in excess of 30 percent for Parkinson’s disease with right upper extremity (RUE) tremor and bradykinesia is denied. Entitlement to an initial evaluation in excess of 10 percent for balance impairment is denied. Entitlement to an initial evaluation in excess of 10 percent for sleep disturbances is denied. FINDINGS OF FACT 1. In a June 2010 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for bilateral hearing loss; the Veteran appealed the decision, but did not perfect his appeal; no new and material evidence was received within one year of the rating decision, and the decision became final. 2. The evidence received since the June 2010 rating decision is cumulative or redundant of the evidence or record, does not relate to an unestablished fact, and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for bilateral hearing loss. 3. In a June 2010 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for tinnitus; the Veteran did not submit a Notice of Disagreement (NOD), no new and material evidence has been received within one year of the decision, and the decision became final. 4. The evidence received since the June 2010 rating decision is cumulative or redundant of the evidence or record, does not relate to an unestablished fact, and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for tinnitus. 5. In a June 2010 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for chloracne, to include as due to herbicide exposure; the Veteran did not submit a NOD, no new and material evidence has been received within one year of the decision, and the decision became final. 6. The evidence received since the June 2010 rating decision is cumulative or redundant of the evidence or record, does not relate to an unestablished fact, and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for chloracne, to include as due to herbicide exposure. 7. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed cervical spine degenerative disc disease is etiologically related to his active duty service. 8. From March 8, 2013 to January 28, 2018, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not more closely approximate flexion limited to 90 degrees. 9. From January 29, 2018, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not more closely approximate flexion limited to 55 degrees. 10. From March 8, 2013 to January 28, 2018, the Veteran’s chronic left radial humerus bursitis, limitation of supination and pronation, does not more closely approximate limitation of pronation with motion lost beyond last quarter of arc, the hand does not approach full pronation; limitation of pronation with motion lost beyond middle of arc; loss of bone fusion with the hand fixed near the middle of the arc or moderate pronation; or loss of bone fusion with the hand fixed in full pronation. 11. From January 29, 2018, the Veteran’s chronic left radial humerus bursitis, limitation of supination and pronation, does not more closely approximate loss of bone fusion with the hand fixed in supination or hyperpronation. 12. Throughout the appeal period, the Veteran’s Parkinson’s disease with RUE tremor and bradykinesia does not more closely approximate severe incomplete paralysis of the radial nerve. 13. Throughout the appeal period, the Veteran’s balance impairment does not manifest dizziness and occasional staggering. 14. Throughout the appeal period, the Veteran’s sleep disturbances do not more closely approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupation tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). CONCLUSIONS OF LAW 1. The June 2010 rating decision that denied the claim for entitlement to service connection for bilateral hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.52, 20.1103. 2. New and material evidence has not been received to reopen a claim for entitlement to service connection for bilateral hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The June 2010 rating decision that denied the claim for entitlement to service connection for tinnitus is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.52, 20.1103. 4. New and material evidence has not been received to reopen a claim for entitlement to service connection for tinnitus. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The June 2010 rating decision that denied the claim for entitlement to service connection for chloracne, to include as due to herbicide exposure, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.52, 20.1103. 6. New and material evidence has not been received to reopen a claim for entitlement to service connection for chloracne, to include as due to herbicide exposure. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 7. The criteria for entitlement to service connection for a cervical spine disability, to include as secondary to service-connected Parkinson’s disease with RUE tremor and bradykinesia and/or migraine headaches, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 8. The criteria for entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from March 8, 2013 to January 28, 2018 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019-5206. 9. The criteria for entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from January 29, 2018 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019-5206. 10. The criteria for entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from March 8, 2013 to January 28, 2018 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019-5213. 11. The criteria for entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from January 29, 2018 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019-5213. 