Citation Nr: 21021938 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 20-28 972 DATE: April 14, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for a right shoulder disability has been withdrawn. Entitlement to a disability rating in excess of 20 percent for a left shoulder disability has been withdrawn. Entitlement to a compensable rating for bilateral pinguecula has been withdrawn. Entitlement to service connection for a blurry vision disability has been withdrawn. Entitlement to service connection for periodontal disease has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a back disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left knee disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right knee disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for post-traumatic stress disorder (PTSD) has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right shoulder disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left shoulder disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pes cavus has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for hypertension has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for tinnitus has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for left ear hearing loss has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left elbow disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right elbow disability has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pinguecula has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for service connection for erectile dysfunction has been withdrawn. Entitlement to an earlier effective date prior to February 7, 2018, for special monthly compensation (SMC) based on loss of use of a creative organ has been withdrawn. Entitlement to a disability rating of 70 percent for PTSD for the period prior to May 6, 2019 is granted. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from July 1, 2019 is denied. Entitlement to a compensable rating for erectile dysfunction is denied. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to a total disability rating based upon unemployability (TDIU) is granted. REMANDED Entitlement to a disability rating in excess of 10 percent for a right elbow disability is remanded. Entitlement to a disability rating in excess of 10 percent for a left elbow disability is remanded. Entitlement to a disability rating in excess of 10 percent for a right knee disability is remanded. Entitlement to a disability rating in excess of 10 percent for a left knee disability is remanded. Entitlement to a disability rating in excess of 10 percent for service-connected bilateral pes cavus is remanded. Entitlement to a disability rating in excess of 10 percent for a back disability is remanded. Entitlement to a compensable disability rating for hypertension is remanded. Entitlement to a compensable disability rating for left ear hearing loss is remanded. Entitlement to service connection for a right ear hearing loss disability is remanded. FINDINGS OF FACT 1. On February 23, 2021, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant that a withdrawal of the appeal for the following issues was requested, with full understanding that the Board would not render a decision on these issues: higher initial ratings for the service-connected bilateral shoulder disabilities and bilateral pinguecula; service connection for vision loss and periodontal disease; and earlier effective dates for the grant of service connection for the bilateral shoulder, knee, feet, and elbow disabilities, the back disability, the psychiatric disability, the bilateral pinguecula, hypertension, erectile dysfunction, left ear hearing loss, and tinnitus. 2. For the period on appeal prior to May 6, 2019, the Veteran’s PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. For the period on appeal from July 1, 2019, the Veteran’s PTSD symptoms did not result in total occupational and social impairment. 4. The evidence of record does not indicate that the Veteran has a penis deformity. The Veteran is, however, in receipt of special monthly compensation based on loss of use of a creative organ due to the service-connected erectile dysfunction. 5. Resolving reasonable doubt in the Veteran’s favor, the Veteran has a current obstructive sleep apnea disability that is at least as likely as not related to his active service. 6. The Veteran’s service-connected disabilities have prevented him from obtaining and maintaining employment consistent with his occupational and vocational experience throughout the entire period on appeal. CONCLUSIONS OF LAW 1. The criteria for withdrawal of entitlement to a disability rating in excess of 20 percent for a right shoulder disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § § 19.55. 2. The criteria for withdrawal of entitlement to a disability rating in excess of 20 percent for a left shoulder disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of entitlement to a compensable rating for bilateral pinguecula by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a back disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left knee disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 6. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right knee disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 7. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left shoulder disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 8. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right shoulder disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 9. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left elbow disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 10. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right elbow disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 11. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pes cavus by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 12. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for PTSD by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 13. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for hypertension by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 14. