Citation Nr: 21023878 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 20-06 268 DATE: April 21, 2021 ORDER Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a gastrointestinal disorder is denied. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a skin condition of the hands and feet is denied. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability is granted. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for bilateral hearing loss (BHL) is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for allergic rhinitis is denied. Entitlement to service connection for chronic fatigue syndrome (CFS) is denied. Entitlement to service connection for a liver condition is denied. A rating reduction from 20 percent to 10 percent for lumbar spine degenerative disc disease (DDD) was improper; the 20 percent rating is restored. Entitlement to an initial compensable rating for service-connected bilateral ingrown toenails is denied. Entitlement to a rating in excess of 10 percent disabling for service-connected right lower extremity (RLE) radiculopathy is denied. Entitlement to an initial rating of 10 percent, but no higher, for migraine headaches is granted. REMANDED Entitlement to service connection for obstructive sleep apnea as secondary to obesity and service-connected lumbar spine disability is remanded. Entitlement to service connection for chronic sinusitis is remanded. Entitlement to a rating in excess of 10 percent disabling for service-connected cervical spine disability is remanded. Entitlement to rating in excess of 20 percent disabling for service-connected lumbar spine DDD is remanded. Entitlement to a compensable rating for service-connected costochondritis claimed as pectoral popping is remanded. FINDINGS OF FACT 1. In an unappealed decision, dated February 2014, the AOJ denied claims of service connection for a gastrointestinal disorder, a skin condition of the hands and feet, and a right knee disability, among other issues. 2. Evidence associated with the claims file after the February 2014 rating decision is cumulative, redundant and fails to raise a reasonable possibility of substantiating the claims of a gastrointestinal disorder and skin condition. 3. Evidence associated with the claims file after the February 2014 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the claim of service connection for a right knee disability. 4. In an October 2018 decision, the Board denied the claim of entitlement to service connection for OSA. 5. Evidence associated with the claims file after the October 2018 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the claim of service connection for OSA. 6. The preponderance of the evidence is against finding that the Veteran’s right knee disability began during active service or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence of record is against finding that the Veteran has had bilateral hearing loss at any time during or approximate to the pendency of the claim. 8. The preponderance of the evidence of record is against finding that the Veteran has had bilateral recurrent tinnitus at any time during or approximate to the pendency of the claim. 9. The preponderance of the evidence is against finding that the Veteran’s allergic rhinitis began during active service or is otherwise related to an in-service injury or disease. 10. The preponderance of the evidence of record is against finding that the Veteran has had CFS at any time during or approximate to the pendency of the claim 11. Fatty liver is not a disability for VA compensation purposes. The preponderance of the evidence is against finding that the Veteran’s hepatic steatosis began during active service or is otherwise related to an in-service injury or disease. 12. The reduction in rating for the Veteran’s lumbar spine disability, from 20 percent to 10 percent, effective January 22, 2016, was improper. 13. The Veteran’s bilateral ingrown toenails affected less than five percent of the entire body, none of the Veteran’s exposed areas, and required no more than topical therapy during the past twelve-month period. 14. The Veteran’s RLE radiculopathy manifested as mild incomplete paralysis of the sciatic nerve. 15. The evidence of record is at least evenly balanced as to whether the Veteran’s migraine headache symptomatology more nearly approximates prostrating attacks averaging one in two months. CONCLUSIONS OF LAW 1. The February 2014 rating decision that denied entitlement to service connection for a gastrointestinal disorder, skin condition of the hands and feet, and a right knee disability was final. 38 U.S.C. § 7105 (c) (2012); 38 C.F.R. §§ 19.52, 20.1103 (2019). 2. New and material evidence has not been received since the February 2014 rating decision, thus the claims seeking service connection for a gastrointestinal disorder and skin condition of the hands and feet are not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2019). 3. New and material evidence has been received since the February 2014 rating decision, thus the claim of service connection for a right knee disability is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2019). 4. The October 2018 Board decision, which denied the claim of entitlement to service connection for OSA was final. 38 U.S.C. §§ 511, 7103 (a), 7104 (a) (2012); 38 C.F.R. § 20.1100 (2019). 5. Evidence received since the October 2018 Board decision is new and material; thus, the claim of entitlement to service connection for OSA is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2019). 6. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 7. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 8. The criteria for service connection for bilateral recurrent tinnitus have not been met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 9. The criteria for service connection for allergic rhinitis are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 10. The criteria for service connection for chronic fatigue syndrome (CFS) have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 11. The criteria for service connection for a liver condition have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 12. The rating reduction for a lumbar spine disability, from 20 percent to 10 percent was not proper. 38 U.S.C. § 1155, 5107, 5112 (2012); 38 C.F.R. § 3.105, 4.71a, Diagnostic Code (DC) 5243 (2019). 13. The criteria for an initial compensable disability rating for bilateral ingrown toenails have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7806 (2019). 14. The criteria for a disability rating in excess of 10 percent for RLE radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520 (2019). 