12. The criteria for entitlement to an initial evaluation in excess of 30 percent for Parkinson’s disease with RUE tremor and bradykinesia have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8004-8514. 13. The criteria for entitlement to an initial evaluation in excess of 10 percent for balance impairment have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.87, Diagnostic Code 6204. 14. The criteria for entitlement to an initial evaluation in excess of 10 percent for sleep disturbances have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.126, 4.130, Diagnostic Code 9310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force and had honorable active duty service from July 1968 to July 1972 and from December 1972 to July 1976 and had dishonorable active duty service for VA purposes from August 1982 to August 1985. The Veteran’s DD Form 214 showed that he was discharged in August 1985 for bad conduct. A December 1987 administrative decision determined that the Veteran had a bad conduct discharge as part of the sentence of a special court martial. The discharge for the period of service from August 1982 to August 1985 was considered to be a bar to VA benefits. The Veteran did not appeal this decision, and it became final. All determinations on the Veteran’s service connection claims must be based on his service between July 1968 and July 1972 and between December 1972 to July 1976, because benefits cannot be awarded on his dishonorable service. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in November 2013 and June 2014 by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana and St. Louis, Missouri, respectively. Jurisdiction of the case is now before the RO in St. Paul, Minnesota. In the November 2013 rating decision, the RO granted service connection for Parkinson’s disease and assigned a 30 evaluation, effective July 16, 2013; denied a higher than 10 percent evaluation for chronic left radial humerus bursitis; and denied reopening the claims for service connection for bilateral hearing loss, tinnitus, and chloracne. The Veteran appealed for an earlier effective date for the award of the grant of service connection for Parkinson’s disease; a higher initial evaluation for Parkinson’s disease; a higher evaluation for chronic left radial humerus bursitis; and service connection for bilateral hearing loss, tinnitus, and chloracne. In the June 2014 rating decision, the RO denied service connection for multilevel degenerative disc disease of the cervical spine. The Veteran appealed the decision. The Veteran testified before the undersigned Veterans Law Judge at a January 2018 videoconference hearing. A transcript of this hearing is of record. Most recently, in June 2018, the Board denied the claim for an earlier effective date for the award of the grant of service connection for Parkinson’s disease and remanded the remaining issues on appeal for additional development. As the actions specified in the remand have been substantially completed, the matters have been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). In a July 2020 rating decision, the Veteran was granted service connection for irritable bowel syndrome and migraine headaches, issues that had been on appeal. As these issues have been resolved by a full grant of benefits, and the Veteran has not submitted any documents indicating that he is not satisfied with the decision, the Board finds that the issues are no longer part of the current appeal. See 38 C.F.R. § 19.26(d). During the pendency of the appeal, the RO issued an October 2020 rating decision granting a higher 20 percent evaluation for chronic left radial humerus bursitis, forearm limitation of flexion, effective January 29, 2018; granting service connection for chronic left radial humerus bursitis, impairment of supination and pronation, and assigning a 10 percent evaluation, effective March 8, 2013 and assigning a 20 percent evaluation, effective January 29, 2018; granting service connection for RUE tremor and bradykinesia and continuing a 30 percent evaluation for Parkinson’s disease with RUE tremor and bradykinesia; granting service connection for balance impairment and assigning a 10 percent evaluation, effective January 29, 2018; and granting service connection for sleep disturbances and assigning a 10 percent evaluation, effective January 29, 2018. The Veteran continued to appeal for higher evaluations for chronic left radial humerus bursitis and Parkinson’s disease with RUE tremor and bradykinesia as well as the residuals of Parkinson’s disease, balance impairment and sleep disturbances. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). New and Material Evidence Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 19.20, 19.21, 19.22, 19.52. If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The U.S. Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for bilateral hearing loss In a June 2010 rating decision, the RO denied the Veteran’s original claim for service connection for bilateral hearing loss, because there was no evidence that his bilateral hearing loss was diagnosed within one year of separation from service or that his bilateral hearing loss occurred in or was caused by service. That decision is final. Since the Veteran’s last prior final denial in June 2010, the record includes lay statements, January 2018 Board hearing testimony, additional VA treatment records, and Social Security Administration (SSA) records. None of these records establish that the Veteran’s bilateral hearing manifested within one year of separation from service or was caused by service. The Board finds that these records, while new, are cumulative or redundant of the evidence at the time of the last prior final denial. They do not relate to an unestablished fact and do not raise a reasonable possibility of substantiating the claim. Consequently, the claim may not be reopened, because no new and material evidence has been received suggesting that the Veteran’s bilateral hearing loss was etiologically related to his active duty service. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for tinnitus In a June 2010 rating decision, the RO denied the Veteran’s original claim for service connection for tinnitus, because there was no evidence that his tinnitus occurred in or was caused by service. That decision is final. Since the Veteran’s last prior final denial in June 2010, the record includes lay statements, January 2018 Board hearing testimony, additional VA treatment records, and SSA records. None of these records establish that the Veteran’s tinnitus was etiologically related to service. The Board finds that these records, while new, are cumulative or redundant of the evidence at the time of the last prior final denial. They do not relate to an unestablished fact and do not raise a reasonable possibility of substantiating the claim. Consequently, the claim may not be reopened, because no new and material evidence has been received suggesting that the Veteran’s tinnitus was etiologically related to his active duty service. 3. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for chloracne, to include as due to herbicide exposure In a June 2010 rating decision, the RO denied the Veteran’s original claim for service connection for chloracne, to include as due to herbicide exposure, because there was no evidence that he was clinically diagnosed with chloracne, that chloracne manifested within one year of his last exposure to herbicides, or that chloracne occurred in or was caused or aggravated by service. That decision is final. Since the Veteran’s last prior final denial in June 2010, the record includes lay statements, January 2018 Board hearing testimony, additional VA treatment records, and SSA records. None of these records establish that the Veteran had a diagnosis for chloracne or that his chloracne was related to service. The Board finds that these records, while new, are cumulative or redundant of the evidence at the time of the last prior final denial. They do not relate to an unestablished fact and do not raise a reasonable possibility of substantiating the claim. Consequently, the claim may not be reopened, because no new and material evidence has been received suggesting that the Veteran had a clinical diagnosis for chloracne or that his chloracne was etiologically related to service. Service Connection 4. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected Parkinson’s disease with RUE tremor and bradykinesia and/or migraine headaches The Veteran asserts that he warrants service connection for a cervical spine disability. At a January 2018 Board hearing, the Veteran testified that he noticed his neck problems about six months to a year after he returned from Vietnam. He said that his neck problems continued after service. Alternatively, the Veteran asserts that his neck problems were caused by his service-connected Parkinson’s disease or migraine headaches. The Veteran described how he had severe headaches during service, which originated from his cervical spine and went up. He said that his neurologist told him that his cervical spine problems were due to his migraine headaches. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The question before the Board is whether the Veteran’s cervical spine disability is etiologically related to active duty service or a service-connected disability. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for a cervical spine disability is warranted. The evidence shows that the Veteran has a current diagnosis for cervical spine degenerative disc disease. See February 2013 VA Neurology Note. According to the Veteran’s DD Form 214s, during his two honorable periods of service, his military occupational specialty was Aircraft Mechanic Specialist and Inventory Specialist. His service records also show that he served in Vietnam. The Veteran’s service treatment records do not document any findings related to any complaints, treatment, or diagnosis for any neck problems. At his June 1976 separation examination, the Veteran had normal clinical evaluation results, and no pertinent symptomatology was identified on his associated report of medical history. Now, the Board recognizes that the record includes conflicting medical opinions concerning whether the Veteran’s current cervical spine degenerative disc disease was etiologically related to his active duty service or a service-connected disability. With regard to the medical opinions obtained, as with all types of evidence, it is the Board's responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). In March 2014, the Veteran underwent a VA examination. After conducting an objective evaluation, the Veteran diagnosed the Veteran with multilevel cervical spine degenerative disc disease. The Veteran reported that he did not recall a specific injury to his neck during service, but he had noticed having neck pain since returning from Vietnam in 1970. He also indicated that he had occasional headaches, which he felt were associated with his neck, because the headaches started at the base of his neck and migrated to the top of his head. The VA examiner opined that the Veteran’s claimed condition, which clearly