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for tinnitus by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 15. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for left ear hearing loss by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 16. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pinguecula by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 17. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for service connection for erectile dysfunction by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 18. The criteria for withdrawal of entitlement to an earlier effective date prior to February 7, 2018, for SMC based on loss of use of a creative organ by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 19. The criteria for withdrawal of entitlement to service connection for a blurry vision disability by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 20. The criteria for withdrawal of entitlement to service connection for periodontal disease by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 21. The criteria for entitlement to a disability rating of 70 percent for the period prior to May 6, 2019, but no higher for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411. 22. The criteria for entitlement to a disability rating in excess of 70 percent for PTSD for the period from July 1, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411. 23. The criteria for entitlement to a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.20, 4.21, 4.31, 4.115b, DC 7599-7522. 24. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 25. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1997 to March 1998, from November 2000 to July 2002, and from July 2010 to February 2018. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran attended a hearing before the undersigned Veterans Law Judge in February 2021. A transcript of the hearing is of record. 1. Withdrawn Issues The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the appellant has withdrawn the issues of entitlement to a disability rating in excess of 20 percent for a right shoulder disability; entitlement to a compensable rating for bilateral pinguecula; entitlement to a disability rating in excess of 20 percent for a left shoulder disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a back disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left knee disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for PTSD; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right shoulder disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right knee disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pes cavus; entitlement to an earlier effective date prior to February 7, 2018, for service connection for hypertension; entitlement to an earlier effective date prior to February 7, 2018, for service connection for tinnitus; entitlement to an earlier effective date prior to February 7, 2018, for service connection for left ear hearing loss; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left elbow disability; entitlement to an earlier effective date prior to February 7, 2018, for service connection for bilateral pinguecula; entitlement to an earlier effective date prior to February 7, 2018, for service connection for erectile dysfunction; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a right elbow disability; entitlement to an earlier effective date prior to February 7, 2018, for SMC based on loss of use of a creative organ; entitlement to an earlier effective date prior to February 7, 2018, for service connection for a left shoulder disability; entitlement to service connection for a blurry vision disability; and entitlement to service connection for periodontal disease. Specifically, the Veteran withdrew the issues during the February 2021 Board hearing. The withdrawal of the appeals was explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). There remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 2. Entitlement to a disability rating in excess of 30 percent for PTSD for the period prior to May 6, 2019 The Veteran’s service-connected PTSD is rated as 30 percent disabling from February 7, 2018, 100 percent disabling from May 6, 2019, and 70 percent disabling from July 1, 2019, under VA’s General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. The Board notes that the RO awarded the Veteran a temporary 100 percent disability rating for his PTSD from May 6, 2019 to July 1, 2019. Accordingly, the Board may only review the periods on appeal when the 100 percent rating does not apply. Under the formula, a 30 percent evaluation is warranted where there is 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 symptoms such as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board notes that the Veteran need not exhibit “all, most, or even some” of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant’s social and work situation. Id. The Veteran had an examination for his PTSD in July 2017. The Veteran exhibited PTSD symptoms including depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and disturbances of motivation and mood. The Veteran reported that he has been married three times and described his current marriage as in distress. The Veteran stated that he feels that he has a short temper and isolates himself at home, and that these issues are causing distress in his marriage. The Veteran was alert and fully oriented. He manifested a range of affect appropriate to the content of the various topics discussed throughout the examination. He was fully cooperative and maintained good eye contact and manifested both continuity and clarity of thought as well as prosody of expression. The Veteran denied suicidal and homicidal ideation, as well as delusions or hallucinations. In a suicide risk screening from December 2018, the Veteran reported having suicidal thoughts over the past month. The Veteran further reported feeling like he wished he was dead or wished he could go to sleep and not wake up. The Veteran denied any homicidal ideations, plans, or intentions. VA treatment records from February 2019 note that the Veteran was alert and