15. An initial rating of 10 percent but no higher, for migraine headaches have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8100 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Navy from April 1999 to April 2004, with service in the Southwest Asia theater of operations. This case comes before the Board on appeal of rating decisions from August 2016, July 2017, June 2018, and November 2018. Generally, the propriety of a rating reduction is a separate issue from a claim for an increased evaluation. Where the AOJ processes the appeal of a reduction as if it were an increased rating claim, the Board waives any jurisdictional or procedural barriers to consideration of that claim. See Dofflemeyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992); see also Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991) (“This is a rating reduction case, not a rating increase case.”); see also Percy v. Shinseki, 23 Vet. App. 37, 46 (2009). Here, the AOJ processed the appeal of the August 2016 reduction as both a challenge of the reduction and an increased rating claim. The August 2016 rating decision and January 2020 statement of the case (SOC) not only reduced the Veteran’s rating from 20 percent to 10 percent, it explained why the Veteran was not entitled to a higher rating of 20 percent. Accordingly, because the AOJ treated the Veteran’s claim as challenging both the reduction of his rating and the assignment of the current 20 percent rating, the AOJ has led the Veteran to believe that both of those issues are on appeal, and has therefore taken jurisdiction over the issue of increased rating for the Veteran’s lumbar spine disability in addition to the rating reduction. See Percy, 23 Vet. App. 37, 46. The Board notes that the Veteran’s attorney submitted June 2020 argument in support of the currently appealed claims in which he challenged the adequacy of VA examinations conducted during the appeal period. In advancing this argument, the Veteran appears to be raising a general challenge to the professional competence of the VA examiner(s) who conducted the examinations. For example, the Veteran’s attorney indicates the examiner, a nurse practitioner, is not noted to have specialized training or experience in psychiatry or otolaryngology. However, the Board sees no reason why a specialist is required for any opinion in this case to be adequate. Again, the examiner is a nurse practitioner. That means the examiner has medical training and experience such that the examiner is competent to offer medical opinions. The examiner was directed to review the pertinent history. There is no evidence to indicate that the examiner did not review the pertinent history or that the examiner reviewed the incorrect history. The examiner need not specifically reference every piece of evidence that was reviewed. Based on the summary provided, the Board decides that the examiner has obtained the pertinent medical history during the examination and through review of the file. The Board ultimately decides that the VA examiner is competent to render the proffered opinions. New and Material Evidence Generally, a claim that has been denied in a final unappealed RO decision may not be reopened and re-adjudicated. 38 U.S.C. § 7105(c) (2012). Similarly, a Board decision is final unless the Chairman of the Board orders reconsideration. See 38 U.S.C. §§ 7103 (a), 7104; 38 C.F.R. § 20.1100 (a). An exception to that rule is that if new and material evidence is presented or secured with respect to a claim, which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108 (2012). A claim may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered “new” if it was not previously submitted to agency decision makers. “Material” evidence is 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). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the “credibility” of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156 (a) creates a low threshold for finding new and material evidence and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a gastrointestinal disorder and a skin condition of the hands and feet At the outset, the February 2014 rating decision, which among other issues, denied the Veteran’s claims of service connection for a gastrointestinal (GI) disorder, skin condition and right knee disability, was final. The Veteran received notification of the rating decision in February 2014, but only appealed the denial of his claim for OSA. Thus, the rating decision became final in regard to the claims for a GI disorder, skin condition and right knee disability. At the time of the February 2014 rating decision, the evidence of record consisted of the Veteran’s service treatment records (STRs), VA outpatient treatment records, VA examinations from January 2014, private treatment records, and the Veteran’s contentions. In the February 2014 rating decision, the AOJ explained that the Veteran’s STRs were silent for complaints, treatment, or a diagnosis of a GI disorder. Similarly, the AOJ stated that the STRs did not contain complaints, treatment, or a diagnosis for a skin condition of the hands and feet. Thus, both claims were denied. The Board notes that the Veteran underwent a VA examination in January 2014. The examination showed that the Veteran had eczematous/psoriasis but the tinea pedis and contact dermatitis that was assessed during service had resolved. At that time, the Veteran had dry flaky skin rash on his palms and soles of his feet. However, the examiner remarked that the Veteran’s current skin condition was not related to his rash in service, as his current skin condition was not diagnosed in service. Additionally, in the esophageal examination, it was shown that the Veteran had a hiatal hernia with Barrett’s esophagus based on an esophagogastroduodenoscopy (EGD) from September 2012. Since the February 2014 rating decision, the evidence associated with the claims file is cumulative, redundant and fails to raise a reasonable possibility of substantiating the claims on appeal. Specifically, VA treatment records from 2016 showed the Veteran had a rash of his hands and feet, but more recent treatment records were negative for rashes or any other skin condition of his hands and feet. At the time of the February 2014 rating decision, there was evidence that the Veteran had dry flaky skin on his hands and feet. Therefore, the evidence of record after the February 2014 rating decision is cumulative and redundant. Moreover, the evidence is not material, as there is no indication that the Veteran’s skin condition is related to active duty service. Similarly, regarding the Veteran’s GI disorder, the evidence since February 2014 shows that the Veteran has gastroesophageal reflux disease (GERD) with hiatal hernia. Yet, this evidence is cumulative and redundant of the evidence before the AOJ in February 2014. At that time, there was evidence of a hiatal hernia with Barrett’s esophagus. Moreover, the evidence of record after February 2014 is not material as there is no indication that the Veteran’s GERD began or was incurred during active duty service. The Board acknowledges the Veteran’s contentions that his GERD began during active duty service due to the foods he consumed. However, the Veteran’s STRs were silent for any complaints, treatment, or a diagnosis of a GI disorder. In fact, his condition was diagnosed first in 2012. See VA treatment records. Moreover, although the Veteran is competent to report on lay observable symptoms, his GI disorder was determined using diagnostic testing by a medical specialist. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Based on the foregoing, the Board finds that new and material evidence has not been received to reopen the claims of service connection for a GI disorder and skin condition. Accordingly, as the evidence received following the February 2014 rating decision is neither new nor material, the Veteran’s claims of service connection for a GI disorder and skin condition are not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability As discussed above, the February 2014 rating decision was final as to the issue of a right knee disability. The AOJ explained that the Veteran’s STRs did not contain complaints, treatment, or a diagnosis for a right knee disability. Thus, the claim was denied. However, since the February 2014 rating decision, the Veteran underwent a VA examination in October 2018. On the examination, the Veteran was diagnosed with a right knee strain. The Veteran reported that his right knee condition was incurred during active duty when he slipped on the deck of a naval ship. He explained that he heard a loud pop and his knee hurt ever since. He reported ongoing pain and swelling. On examination, the Veteran had abnormal range of motion (ROM) on flexion and extension. After conducting the examination, the examiner explained that the Veteran was treated and diagnosed with right knee patellofemoral syndrome (PFS) during service and rendered a medical opinion on whether the Veteran’s in-service treatment and diagnosis of right knee PFS was related to his current right knee strain. Based on the foregoing, the Board finds that the October 2018 VA examination and opinion are new and material. The examination is “new” as it was not before the AOJ during the February 2014 rating decision. Likewise, it is not cumulative or redundant of the evidence at the time of the February 2014 rating decision. Moreover, the opinion is “material,” as it relates to an unestablished fact necessary to substantiate the claim on appeal. Specifically, that the Veteran was treated for and assessed with right knee PFS during service. Moreover, the Board notes that the language of 38 C.F.R. § 3.156 (a) creates a low threshold for finding new and material evidence and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Accordingly, as the evidence received following the February 2014 rating decision is new and material, the Veteran’s claim of service connection for a right knee disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for obstructive sleep apnea (OSA) Here, the October 2018 Board decision, which denied the Veteran’s claim of service connection for OSA was final. Generally, all Board decisions are final on the date stamped on the face of the decision, unless reconsideration is ordered. See 38 C.F.R. § 20.1100. At the time of the October 2018 decision, the evidence of record consisted of the Veteran’s STRs, personnel records, VA outpatient treatment records, private treatment records, VA examinations, and the Veteran’s contentions. In the decision, the Board explained that there was little evidence in the Veteran’s STRs that reflected signs or symptoms of obstructive sleep apnea. Additionally, the first documented complaints of tiredness and fatigue were in VA treatment records from October 2010, where the Veteran reported only a two-month history of those symptoms. The Board found that the preponderance of evidence was against finding that the Veteran’s OSA had its onset during active service. However, since the October 2018 decision, the evidence associated with the record is new and material as it relates to the claim of OSA. Specifically, the Veteran contended that his OSA was caused by obesity, which in turn was caused or aggravated by his lumbar spine disability. In his claim to reopen, the Veteran asserted that his OSA was secondary to medications, depression, and obesity (due to his lumbar spine condition). First, in an October 2018 VA medical opinion, the examiner opined that the Veteran’s sleep apnea was not proximately due to or the result of medications for his service-connected conditions. Likewise, in a November 2019 VA medical opinion, another examiner opined that the Veteran’s OSA was less likely than not due to or a result of his service-connected psychiatric disorder. The examiner reasoned that the two conditions are not medically related. The OSA is a separate entity entirely from the service-connected condition and unrelated to it. The examiner added that the medical literature did not support a medical relationship, thus a nexus has not been established. The Board finds that both medical opinions are inadequate as they fail to consider aggravation. Specifically, an opinion on secondary service connection requires a discussion on causation and/or aggravation. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. Moreover, a recent decision of the United States Court of Appeals for Veterans Claims (Court) held that while obesity is not itself recognized as a disability, it may be recognized as an intermediate step between a service-connected disability and a disability claimed as secondary to that service-connected disability, based on the service-connected disability causing or aggravating the obesity. Walsh v. Wilkie, No. 18-0495, 2020 U.S. App. Vet. Claims LEXIS 295, at 12-13 (Vet. App. Feb. 24, 2020). In this case, the Veteran’s contends that his obesity is at least aggravated by his inability to exercise due to his service-connected lumbar spine disability. Likewise, VA treatment records showed that the Veteran was advised to diet to treat his obesity, but he was unable to exercise due to his back pain. As discussed above, evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). Given the foregoing, the Board finds that new and material evidence has been received to reopen the claim of service connection for OSA. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Service Connection Generally, to establish service connection a Veteran must show: “(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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted through the application of statutory presumptions for chronic conditions, which includes hypertension, sensorineural hearing loss and tinnitus. See 38 C.F.R. §§ 3.303 (b), 3.309 (a) (2019); see also 38 U.S.C. §§ 1112, 1137 (2012). First, a claimant may benefit from a presumption of service connection where a chronic disease has been shown during service. 38 C.F.R. § 3.303 (b). In the alternative, if a chronic disease was not shown in service, but manifested to a degree of 10 percent or more within some specified time after separation from active service, such disease shall be presumed to have been incurred or aggravated in service, even if there is no evidence of such disease during service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. § 3.307 (a)(3) (2019). The application of these presumptions operates to satisfy the “in-service incurrence or aggravation” element and establish a nexus between service and a present disability, which must be found before entitlement to service connection can be granted. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303 (b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in-service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifest either during active service in Southwest Asia during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1)(i). Service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of “qualifying chronic disability,” a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 U.S.C. § 1117. An “undiagnosed illness” is one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(ii). If signs or symptoms have been medically attributed to a diagnosed illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). The Persian Gulf War presumption is only available to Persian Gulf veterans who exhibit objective indications of a qualifying chronic disability, provided that such disability became manifest either during active military service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021; and such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(i)-(ii) (2019); see also 81 Fed. Reg. 71382 (October 17, 2016). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Likewise, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b) (2012). 4. Entitlement to service connection for a right knee disability. Here, the Veteran contends that his right knee disability had its onset during active duty. Based on a preponderance of evidence, the Board disagrees. At the outset, the Veteran has a current diagnosis of a right knee strain. He also had a diagnosis of right knee patella tendinitis. See January 2014 VA examination ; October 2018 VA examination. Thus, the first element of service connection is met. Likewise, the second element is met. Specifically, in August 2003, the Veteran was assessed with right knee PFS. He reported to the clinic complaining of non-traumatic right knee pain for the prior two weeks. He had full ROM but exhibited pain. He was assessed with right knee PFS, which was continued in a September 2003 treatment record when he again reported right knee pain. Therefore, to warrant service connection, the third element requires a nexus or link between his in-service treatment and assessment of right knee PFS and his current right knee disability, which is generally proven by medical evidence. In that regard, in January 2014 VA examination, the Veteran was diagnosed with right knee patella tendonitis and right knee pain. The Veteran reported that he had right knee pain since service and claimed that it bothered him to use the vertical stairs onboard the ship. He reported a twisting injury onboard the ship. On examination, the Veteran had some limitation of motion, pain on movement, but normal stability tests. Additionally, x-rays did not show an acute fracture, dislocation, or degenerative changes. The examiner opined that the Veteran’s knee disability was less likely than not incurred in or caused by the claimed in-service event. He reasoned that the Veteran’s knee condition was not diagnosed in service. Then, in the October 2018 VA examination, the Veteran was diagnosed with a right knee strain. No other right knee diagnoses were identified. The Veteran reported that his condition started in service when his slipped on the deck of the naval ship. He explained that his right knee hurt even since then. On examination, the he had limited ROM in his right knee with objective evidence of pain. The examiner opined that the right knee disability had a clear diagnosis and etiology and thus was not part of an undiagnosed illness or MUCMI. The examiner continued that the right knee was less likely than not incurred in service as there was no chronicity to the right knee condition in service. The examiner noted that the Veteran had PFS in service, but there were no records to indicate a chronic condition. He explained that medical literature supported that PFS was a resolvable condition with proper treatment. He added that post-service treatment records were silent for a chronic right knee condition or complaints with a treatment plan. The examiner stated that the Veteran’s right knee pain was most likely related to his chronic obesity. The examiner showed that the Veteran had his diagnosis of right knee PFS in September 2003, but the earliest record of right knee pain post-service was in April 2007 and June 2007. The examiner also provided medical literature that showed that PFS was resolvable in 75 to 85 percent of patients that were put on a program. Likewise, he detailed that obesity and pain have a complex interwoven relationship. The Board finds the October 2018 opinion to be competent, credible, and highly probative. The examiner evaluated the Veteran, accounted for his lay statements, and provided an opinion based on the medical evidence and literature. Conversely, the Board finds the opinion of January 2014 to be of little probative value as the examiner failed to provide an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). The Board acknowledges the Veteran’s contentions that he complained of right knee pain since service. The Veteran is competent to report on lay observable symptomology such as knee pain. However, the lack of medical evidence showing chronicity of a right knee condition since service preponderates against his claims. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994). As discussed above, the earliest record of knee pain after service was in 2007, then again in November 2013 and January 2014. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 5. Entitlement to service connection for BHL and tinnitus. Here, the Veteran filed a claim for bilateral hearing loss and recurrent tinnitus. However, there is no evidence of hearing loss for VA purposes or recurrent tinnitus. Specifically, the Veteran’s treatment records routinely showed that the Veteran denied hearing loss and there was no indication of hearing loss on ENT review. In only one instance, in a January 2017 colorectal surgery consult did it show that the Veteran was positive for decreased hearing. Yet, there was no diagnosis of a hearing disorder and review of his ENT was normal. In fact, several treatment records subsequent to the January 2017 record showed no hearing loss. Moreover, current treatment records fail to show any hearing disorder. Additionally, there is no report of tinnitus in the Veteran’s treatment records. In fact, in the lone treatment record that mentioned tinnitus from June 2018, the Veteran denied having it. The Board notes that where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 6. Entitlement to service connection for allergic rhinitis Here, the Veteran contends that his allergic rhinitis was incurred in service. Based on the evidence, the Board disagrees. At the outset, the Veteran has a current diagnosis of allergic rhinitis. See October 2018 VA examination. Thus, the first element is met. Likewise, the second element is met. Although the Veteran’s STRs are silent for any complaints, treatment, or a diagnosis of allergic rhinitis. His STRs showed that he was treated for upper respiratory infections (URIs) on a couple of occasions during