and mistakably existed prior to service, was not aggravated beyond its natural progression by service. In the rationale, the VA examiner explained that the Veteran had a pre-existing low back injury that had been ongoing. The VA examiner noted that the Veteran did not have a documented neck injury before or during service. Given that the VA examiner used the incorrect legal standard for addressing direct service connection, and that the VA examiner’s rationale was focused on a pre-existing low back injury rather than the Veteran’s cervical spine disability, the Board finds that this opinion is inadequate. In June 2019, the VA examiner provided several opinions addressing the etiology of the Veteran’s cervical spine disability. The VA examiner did not find that the Veteran’s service-connected Parkinson’s disease and service-connected migraine headaches caused or aggravated his cervical spine degenerative disc disease. However, the VA examiner noted that the clinical evidence, in the form of a February 2013 MRI, showed that the Veteran had multilevel degenerative disc disease of the cervical spine, that degeneration of the spine takes time to form, and that degeneration is due to wear and tear over time. The VA examiner opined that “[s]ince the claimant had symptoms of neck pain and headaches in service, then it is at least as likely as not that it was due to developing or progressing cervical degeneration.” The Board finds that the June 2019 VA examiner’s opinion took into consideration the Veteran’s lay statements concerning his history of neck symptoms and provided an underlying rationale that discussed relevant medical principles and clinical evidence. Accordingly, the Board finds that the June 2019 VA examiner’s opinion provides the most persuasive evidence concerning the etiology of the Veteran’s cervical spine disability. In summary, resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed cervical spine degenerative disc disease is etiologically related to his active duty service. Accordingly, the Veteran’s service connection claim must be granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 125; 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). It should also be noted that, when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; DeLuca, 8 Vet. App. at 205. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating, and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 09-1998. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14. 5. Entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from March 8, 2013 to January 28, 2018 6. Entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, forearm limitation of flexion, from January 29, 2018 7. Entitlement to an evaluation in excess of 10 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from March 8, 2013 to January 28, 2018 8. Entitlement to an evaluation in excess of 20 percent for chronic left radial humerus bursitis, limitation of supination and pronation, from January 29, 2018 The Veteran asserts that his chronic left radial humerus bursitis is worse than his current evaluations reflect. At a January 2018 Board hearing, the Veteran testified that his left arm and hand throbbed and hurt all the time. During the relevant appeal period, the Veteran’s chronic left radial humerus bursitis, forearm limitation of motion, has been currently evaluated as 10 percent disabling, effective November 6, 2009, and 20 percent disabling, effective January 29, 2018, under 38 C.F.R. § 4.71a, Diagnostic Codes 5019-5206. The Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, has been currently evaluated as 10 percent disabling, effective March 9, 2013, and 20 percent disabling, effective January 29, 2018, under 38 C.F.R. § 4.71a, Diagnostic Code 5019-5213. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, the hyphenated code indicates that the Veteran's disability is evaluated as bursitis based on the criteria found under Diagnostic Code 5019. Diseases under Diagnostic Codes 5013 through 5024 are to be evaluated as degenerative arthritis, based on limitation of motion of affected parts. 38 C.F.R. § 4.71a, Note. The Board notes that VA has amended the rating criteria for musculoskeletal system disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. With respect to disabilities of the elbow and forearm, 38 C.F.R. § 4.71a, Diagnostic Codes 5205 through 5213 set forth the relevant provisions. The Board notes that the diagnostic codes pertaining to the elbow and forearm were not changed by the February 7, 2021 amendments. In this case, the evidence does not demonstrate ankylosis of the elbow (Diagnostic 5205), elbow, other impairment of flail joint (Diagnostic Code 5209), nonunion of radius and ulna with flail false joint (Diagnostic Code 5210), impairment of ulna (Diagnostic Code 5211), and impairment of radius (Diagnostic Code 5212); thus, the diagnostic codes pertaining to such impairments are not applicable. Handedness for the purpose of a dominant extremity rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. In this case, the evidence (e.g., June 2019 VA examination) shows that the Veteran is right-handed. Consequently, for rating purposes, the left elbow and forearm is the minor upper extremity. Under Diagnostic Code 5206 for limitation of flexion of the forearm, pertinent to the minor upper extremity, a noncompensable rating is assigned for flexion limited to 110 degrees. A 10 percent rating is assigned for flexion limited to 100 degrees. A 20 percent rating is assigned for flexion limited to 90 degrees. A 20 percent rating is assigned for flexion