oriented times three, isolating, and his mood was dysphoric. There was no evidence of thought or perceptual disturbance. The Veteran’s physician noted that his circumstance was worsening with the specter of impending divorce and the loss of his immediate family unit, increasing his suicide risk. The Veteran admitted to having occasional suicidal thoughts but denied that he would act on it. The Veteran testified at his February 2021 Board hearing that he was experiencing severe PTSD symptoms, including suicidal ideation, since his discharge from service. The Board concludes that the objective medical evidence and the Veteran’s statements regarding his symptomatology show disability that more nearly approximates the higher, 70 percent disability rating for the period on appeal prior to May 6, 2019. See 38 C.F.R. § 4.7. The Veteran’s symptoms include reports of intermittent suicidal ideation, depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. He has significant difficulty maintaining relationships. As a result, the Board finds that the Veteran’s described symptoms more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as described by the 70 percent rating criteria for the period on appeal prior to May 6, 2019. However, a rating greater than 70 percent is not appropriate because the evidence of record does not indicate that the Veteran had total occupational and social impairment as contemplated by the 100 percent rating criteria. While the Veteran’s PTSD causes severe impairment, the evidence of record is against a finding that his PTSD caused total impairment. There is no evidence in the record showing that his service-connected PTSD has manifested in those symptoms typically associated with total social and occupational impairment, such as gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The record also does not support that he has other symptoms on par with the level of severity contemplated by those symptoms. The medical evidence of record consistently notes that the Veteran has been oriented to person, time, and place, casually and appropriately dressed, with intact thought processes. Additionally, while he has described having had suicidal ideation, the evidence does not indicate that he is a persistent danger to himself or others. Although the Veteran has at times had suicidal thoughts and has reported distress in his marriage, the weight of the evidence shows that his PTSD did not cause total occupational and social impairment, warranting an increased rating to 100 percent for the period on appeal prior to May 6, 2019. In short, prior to May 6, 2019 the Veteran’s PTSD symptoms cause occupational and social impairment in most areas, as contemplated by the 70 percent rating. The benefit sought for the period on appeal prior to May 6, 2019 is granted to 70 percent disabling, but no higher. 3. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from July 1, 2019 The Veteran had an examination for his PTSD in August 2019. The Veteran exhibited symptoms including depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran reported that he was going through a divorce and that he has been married three times. The Veteran reported that his twin daughters from his second marriage have changed their last name and refuse to have a relationship with him. The Veteran stated that he has gone through “some very dark episodes in his life where he will isolate himself”. However, the Veteran reported that despite having many struggles in his life, he is doing better and dealing with things more effectively than before. The Veteran indicated that he continues to isolate himself to a degree and does not socialize with others, although he noted that he does see people at church. The Veteran denied any intent to hurt himself or others but stated that until recently he has experienced passive suicidal thoughts without intent to act. The Veteran was cooperative and pleasant throughout the session. He was neatly groomed. He was able to focus and attend to the conversation at hand. His insight and judgment were both within normal limits, and long term and short-term memory were grossly intact. The Veteran’s mood appeared stable and consistent with the conversation at hand. His speech was normal with adequate content and appropriate organization. His thought content and processes were normal, and there were no signs of loss of contact with reality. The Veteran had another examination for his PTSD in March 2021. The Veteran exhibited symptoms including depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; and inability to establish and maintain effective relationships. The Veteran reported that he has been divorced since 2018. He further reported that he has been distant, disengaged, and isolative from his family. The Veteran was cooperative. His grooming was intact. His speech prosody, rate and rhythm were within normal limits. He engaged appropriately with the examiner and made appropriate eye contact. He was oriented on all spheres. He indicated his moods as “depressed.” His affect was stressed. There was no evidence of psychotic thinking noted. His thought content, abstractions and thought processing were intact. His insight and judgment were fair. The Veteran denied suicidal or homicidal ideation. As noted above, to warrant the assignment of a higher 100 percent rating, the Veteran’s acquired mental condition must manifest in symptoms causing total occupational and social impairment. While the Veteran’s PTSD does cause severe impairment, the evidence of record is against a finding that his acquired mental condition causes total impairment for the period on appeal from July 1, 2019. Although the Veteran reported being generally isolated and distant from his family, he has described being occasionally social with others at his church. There is also no evidence in the record showing that his service-connected PTSD has manifested in those symptoms typically associated with total social and occupational impairment, such as gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The record also does not support that he has other symptoms on par with the level of severity contemplated by those symptoms. The medical evidence of record consistently notes that the Veteran has been oriented to person, time, and place. Furthermore, he has consistently been described as being able to handle his own finances. Although the Veteran has difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, and intermittent suicidal thoughts, the weight of the evidence shows that his PTSD does not cause total occupational and social impairment, warranting an increased rating to 100 percent for the period on appeal from July 1, 2019. In short, for the period on appeal from July 1, 2019, the Veteran’s PTSD symptoms cause occupational and social impairment in most areas, as contemplated by the 70 percent rating currently assigned. For these reasons, the benefit sought on appeal is denied. 