service. Likewise, the Veteran reported that his symptoms began in 1999 with nasal congestion and nasal discharge. The Board finds that the Veteran is competent to report on lay observable symptoms such as nasal congestion and discharge; thus, his statements are competent, credible, and of significant probative value. Therefore, to warrant service connection, there must be evidence of a nexus or link between the Veteran’s in-service URIs and his current diagnosis of allergic rhinitis. In that regard, in the September 2018 VA examination, the Veteran explained that his rhinitis began in service with nasal congestion and discharge. After discharge from service, the Veteran reported treatment with antibiotics and the use of Flonase nasal spray. He stated that he was informed he had allergies as well. He remarked that his condition had worsened with increasing symptoms of congestion. On examination, the examiner indicated that the Veteran had rhinitis, but indicated that there was not greater than 50 percent obstruction of the nasal passage on both side, or complete obstruction on either side. Likewise, there were no permanent hypertrophy of the nasal turbinates or nasal polyps. The examiner opined that the Veteran’s rhinitis was less likely than not incurred in or caused by active duty service. The examiner reasoned that his review of the Veteran’s history and medical history failed to suggest that his condition was caused by service. He explained that review of the medical records from service were silent for an evaluation, diagnosis, or treatment of rhinitis during active duty service. Then, an October 2018 VA examination, the Veteran’s diagnosis of allergic rhinitis was maintained. He reported that his rhinitis condition started on or about a few years back. He explained that he was an employee at Lake Nona where he was diagnosed with allergic rhinitis. The Veteran reviewed his military records and felt that the symptoms then were the same at the time of the examination. He reported the use of oral meds and sprays and felt that one nostril was clearer than the other. On examination, the examiner indicated that the Veteran had rhinitis, but indicated that there was not greater than 50 percent obstruction of the nasal passage on both side, or complete obstruction on either side. Likewise, there were no permanent hypertrophy of the nasal turbinates, nasal polyps, or granulomatous conditions. The examiner opined that the Veteran’s rhinitis was a clear diagnosis and the medical literature did not support that service in Southwest Asia caused allergic rhinitis. The examiner remarked that allergic rhinitis was worldwide condition not exclusive to service members in the Persian Gulf. He continued that the Veteran’s medical record indicated an acute sporadic sinusitis condition that resolved with conservative care. In a November 2018 addendum opinion, the examiner opined that the Veteran’s current allergic rhinitis was not caused or incurred in service. He explained that the Veteran’s condition was diagnosed in 2018, and it is not the same as acute URIs on duty. The examiner added that the Veteran’s acute URIs resolved on duty and did not meet the medical criteria for diagnosis of chronic sinusitis/rhinitis. Therefore, the examiner concluded that the Veteran’s current allergic rhinitis was less likely than not due to the sinus issues shown in service. The Board finds that the evidence of record is against finding that the Veteran’s allergic rhinitis was caused or incurred in service. The Veteran reported that his allergic rhinitis began a few years back during the October 2018 VA examination. The Board adds that the Veteran’s treatment record showed that allergic rhinitis was diagnosed in August 2018. Additionally, the medical opinion from October and November 2018 is competent, credible, and highly probative. The examiner evaluated the Veteran, reviewed the pertinent evidence, accounted for the Veteran’s lay statements, then provided an opinion based on the evidence and medical principles. The Board acknowledges the Veteran’s contention that his symptoms from service are similar to his current condition, but as explained by the examiner, the Veteran had sporadic acute URIs that resolved during service. His in-service condition is not related to his current allergic rhinitis. Furthermore, the September 2018 examiner’s opinion weighs against the Veteran’s claim. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 7. Entitlement to service connection for CFS. Here, the Veteran contends that he has CFS that was incurred in service to include as part of an undiagnosed illness or MUCMI. Based on the evidence, the Board disagrees. To begin, the Veteran does not have a diagnosed fatigue condition. In the October 2018 VA examination, the examiner indicated that the Veteran did not have nor had ever been diagnosed with chronic fatigue syndrome. The Veteran stated that his claimed fatigue condition started years ago. He reported that he was always tired, always fatigued. He added that he would walk a block which caused heavy breathing and feeling wiped out. The examiner indicated that there were signs or symptoms of CFS. The examiner opined that the Veteran’s claimed fatigue was less likely than not incurred in or caused by service to include as part of an undiagnosed illness or MUCMI. The examiner reasoned that the Veteran had a variety of medical illnesses/conditions which were causing him to experience numerous symptoms. He added that the medical conditions causing his symptoms are recognized clinical disease entities. The examiner continued that the Veteran did not meet the criteria for diagnosis of CFS. He explained that CFS is a diagnosis of exclusion and that the Veteran had multiple diagnoses that when taken into consideration (include age and obesity) account for his fatigue-like symptoms. Then, in the November 2019 VA examination, the Veteran reported fatigue symptoms started in service. He stated he was always tired with heavy lifting, gym, and little sleep. The Veteran remarked that his sleep became better when he received his CPAP. He explained that he uses it on maximum pressure due to constant fatigue. He reported daytime sleepiness. On examination, the examiner indicated that the Veteran did not have CFS or a fatigue disorder. The examiner remarked that the Veteran’s condition was subjective as there was no diagnosis of a fatigue condition. The examiner opined that the Veteran’s claimed fatigue was not related to his service-connected psychiatric disorder. She reasoned that the two conditions were not medically related. She stated that the claimed disorder was a separate entity entirely from the service-connected condition. She remarked that the medical literature did not support a medical relationship; thus, she concluded that no nexus had been established. The Board finds the examiner’s opinion to be competent, credible, and highly probative. The examiner reviewed the pertinent evidence, evaluated the Veteran, accounted for his lay statements, and provided an opinion based on the evidence and medical principles. The Board