limited to 70 degrees. A 30 percent rating is assigned for flexion limited to 55 degrees. A maximum 40 percent rating is assigned for flexion limited to 45 degrees. Under Diagnostic Code 5207 for limitation of extension of the forearm, pertinent to the minor upper extremity, a 10 percent rating is assigned for extension limited to 45 degrees. A 10 percent rating is assigned for extension limited to 60 degrees. A 20 percent rating is assigned for extension limited to 75 degrees. A 20 percent rating is assigned for extension limited to 90 degrees. A 30 percent rating is assigned for extension limited to 100 degrees. A maximum 40 percent rating is assigned for extension limited to 110 degrees. Under Diagnostic Code 5208, a single, maximum 20 percent rating is assigned for forearm, flexion limited to 100 degrees and extension to 45 degrees. This rating applies to both the major and minor upper extremity. Under Diagnostic Code 5213 for impairment of supination and pronation, pertinent to the minor upper extremity, a 10 percent rating is assigned for limitation of supination to 30 degrees or less. A 20 percent rating is assigned for limitation of pronation with motion lost beyond last quarter of arc, the hand does not approach full pronation. A 20 percent rating is assigned for limitation of pronation with motion lost beyond middle of arc. A 20 percent rating is assigned for loss of bone fusion with the hand fixed near the middle of the arc or moderate pronation. A 20 percent rating is assigned for loss of bone fusion with the hand fixed in full pronation. A maximum 30 percent rating is assigned for loss of bone fusion with the hand fixed in supination or hyperpronation. In all the forearm and wrist injuries, diagnostic codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury are to be separately rated and combined not to exceed rating for loss of use of hand. 38 C.F.R. § 4.71a, Note. Normal elbow and forearm range of motion is from zero to 145 degrees flexion, from 145 to zero degrees extension, zero to 80 degrees pronation and zero to 85 degrees supination. 38 C.F.R. § 4.71, Plate I. Consequently, for pronation, the middle of the arc is to 40 degrees and the last quarter of the arc is to 20 degrees. Based on a careful review of all the subjective and clinical evidence, the Board finds that from March 8, 2013 to January 28, 2018, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not warrant a higher 20 percent evaluation under Diagnostic Code 5206. In other words, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not manifest flexion limited to 90 degrees. At an October 2013 VA examination, the Veteran’s range of motion testing revealed left elbow flexion to 145 degrees with pain. Upon repetitive use testing, there was no additional limitation in range of motion. The Veteran reported having flare-ups, which made bending his left elbow difficult due to pain. There was no additional limitation of functional ability of the elbow joint during flare-ups or with repeated use over time. VA treatment records from 2015 to 2017 document the Veteran’s reports of left elbow pain. Nevertheless, the records also indicate normal left elbow x-rays (March 2016 VA treatment record); reports of “tolerable” left elbow pain and full, active range of motion of the left elbow with localized tenderness (October 2016 VA treatment record); and reports of infrequent left elbow pain and an ability to control his activity and articular problems (April 2017 VA treatment record). The Board is sympathetic to the Veteran’s reports of difficulty bending his elbow due to pain; however, there is no basis upon which to award a higher 20 percent evaluation for chronic left radial humerus bursitis under Diagnostic Code 5206. Therefore, from March 8, 2013 to January 28, 2018, the Board finds that the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, is no more than 10 percent disabling. Furthermore, the Board has also considered whether a higher evaluation for chronic left radial humerus bursitis, forearm limitation of flexion, based on functional loss due to flare-ups is warranted. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also 38 C.F.R. §§ 4.40, 4.45. Although the Veteran reported having flare-ups, described as left elbow pain causing difficulty with bending his elbow, the October 2013 VA examiner found no evidence of functional loss with flare-ups. Given that the clinical findings showed the Veteran’s left elbow had normal flexion and no additional limitation in range of motion or functional loss with either flare-ups or repeated use, the Board finds that the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, is more consistent with a 10 percent evaluation for painful motion from March 8, 2013 to January 28, 2018. Based on a careful review of all the subjective and clinical evidence, the Board finds that from January 29, 2018, the date of his January 2018 Board hearing, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not warrant a higher 30 percent evaluation under Diagnostic Code 5206. In other words, the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, does not manifest flexion limited to 55 degrees. At a June 2019 VA examination, the Veteran reported having severe flare-ups, which occurred with use and lasted 30 to 35 minutes. He also experienced functional loss in which heavy lifting was decreased. Range of motion testing revealed left elbow flexion to 80 degrees with pain. The VA examiner noted that the Veteran had functional loss, which was exhibited by limited bending to aid in lifting. Upon repetitive use testing, no additional loss of function or range of motion was found. However, the VA examiner determined that pain significantly limited functional ability with repeated use over a period of time and with flare-ups. As a result, the VA examiner found that the Veteran’s flexion was further limited to 75 degrees. The Board is sympathetic to the Veteran’s reports of severe pain with use; however, there is no basis upon which to award a higher 30 percent evaluation under Diagnostic Code 5206. Notably, the Veteran’s current evaluation already takes into account his degree of functional loss due to flare-ups and with repeated use. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also 38 C.F.R. §§ 4.40, 4.45. Accordingly, the Board finds that the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, more closely approximates flexion limited to 70 degrees. Therefore, from January 29, 2018, the Board finds that the Veteran’s chronic left radial humerus bursitis, forearm limitation of flexion, is no more than 20 percent disabling. Based on a careful review of all the subjective and clinical evidence, the Board finds that from March 8, 2013 to January 28, 2018, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, does not warrant a higher 20 percent evaluation under Diagnostic Code 5213. In other words, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, does not manifest limitation of pronation with motion lost beyond last quarter of arc, the hand does not approach full pronation; limitation of pronation with motion lost beyond middle of arc; loss of bone fusion with the hand fixed near the middle of the arc or moderate pronation; or loss of bone fusion with the hand fixed in full pronation. As noted above, full pronation is to 80 degrees, middle of arc is to 40 degrees and the last quarter of the arc is to 20 degrees. At an October 2013 VA examination, the Veteran reported having flare-ups, which were described as difficulty bending his left elbow due to pain. Range of motion testing revealed left forearm pronation to 80 degrees with pain and left forearm supination to 85 degrees with pain. There was no additional limitation of functional ability during flare-ups or repeated use over time. There is no basis upon which to award a higher 20 percent evaluation for chronic left radial humerus bursitis, impairment of supination and pronation, under Diagnostic Code 5213. Therefore, the Board finds that from March 8, 2013 to January 28, 2018, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, is no more than 10 percent disabling for painful motion. Furthermore, the Board has also considered whether a higher evaluation for chronic left radial humerus bursitis, impairment of supination and pronation, based on functional loss due to flare-ups is warranted. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also 38 C.F.R. §§ 4.40, 4.45. Although the Veteran reported having flare-ups, described as left elbow pain causing difficulty with bending his elbow, the October 2013 VA examiner found no evidence of functional loss with flare-ups. Given that the clinical findings showed the Veteran’s left elbow had normal supination and pronation and no additional limitation in range of motion or functional loss with either flare-ups or repeated use, the Board finds that the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, is more consistent with a 10 percent evaluation for painful motion from March 8, 2013 to January 28, 2018. Based on a careful review of all the subjective and clinical evidence, the Board finds that from January 29, 2018, the date of the January 2018 Board hearing, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, does not warrant a higher 30 percent evaluation under Diagnostic Code 5213. In other words, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, does not manifest loss of bone fusion with the hand fixed in supination or hyperpronation. At a June 2019 VA examination, the Veteran reported having severe flare-ups with use and lasting 30 to 35 minutes. He did not perform any heavy lifting with his left arm. Range of motion testing revealed left forearm supination to 60 degrees with pain and left forearm pronation to 20 degrees with pain. The VA examiner noted that the Veteran had functional loss, which was exhibited by limited turning of the left arm. There was no additional loss of function or range of motion upon repetitive use testing. However, the VA examiner found that pain significantly limited functional ability with repeated use over a period of time and with flare-ups. As a result, the VA examiner found that the Veteran’s forearm supination was further limited to 55 degrees and forearm pronation was further limited to 15 degrees. The Board is sympathetic to the Veteran’s reports of severe pain with use; however, there is no basis upon which to award a higher 30 percent evaluation under Diagnostic Code 5213. Notably, the Veteran’s current evaluation already takes into account his degree of functional loss due to flare-ups and with repeated use. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also 38 C.F.R. §§ 4.40, 4.45. Accordingly, the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, is more consistent with limitation of pronation with motion lost beyond middle of arc. Therefore, from January 29, 2018, the Board finds that the Veteran’s chronic left radial humerus bursitis, impairment of supination and pronation, is no more than 20 percent disabling. Finally, the Board also considered whether the Veteran was entitled to separate or higher evaluations under Diagnostic Codes 5207 (limitation of extension of the forearm) and 5208 (forearm, flexion limited to 100 degrees and extension to 45 degrees). However, throughout the appeal period, the clinical evidence demonstrates that the Veteran’s left forearm exhibited full extension. See October 2013 VA examination and June 2019 VA examination. Thus, the Veteran is not entitled to separate or higher evaluations under these diagnostic codes. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 10 percent evaluation claim from March 8, 2013 to January 28, 2018, and higher than 20 percent evaluation claim from January 29, 2018, for chronic left radial humerus bursitis, forearm limitation of flexion. Additionally, the preponderance of the evidence of weighs against finding in favor of the Veteran’s higher than 10 percent evaluation claim from March 8, 2013 to January 28, 2018, and higher than 20 percent evaluation claim from January 29, 2018, for chronic left radial humerus bursitis, impairment of supination and pronation. Therefore, the benefit-of-the-doubt rule does not apply, and the higher evaluation claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 9. Entitlement to an initial evaluation in excess of 30 percent for Parkinson’s disease with RUE tremor and bradykinesia The Veteran asserts that his Parkinson’s disease is worse than his current evaluation reflects. At a January 2018 Board hearing, the Veteran testified that his Parkinson’s disease symptoms had worsened. He described how he had RUE tremors. He said that he experienced dizziness from his Parkinson’s disease medication. The Veteran’s Parkinson’s disease with RUE tremor and bradykinesia has been currently evaluated as 30 percent disabling, effective July 16, 2013, under 38 C.F.R. § 4.124a, Diagnostic Codes 8004-8514. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. Under Diagnostic Code 8004, paralysis agitans assigns a minimum 30 percent rating. Paralysis agitans is also known as Parkinson's disease. Dorland's Illustrated Medical Dictionary 972 (26th ed. 1990). Under this diagnostic code, a minimum 30 percent rating is assigned. This is the highest schedular rating available under this diagnostic code. If, however, there are identifiable residuals that can be rated under a separate diagnostic code and the combined disability rating resulting from these residuals exceeds 30 percent, the separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. VA must also continually analyze individual chronic symptoms residual to Parkinson's disease under the appropriate diagnostic code for that body system. Neurological conditions such as Parkinson's disease are evaluated under the section of the Rating Schedule beginning at 38 C.F.R. § 4.120, conducting evaluations by comparison. 38 C.F.R. § 4.120 provides that disability in this field is ordinarily to be rated in proportion to the impairment of motor, sensory or mental function. The rater is to consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating such disability, the rater is to refer to the appropriate schedule. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. In this case, the Veteran was rated for a residual of his Parkinson's disease. Diagnostic Code 8514 provides the rating criteria for paralysis of the radial nerve, and therefore, neuritis and neuralgia of that nerve. As noted above, given that the Veteran is right-hand dominant, for rating purposes, the RUE is the major extremity. For the major extremity, disability ratings of 20 percent, 30 percent and 50 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. A 70 percent rating is warranted for the major extremity for complete paralysis, which contemplates the drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Additionally, the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. Id. Based on a careful review of all the subjective and clinical evidence, the Board finds that throughout the appeal period, the Veteran’s Parkinson’s disease with RUE tremor and bradykinesia does not warrant a higher 50 percent initial evaluation under Diagnostic Code 8514. In other words, the evidence does not demonstrate that the Veteran’s RUE symptoms are more appropriately characterized as severe incomplete paralysis of the radial nerve. According to a May 2013 Parkinson’s Disease Disability Benefits Questionnaire, the Veteran had symptoms of mild RUE tremors. No other manifestations of Parkinson’s disease were identified. The VA treating physician, who conducted the evaluation, diagnosed the Veteran with mixed tremors, Parkinsonian, and found that the Veteran presented with only mild RUE tremor. In an August 2013 VA opinion, the VA examiner reviewed the Veteran’s medical records and determined that at his last VA clinic visit in August 2013, he continued to have RUE tremor at rest; however, he did not have any other signs or symptoms of Parkinson’s disease. At a June 2014 VA clinic visit, the Veteran complained of RUE tremor while using his hand for feeding, drinking, and holding objects. He affirmatively denied any worsening of his RUE tremors. At an October 2017 VA clinic visit, the Veteran reported having worsening tremor at times, which caused difficulty with signing documents, eating, and shaving. He accommodated for this difficulty when necessary by using his left hand. According to the clinical findings at a June 2019 VA examination, the Veteran had motor manifestations of Parkinson’s disease characterized by moderate bradykinesia or slowed motion and moderate RUE tremor. The VA examiner noted that the Veteran had some moderately intense tremors of his right hand, which limited function. The Veteran reported that his