4. Entitlement to a compensable rating for erectile dysfunction The Veteran contends that his erectile dysfunction warrants a compensable rating. The Veteran’s erectile dysfunction is currently rated under 38 C.F.R. § 4.115b, DC 7522. Under that diagnostic code, deformity of the penis with loss of erectile power warrants a 20 percent rating. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The Veteran had an examination for male reproductive system conditions in August 2017. The Veteran reported taking continuous medication for his condition. The examiner specifically noted that the Veteran was unable to achieve an erection sufficient for penetration and ejaculation without medication but was able to perform with medication. The examiner noted that the Veteran’s penis and testes were normal. At the February 2021 Board hearing, the Veteran testified that he had to change medications since his initial grant of service connection for erectile dysfunction because the medications he was taking were not working. The Board finds that the August 2017 examination is adequate for adjudication purposes. In that regard, the examiner accurately documented and discussed all the relevant findings pertaining to the Veteran’s erectile dysfunction. As the examination is adequate, the Board assigns it great probative weight. The Board acknowledges the February 2021 testimony from the Veteran that his erectile dysfunction currently requires new medication because his previous treatment was ineffective. However, the Veteran has not alleged, and the evidence does not otherwise indicate, that he has deformity of his penis. Rather, the Veteran has argued that his inability to achieve an erection and orgasm without medication should be compensated at a higher rate. At no point has the Veteran reported a deformity. As such, the Board finds that a remand for a new examination is not warranted at this time. The Board finds that the Veteran is not entitled to a compensable rating for erectile dysfunction. In this regard, there is no indication from the record that the Veteran has deformity of the penis. The Veteran has never asserted, either expressly or implicitly, that his penis has a deformity, and the August 2017 examination specifically noted that the Veteran’s penis and testes were normal. As such, a compensable rating is not warranted. 38 C.F.R. § 4.115b, DC 7522. The Board notes that despite the zero percent rating, the Veteran does in fact receive compensation because of this service-connected disability – namely special monthly compensation due to the loss of use of a creative organ. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to a compensable rating for erectile dysfunction is not warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for obstructive sleep apnea The Veteran claims that service connection is warranted for his obstructive sleep apnea disability. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). There is conflicting medical evidence of record regarding whether the Veteran has a current diagnosis of obstructive sleep apnea. In a polysomnography report from October 2016 noted in the Veteran’s service treatment records, he was diagnosed with “primary snoring”. Service treatment records from November 2016 note a provisional diagnosis of sleep apnea. The Veteran had an examination for his sleep apnea condition in August 2017. The examiner stated that the Veteran did not have a diagnosis of sleep apnea. The examiner noted that the Veteran’s sleep study resulted in a diagnosis of primary snoring. In June 2018, the Veteran had an additional sleep study. VA treatment records note an impression of no significant obstructive sleep apnea with no desaturation and that the Veteran had a snoring disorder. VA treatment records from April 2019 note an impression of no significant obstructive sleep apnea with no desaturation. However, an additional VA treatment record from April 2019 noted an assessment of obstructive sleep apnea. VA treatment records from August 2019 note a sleep study that resulted in an AHI of 5.19 and oxygen saturation nadir of 88 percent. VA treatment records from September 2019 noted that the June 2018 sleep study showed a baseline AHI of 12. The Veteran had a provisional diagnosis of sleep apnea, unspecified. In a letter from February 2021, Dr. R.M. stated that the Veteran’s June 2018 sleep study showed a baseline AHI of 12 and that the Veteran was provided a CPAP. Dr. R.M. further stated that according to the American Academy of Sleep Medicine, an AHI score of 5 to 14.9 indicates mild sleep apnea. Furthermore, Dr. R.M. noted that an August 2019 sleep study resulted in an AHI score indicative of mild sleep apnea. The Board finds that the Veteran has a current obstructive sleep apnea disability. Pursuant to the “benefit-of-the-doubt” rule, where there is “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. 