acknowledges the Veteran’s contentions but notes that he does not have the requisite expertise or training to diagnose CFS. See 38 C.F.R. § 3.159 (a)(2). Importantly, in the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 8. Entitlement to service connection for a liver condition In this instance, the Veteran contends that he has a liver condition that was caused or incurred in service to include as due to include as part of an undiagnosed illness or MUCMI. Based on the evidence, service connection is not warranted. At the outset, the first and second element of service connection is met. The Veteran has a current diagnosis of hepatic steatosis (fatty liver). Likewise, the Veteran had abnormal laboratory findings of his liver in 2001 during service. Therefore, to warrant service connection, there must be a nexus or link between the Veteran’s condition and his in-service findings, which is generally proven by medical evidence. In the October 2018 VA examination, the Veteran had diagnoses of fatty liver and hepatic steatosis (fatty liver disease). The Veteran claimed that his liver condition started on about active duty. He was told he had a fatty liver in service. He was retested again, and it was still there. He reported that he drank a lot of hard alcohol in service. On examination, the Veteran did not take any medication for his liver condition. There were no signs or symptoms attributable to chronic or infectious liver disease. No diagnosis of hepatitis C. The Veteran did not have incapacitating episodes due to his liver condition. The examiner indicated that the Veteran’s laboratory study was normal 2017. There were no other significant diagnostic tests or results. The examiner opined that the Veteran’s liver condition had a clear diagnosis and etiology and thus was not part of an undiagnosed illness or MUCMI. The examiner added that the Veteran’s liver condition was less likely than not caused by service. The examiner reasoned that the Veteran’s abnormal lab in 2002 were more like related to his alcohol abuse in service and subsequent labs over the years declined to normal. The examiner added that the Veteran’s CT scans were consistent with his medical history. He remarked that per medical literature, hepatic steatosis/fatty liver is associated with obesity, hypertension, diabetes mellitus, hyperlipidemia and/or alcohol use. The examiner explained that the Veteran is obese, has hypertension, hyperlipidemia, and a past history of alcohol use. The examiner highlighted evidence that showed the Veteran was diagnosed with alcohol abuse in a February 2018 psychiatry note. The Board finds the examiner’s opinion to be competent, credible, and highly probative. He reviewed the pertinent evidence, evaluated the Veteran, accounted for his lay statements, and provided an opinion based on the evidence and medical principles. The Board acknowledges the Veteran’s contention that his condition was caused by service; however, the Veteran does not have medical expertise to render such an opinion. As discussed above, the Veteran’s obesity, hypertension, hyperlipidemia, and alcohol abuse are associated with his condition. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, separate ratings for distinct periods of time, based on the facts may be for consideration. Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. Propriety of Rating Reduction In any case involving a rating reduction, the fact-finder must ascertain, based upon a review of the entire record, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such a change are based upon a thorough examination. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993) (citing 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13). The reduction of a rating generally must have been supported by the evidence on file at the time of the reduction, but pertinent post-reduction evidence favorable to restoring the rating must also be considered. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). When the reduction in evaluation of a service-connected disability would result in a reduction or discontinuance of compensation payments, specific procedural steps are required under 38 C.F.R. § 3.105 (e), including the issuance of a proposed rating, granting 60 days for the presentation of additional evidence by the Veteran, and restrictions on when the reductions may be effective. Specific procedural steps are also required for ratings that have been in place for five years or more under 38 C.F.R. § 3.344. The Board notes that in this instance, the procedural requirement is not applicable as the reduction of the Veteran’s rating did not result in a reduction or discontinuance of compensation payments. Reducing a rating also brings concurrent substantive requirements that must be followed. When a disability rating has been in effect less than five years, as in this case, a rating reduction is warranted where reexamination of the disability discloses improvement of that disability. 38 C.F.R. § 3.344 (c). In making this determination, however, VA is required to comply with several regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13; see Brown v. Brown, 5 Vet. App. 413, 420 (1993). The regulations impose a clear requirement that rating reductions be based upon review of the entire history of the veteran’s disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case it not only must be determined whether an improvement in disability occurred but whether it actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; Faust v. West, 13 Vet. App. 342, 350 (2000); see also 38 C.F.R. §§ 4.2, 4.10. 9. Entitlement to restoration of a 20 percent rating for lumbar spine DDD. Here, the Veteran contends that he is entitled to a restoration of the 20 percent rating for his lumbar spine disability. Based on the evidence, the Board agrees. Specifically, the Board finds that the August 2016 VA examination which formed the basis of the reduction at issue was inadequate; thus, the reduction was improper. In so finding, the Board notes that pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017), VA examiners must obtain information from the Veteran as to the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. It also requires that VA examiners estimate the additional loss of range of motion (ROM) during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. If an estimate cannot be provided without resorting to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Here, although the Veteran provided relevant information regarding his flare-ups, the examiner did not offer an opinion as to additional functional loss during flare-ups due to a lack of direct observation, as prohibited under Sharp. An examination that fails to make a proper evaluation of the Veteran’s limitations due to pain, weakness, fatigability, and incoordination and of his limitations during flare-ups, as this one, is inadequate. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, the Board finds the August 2016 examination is inadequate and the rating reduction is improper. The Board notes that there is no other evidence of record at the time of the reduction that would support the Veteran’s reduced rating; therefore, the reduction was improper and the Veteran’s 20 percent rating is restored, effective January 22, 2016. 