right-hand shaking symptoms have persisted over the years and impacted his ability to lift, push, pull, and hold items. Given the above reported symptomatology without a significant functional decline commensurate with severe symptoms coupled with the clinical finding that the Veteran’s symptoms were characterized as moderate, the Board concludes that throughout the appeal period, the evidence does not support finding that the Veteran’s RUE symptoms demonstrates more than moderate incomplete paralysis of the radial nerve. Therefore, the Board finds there is no basis upon which to award a 50 percent initial evaluation for Parkinson’s disease with RUE tremor and bradykinesia under Diagnostic Code 8514. Accordingly, throughout the appeal, the Veteran’s Parkinson’s disease with RUE tremor and bradykinesia is no more than 30 percent disabling. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 30 percent initial evaluation for Parkinson’s disease with RUE tremor and bradykinesia. Therefore, the benefit-of-the-doubt rule does not apply, and the higher initial evaluation claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 10. Entitlement to an initial evaluation in excess of 10 percent for balance impairment The Veteran generally asserts that his balance impairment, as a residual of Parkinson’s disease, is worse than his current evaluation reflects. The Veteran’s balance impairment has been currently evaluated as 10 percent disabling, effective January 29, 2018, under 38 C.F.R. § 4.87, Diagnostic Code 6204. Diagnostic Code 6204 provides the rating criteria for peripheral vestibular disorders. A 10 percent rating is warranted for manifestation of occasional dizziness. A maximum 30 percent rating is warranted when there is dizziness and occasional staggering. A note provides that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code. Hearing impairment or suppuration shall be separately rated and combined. Based on a careful review of all the subjective and clinical evidence, the Board finds that throughout the appeal period, the Veteran’s balance impairment does not warrant a higher 30 percent initial evaluation. In other words, the Veteran’s balance impairment does not manifest dizziness and occasional staggering. At a March 2018 VA clinic visit, the Veteran reported having dizzy spells. According to clinical findings at a June 2019 VA examination, the Veteran had motor manifestations of Parkinson’s disease, which was characterized by moderate balance impairment. No functional limitations associated with his balance impairment were identified. Given the above reported symptomatology coupled with the clinical findings, the Board concludes that there is no basis upon which to award a 30 percent evaluation for balance impairment under Diagnostic Code 6204. Therefore, throughout the appeal period, the Veteran’s balance impairment is no more than 10 percent disabling. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 10 percent initial evaluation for balance impairment. Therefore, the benefit-of-the-doubt rule does not apply, and the higher initial evaluation claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 11. Entitlement to an initial evaluation in excess of 10 percent for sleep disturbances The Veteran generally asserts that his sleep disturbances are worse than his current evaluation reflects. The Veteran’s sleep disturbances have been currently evaluated as 10 percent disabling, effective January 29, 2018, under 38 C.F.R. § 4.130, Diagnostic Code 9310 for unspecified neurocognitive disorder. Under Diagnostic Code 9310, which is governed by a General Rating Formula for Mental Disorders, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and/or mild memory loss (such as forgetting names, directions, recent events). 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; and/or difficulty in establishing and maintaining effective work and social relationships. 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 such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126; see Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner’s assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. Id. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116–17 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Based on a careful review of all the subjective and clinical evidence, the Board finds that throughout the appeal period, the Veteran’s sleep disturbances do not warrant a higher 30 percent initial evaluation under the General Rating Formula for Mental Disorders. In other words, the Veteran’s sleep disturbances do not more closely approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). At a June 2019 VA examination, the VA examiner found that the Veteran had moderate sleep disturbances. No functional impairment associated with his sleep disturbances were identified. Given the clinical finding that the Veteran’s sleep disturbances were characterized as moderate without any functional impairment noted, the Board concludes that there is no basis upon which to award a higher 30 percent initial evaluation for sleep disturbances under the General Rating Formula for Mental Disorders. Therefore, throughout the appeal period, the Veteran’s sleep disturbances are no more than 10 percent disabling. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 10 percent initial evaluation claim for sleep disturbances. Therefore, the benefit-of-the-doubt rule does not apply, and the higher initial evaluation claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Journet Shaw, 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.