38 U.S.C. § 5107. Here, the Board finds that the aforementioned evidence is sufficient to place the relevant evidence, at a minimum, in a state of equipoise as to whether the Veteran has a current obstructive sleep apnea disability. The Veteran’s service treatment records note a provisional diagnosis of sleep apnea. The Veteran’s service treatment records also note treatment for snoring and a documented history of stopping breathing while sleeping. Service treatment records also note that the Veteran reported that his wife has woken him up due to him gagging for air, as well as constant somnolence during the day, and waking up during the night feeling like he is choking. Additionally, the Veteran testified at his February 2021 Board hearing that he had sleeping issues during service, such as waking up gasping for air, feeling like he could not breathe, and fatigue during the day. The Board finds the Veteran’s lay statements competent and credible. Accordingly, the second Shedden element has been demonstrated. As the record contains evidence of a current disability, and evidence of an in-service injury or disease, what remains to be established is whether there is a nexus between the diagnosed sleep apnea and his in-service description of symptoms. In this case, the record includes a February 2021 letter from Dr. R.M., regarding the Veteran’s sleep apnea condition. In the letter, Dr. R.M. opines that it is at least as likely than not that the Veteran’s sleep apnea began during his active military service and has continued to the present day. Dr. R.M. noted that the Veteran suffered from snoring and breathing problems while sleeping during service, and that it is likely that these were the beginning symptoms of obstructive sleep apnea. Dr. R.M. further noted that while the October 2016 sleep study diagnosed the Veteran with primary snoring, the Veteran’s diagnosis of sleep apnea soon after separation from service indicates that it is more likely he was suffering from the beginning stages of sleep apnea in service. The Board finds that the probative evidence of record indicates that the Veteran’s sleep apnea is related to his service. Specifically, the Board finds the February 2021 opinion of Dr. R.M. to carry significant probative weight. The Board finds Dr. R.M.’s opinion to be highly probative because it provided a detailed rationale based on the Veteran’s sleep study, lay statements, and medical history. Furthermore, there are no medical opinions of record that contradict the positive nexus opinion from Dr. R.M. relating the Veteran’s sleep apnea to service. As a result, the probative evidence of record indicates that the Veteran’s sleep apnea had its onset during his active service and has continued ever since. The Board therefore concludes that the probative evidence of record indicates that sleep apnea had its onset during his period of active duty and has continued ever since. Accordingly, service connection for sleep apnea is warranted. The appeal is granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 6. Entitlement to a TDIU The Veteran claims he is entitled to a TDIU, asserting his service-connected disabilities make him unemployable. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” See 38 C.F.R. §§ 3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). The central inquiry is, “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is not whether the Veteran can find employment generally, but whether the Veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board notes that the Veteran meets the statutory criteria for a TDIU for the entire period on appeal. The Veteran’s service-connected disabilities included: PTSD (70 percent disabling per the Board’s decision, with the exception of a temporary 100 percent rating from May 6, 2019 to July 1, 2019); left shoulder acromioclavicular joint osteoarthritis (20 percent); right shoulder labral tear (20 percent); left and right elbow olecranon spurs (both 10 percent); lumbar spondylosis (10 percent); left and right knee tendinopathy (both 10 percent); bilateral pes cavus (10 percent); tinnitus (10 percent); and bilateral pinguecula, left ear hearing loss, hypertension, and erectile dysfunction (all noncompensable). Additionally, the Board has granted entitlement to service connection for obstructive sleep apnea in this decision. The Veteran competed a VA form 21-8940 in February 2021. The Veteran indicated that he last worked full-time in November 2018. The Veteran reported that he worked for one-week ad an operation manager in June 2018. Additionally, the Veteran reported last working as a regional manager from July 2018 to November 2018. The Veteran reported that he attended college. Furthermore, the Veteran stated that he tried to return to work after his military service but was never successful. The Veteran had an examination for his PTSD in August 2017. The Veteran reported that functioning as the logistics officer for his brigade as well as being responsible for his own company. The Veteran had an examination for his lumbar spine disability in August 2017. The examiner noted that the Veteran’s back condition impacted his ability to work. Specifically, the examiner noted the Veteran would have difficulty with squatting, performing sit ups, stretching exercises, jumping, running, lifting, and repetitive bending. Additionally, the Veteran also had an examination for his bilateral foot disability in August 2017. The examiner noted that the Veteran’s bilateral foot disability impacted his ability to work. The examiner noted that the Veteran’s bilateral foot disability was aggravated by prolong walking and prolong standing. The examiner further noted that the Veteran has to stop and rest for a period of time and discontinue any physical activity due to pain. Additionally, the Veteran had examinations for his bilateral knee and bilateral shoulder disabilities in August 2017. The examiners noted that the Veteran’s bilateral knee and bilateral shoulder disabilities impacted his ability to work. The examiner noted that the Veteran’s bilateral knee disabilities would be aggravated by prolonged standing, walking, running, jumping, kneeling, crouching and climbing stairs. Additionally, the examiner noted that extending the knees is painful. The examiner noted that the Veteran’s bilateral shoulder disabilities would be aggravated by overhead activities, weight bearing, push-ups, pulling and pushing, holding weight down, and reaching up over shoulder level. The Veteran had another examination for his PTSD in August 2019. The Veteran reported that since getting out of the military, he has only had one job. Specifically, in June