10. Entitlement to an initial compensable rating for service-connected bilateral ingrown toenails. Here, the Veteran contends that his service-connected ingrown toenails warrant a compensable rating. Based on the evidence, the Board disagrees. At the outset, the Veteran’s bilateral ingrown toenails are evaluated noncompensable under DC 7820-7806. As applied here, hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27 (2019). DC 7820 provides for infections of the skin not listed elsewhere in the diagnostic code including bacterial, fungal, viral, treponemal and parasitic diseases. The rater is directed to rate this condition as a scar under DCs 7800 – 7805, or as dermatitis unde DC 7806, depending upon the predominant disability. For the Veteran’s condition, he is rated under DC 7806 for dermatitis. DC 7806 provides that a noncompensable rating was assignable when the skin disability involved less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and, during the past 12-month period, no more than topical therapy was required. A 10 percent rating is assignable when the skin disability involved at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or, during the past 12-month period, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks. A 30 percent rating is assignable when the skin disability involved 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or, during the past 12-month period, systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly. A 60 percent rating is assignable when the skin disability involved more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or, during the past 12-month period, constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. In the October 2018 VA examination, the Veteran had a diagnosis of ingrown toenail of the great toe from 1999. The Veteran reported that he had ingrown toenails in service that were partially removed. The nail came back and was removed again. The Veteran assed that the podiatrist at Lake Nona removed the left great toenail. On examination, the Veteran treated his condition with topical medical for less than six weeks in the past twelve months. Additionally, the Veteran had his left great toenail removed in the past twelve months. On physical examination, the Veteran’s bilateral ingrown great toenails were less than five percent of total body area and none of his exposed area. There were no visible characteristic lesions. His right great toenail was hard and narrow. There were no other skin conditions indicated. Likewise, there was no scarring or disfigurement of the head, face, or neck. Additionally, the examiner indicated that the Veteran’s ingrown toenail did not affect his ability to work. Based on the foregoing, the Veteran’s bilateral ingrown toenail does not warrant a compensable rating. The Veteran’s condition affects less than 5 percent of his entire body and none of his exposed areas. Likewise, he requires no more than topical therapy for his condition. A higher rating is not warranted as there is no evidence that his condition affects at least 5 percent but less than 20 percent of the entire body, or ast least 5 percent of his exposed areas. Additionally, there is no evidence of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. Furthermore, there are no scars associated with his condition to be applicable to DC 7800 – 7805. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). 11. Entitlement to a rating in excess of 10 percent disabling for service-connected RLE radiculopathy. Here, the Veteran contends that his RLE radiculopathy warrants a rating in excess of 10 percent disabling. Based on the evidence, the Board disagrees. At the outset, the Veteran’s RLE radiculopathy is rated at 10 percent disabling under DC 8520. DC 8520 provides ratings for the sciatic nerve. DC 8520 provides that mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; and moderately severe incomplete paralysis is rated 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated 80 percent disabling. DC 8620 refers to neuritis of the sciatic nerve, while DC 8720 refers to neuralgia of the sciatic nerve. Descriptive words such as “slight,” “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. In the October 2018 VA examination, the Veteran reported that he had constant shooting pain from the back to his legs that occasionally wakes him up at night. He explained that sometime his calves’ cramp, but he did not get numbness in his right leg. He reported tingling in his feet/toes. He reported that after a day of work it feels like needles on the bottom of his feet. On examination, the Veteran reported moderate constant pain, mild paresthesias/dysesthesias, and no numbness of the RLE. The Veteran had normal strength in his RLE and no evidence of muscle atrophy. Reflex examination was normal. On sensory examination, the there was decreased sensation in right lower leg and ankle, but normal sensation on upper thigh, thigh/knee, and foot/toes. There was no evidence of trophic changes of the skin. The Veteran’s gait was antalgic due to his feet (pes planus) and back. The examiner indicated that the Veteran had mild incomplete paralysis of the sciatic nerve. All other nerve groups were normal. The Veteran reported difficulty with prolonged standing/walking. In a November 2019 VA examination, the Veteran reported that his LLE is worse than his RLE. He reported sharper pain, leg spasms down to calves and feet. He reported severe pain when bending or picking up heavy trash bags. On examination, there was no indication of constant pain of the RLE. There was mild intermittent pain, mild paresthesias/dysesthesias, and no numbness of the RLE. The Veteran had normal strength on muscle strength testing. Likewise, there was no evidence of muscle atrophy. Reflex examination was normal. On sensory examination, the Veteran was normal on his RLE. There was no evidence of trophic changes of the skin. The examiner indicated that the Veteran had mild incomplete paralysis of the sciatic nerve of the RLE. All other nerve groups were normal. Based on the foregoing, the Veteran’s RLE radiculopathy most closely approximates a 10 percent disability rating. The Veteran had mild to moderate constant pain, mild intermittent pain, mild paresthesias/dysesthesias, and no numbness of his RLE. The Veteran had full muscle strength with no evidence of atrophy. Likewise, there was some decreased sensation of the RLE but not a complete absence of sensation. Additionally, the Veteran reported that his LLE was worse than his RLE. As such, a higher rating is not warranted as there is little evidence that the Veteran’s RLE manifested with moderate incomplete paralysis. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). 