of 2018 he had a position for three months as a regional manager for a logistics firm. The Veteran reported that while traveling with a project manager he lost his temper with him becoming verbally aggressive and offensive. As a result, the company changed the terms of his contract and made continuing to work for this company unappealing to him, and he did not sign an agreement to continue his work with the company and has not worked in any jobs since that job. The Veteran reported that he worries about his ability not to lose his temper on the job. The Veteran exhibited PTSD symptoms including depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. At the February 2021 Board hearing, the Veteran testified that he made efforts to try to work after separation from service, but ultimately was unsuccessful. Specifically, the Veteran testified that he had difficulty communicating with his co-workers, that he had issues with his memory, and that he was anxious and depressed. The Veteran also testified that he had anger and behavioral control issues, which affected his ability maintain employment. The Veteran further testified that his chronic pain from his service-connected disabilities affected his ability to work. In a February 2021 letter, Dr. R.M. stated that the Veteran has poor behavior controls, unmodulated anger, volatility, and cannot tolerate being around other people and cannot tolerate stress. Dr. R.M. stated that the Veteran is at risk of becoming verbally aggressive with others and that his concentration levels would be severely impaired as a result of his PTSD. Dr. R.M. indicated that the Veteran’s psychological symptoms would result in him being off task at least 25 percent of a typical workday and/or missing more than four workdays per month. Dr. R.M. opined that the Veteran would have a significant problem obtaining full-time work of any type. The Veteran had another examination for his PTSD in March 2021. The Veteran reported that he was not currently working. He further reported that he was anxious and hypervigilant at work and could not focus. The Veteran exhibited symptoms including depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; and inability to establish and maintain effective relationships. The examiner noted that the Veteran has difficulty attending to or is easily distracted from the task at hand, and difficulty maintaining concentration and focus on work over a period of time, tends to skip from one task to another without completing the prior task. Additionally, the examiner noted that the Veteran’s sleep is so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult. Furthermore, the examiner stated that the Veteran is so depressed that he has difficulty sustaining energy and motivation to complete assignments at work. Given the totality of the record, the Board finds that the evidence is at least in equipoise that the Veteran’s service-connected disabilities render him unemployable. The Veteran’s service-connected diabetes render him unable to do physical labor for extended periods of time and limit his mobility. The Veteran’s service-connected back, bilateral shoulder, bilateral knee, and bilateral foot disabilities significantly limit his mobility. Furthermore, the Veteran’s PTSD likely makes him unable to work well with others and secure and maintain sedentary employment. The Veteran’s PTSD symptoms of anxiety, suspiciousness, and chronic sleep impairment likely hinder his ability to concentrate and otherwise function in an office setting. The Veteran also has difficulty in maintaining effective work relationships and adapting to stressful circumstances, which would likely prevent him from working well with others in a sedentary work environment. Although the Veteran is well educated and likely possesses transferable skills, his limited ability to adapt to stressful situations and work well with others, as well as his limited ability to engage in physical labor, render him unable to successfully secure and maintain substantially gainful employment. In short, the Board finds that the Veteran’s disabilities render him unemployable. Because the Veteran is unemployable due to his service-connected disabilities, he is entitled to a TDIU. Thus, the claim is granted. REASONS FOR REMAND 1. & 2. Entitlement to a disability rating in excess of 10 percent for right and left elbow disabilities is remanded. The Veteran contends that his current service-connected right and left elbow disabilities warrant an increased rating. The Veteran most recently underwent an examination related to his service-connected right and left elbow disabilities in August 2017. In his February 2021 testimony before the Board, the Veteran asserted that the range of motion in his elbows has worsened since he was last examined. Additionally, the Veteran reported increased pain in both of his elbows. Since the August 2017 examination findings appear to not be representative of the current severity of the right and left elbow disabilities on appeal, the claim must be remanded as a new VA examination is warranted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 3. & 4. Entitlement to a disability rating in excess of 10 percent for right and left knee disabilities is remanded. The Veteran contends that his current service-connected right and left knee disabilities warrant an increased rating. The Veteran most recently underwent an examination related to his service-connected right and left knee disabilities in August 2017. In his February 2021 testimony before the Board, the Veteran asserted his bilateral knee disabilities have worsened since he was last examined. Specifically, the Veteran reported experiencing locking and significant instability of his right and left knee disabilities. Since the August 2017 examination findings appear to not be representative of the current severity of the right and left knee disabilities on appeal, the claim must be remanded as a new VA examination is warranted. See id. 5. Entitlement to a disability rating in excess of 10 percent for service-connected bilateral pes cavus is remanded. The Veteran contends that his current service-connected bilateral pes cavus disability warrants an increased rating. The Veteran most recently underwent an examination related to his service-connected bilateral pes cavus disability in August 2017. In his February 2021 testimony before the Board, the Veteran asserted his bilateral pes cavus disability worsened since he was last examined. Specifically, the Veteran reported experiencing sharp pains in the arches of his feet if he stands or walks for an extended period. Since the August 2017 examination findings appear to not be representative of the current severity of the Veteran’s service-connected bilateral pes cavus disability on appeal, the claim must be remanded as a new VA examination is warranted. See id. 6. Entitlement to a disability rating in excess of 10 percent for a back disability is remanded. The Veteran contends that his current service-connected back disability warrants an increased rating. The Veteran most recently underwent an examination related to his service-connected back disability in August 2017. In his February 2021 testimony before the Board, the Veteran asserted his back disability has worsened since he was last examined. Specifically, the Veteran reported experiencing increased pain that radiates into his lower extremities. Additionally, the Veteran contends that his examination in August 2017 did not fully consider his claimed radiculopathy. Since the August 2017 examination findings appear to not be representative of the current severity of the Veteran’s service-connected back disability on appeal, the claim must be remanded as a new VA examination is warranted. See id. 7. Entitlement to a compensable disability rating for hypertension is remanded. The Veteran contends that his current service-connected hypertension disability warrants an increased rating. The Veteran most recently underwent an examination related to his service-connected hypertension disability in August 2017. In his February 2021 testimony before the Board, the Veteran asserted his hypertension disability has worsened since he was last examined. Specifically, the Veteran reported that he recently switched hypertension medications due to increased blood pressure readings. Since the August 2017 examination findings appear to not be representative of the current severity of the Veteran’s service-connected hypertension disability on appeal, the claim must be remanded as a new VA examination is warranted. See id. 8. Entitlement to a compensable disability rating for left ear hearing loss is remanded. The Veteran contends that his current service-connected left ear hearing loss warrants an increased rating. The Veteran most recently underwent an examination related to his service-connected left ear hearing loss in August 2017. In his February 2021 testimony before the Board, the Veteran asserted his left ear hearing loss disability has worsened since he was last examined. Since the August 2017 examination findings appear to not be representative of the current severity of the Veteran’s service-connected left ear hearing loss on appeal, the claim must be remanded as a new VA examination is warranted. See id. 9. Entitlement to service connection for a right ear hearing loss disability is remanded. The Board observes that the record shows that the Veteran has left ear hearing loss disability; however, the record does not show that he has a right ear hearing loss disability under the criteria listed under 38 C.F.R. § 3.385. Given the length of time since the Veteran’s last audiological examination and the Veteran’s credible reports of worsening hearing acuity over time, the Board is of the opinion that a new examination should be conducted to ascertain whether the Veteran’s hearing acuity in the right ear meets the regulatory criteria for a hearing loss disability and, if so, whether such disability is related to in-service noise exposure. The matters are REMANDED for the following action: (Please note, this appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right and left elbow disabilities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. The examiner should discuss whether there is any medical reason to accept or reject the lay descriptions of functional impairment on repetitive use or during flares. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right and left knee disabilities, to include whether separate ratings based on instability are warranted. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. The examiner should discuss whether there is any medical reason to accept or reject the lay descriptions of functional impairment on repetitive use or during flares. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral pes cavus disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. The examiner should discuss whether there is any medical reason to accept or reject the lay descriptions of functional impairment on repetitive use or during flares. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected back disability, to include whether separate ratings based on radiculopathy are warranted. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. The examiner should discuss whether there is any medical reason to accept or reject the lay descriptions of functional impairment on repetitive use or during flares. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hypertension. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 6. Schedule the Veteran for a VA audiological examination to determine the current severity of his hearing loss disability. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the Veteran’s hearing loss disability should be reported. The examiner should respond to the following: (a) Clarify whether the Veteran has a hearing loss disability for VA purposes in the right ear. (b) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the current right ear hearing loss is a result of military service, to include as a result of in-service acoustic trauma. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner should note that the lack of diagnosed hearing loss in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, Associate 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.