12. Entitlement to an initial compensable rating for service-connected migraine headaches The Veteran contends that his migraine headache symptomatology warrants a compensable rating. Resolving reasonable doubt in the Veteran’s favor, the Board agrees. At the outset, the Veteran’s migraine headaches are rated under DC 8100. Under DC 8100, a 10 percent rating is assigned with characteristic prostrating attacks averaging one in two months, over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average of once a month over the last several months. Finally, a 50 percent rating is assigned when migraines with very frequent, completely prostrating headaches with prolonged attacks that are productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define “prostrating.” VA’s Adjudication Procedures Manual (M21-1), which is not binding on the Board, see DAV v. Sec’y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) (“The M21-1 Manual is binding on neither the agency nor tribunals”), defines prostrating under DC 8100 as “causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities.” See M21-1, pt. III, Subpt. iv, Ch. 4, Sec. G(7)(b). Here, in the June 2018 VA examination, the Veteran reported ongoing migraine including migraine variants since 2003. He indicated that the headaches were painful on both sides of the head with sensitivity to light. He treated his headaches with over the counter medication, Gabapentin and Duloxetine. The Veteran indicated that the migraines lasted typically one to two days, but the examiner noted that the Veteran did not have characteristic prostrating attacks of migraine or non-migraine headache pain. The examiner noted that the Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to migraine headaches, and stated his headaches did not impact his ability to work. However, the Veteran explained that he lost one week of work in the last twelve months. He added that he has had to call off work as a result of his headaches. Moreover, VA treatment records from 2019 showed that the frequency and severity of the Veteran’s migraine headaches continued. The Veteran reported that his migraines were not well controlled even when using Sumatriptan frequently. He was seen by a neurologist but was informed his MRI was normal. The neurologist told the Veteran to continue with Sumatriptan and prescribed propranolol. Given the medical evidence and the Veteran’s lay statements, the evidence of record is at least evenly balanced as to whether the Veteran’s migraine headache symptomatology more nearly approximates prostrating attacks averaging one in two months, over the last several months as contemplated by a 10 percent disability rating. While there is no evidence of prostrating attacks, the Veteran has described pounding headaches on both sides of the head which requires the use of over the counter medication, Sumatriptan and Propranolol and notes that they typically last one to two days. The Veteran is competent to describe the symptoms associated with his migraine headaches, and there is no evidence of record which suggests he lacks credibility as to this symptomatology. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). The evidence regarding the Veteran’s migraine symptomatology is thus afforded significant probative value. However, an initial rating higher than 10 percent is not warranted. While the Veteran has indicated that he suffers from migraines which last one to two days which he treats with various medications, the evidence of record does not indicate that the Veteran suffers from prostrating attacks one a month over the last several months. The June 2018 examination reflected that the Veteran did not have prostrating attacks of migraine or non-migraine headache pain, and noted no other complications, signs or symptoms related to migraine headaches. While the Veteran has described sensitivity to light during headaches and pounding on the both sides of his head, the evidence does not demonstrate symptomatology that more nearly approximates prostrating attacks occurring on an average of once a month over the last several months. Accordingly, resolving reasonable doubt in the Veteran’s favor, entitlement to an initial 10 percent disability rating for migraine headaches is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). 1. Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to obesity and service-connected lumbar spine disability is remanded. As decided herein, the Veteran’s claim of service connection for OSA is reopened. However, as detailed above, the examiners failed to provide an adequate opinion on causation and aggravation of the Veteran’s OSA. On remand, an addendum opinion should be obtained which addresses the etiology of the Veteran’s OSA and discusses among other things, whether his lumbar spine disability caused or aggravated his obesity which in turn caused his OSA. 2. Entitlement to service connection for chronic sinusitis is remanded. Here, the Veteran contends that his chronic sinusitis was incurred in or caused by active duty service. Based on the evidence, a remand is necessary. Specifically, in the September 2018 VA examination, the examiner indicated that the Veteran did not have chronic sinusitis. The Veteran reported that his sinusitis bean in 1999 with symptoms of nasal congestion and nasal discharge. He reported that his treatment included antibiotics and Flonase nasal spray. He was informed he had allergies as well. On examination, the examiner indicated that the Veteran had allergic rhinitis but no signs or symptoms of chronic sinusitis. The examiner remarked that there was no diagnosis of chronic sinusitis as there was no pathology to render a diagnosis. Then, in an October 2018 VA examination, another examiner indicated that the Veteran had allergic rhinitis but not chronic sinusitis. As the examiner explained, the Veteran’s records indicated an acute sporadic sinusitis condition that resolved with conservative care during service. Likewise, in a November 2018 addendum opinion, the examiner explained that the Veteran’s upper respiratory infection was acute and resolved during service and as such did not meet the medical criteria for a diagnosis of chronic sinusitis. However, the Board notes that the Veteran’s VA treatment records contain several records of chronic sinusitis. For example, the Veteran was diagnosed with bronchitis and sinusitis in July 2018. Then, the Veteran was assessed with recurrent sinusitis in August 2018. However, in a September 2018 sinus x-ray, the impression was negative for paranasal sinuses and sinusitis. Yet, in May 2019, the physician indicated that the Veteran had a history of chronic migraines and chronic sinusitis. Given the conflicting medical evidence, a remand is necessary to determine whether the Veteran has a recurrent or chronic sinus condition that was incurred or caused by service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to a rating in excess of 10 percent disabling for service-connected cervical spine disability is remanded. Here, the Veteran contends that his service-connected cervical spine disability warrants a rating excess of 10 percent disabling. Based on the evidence, a remand is necessary. In this instance, the Veteran was last afforded a VA examination for his cervical spine in August 2016. Generally, a stale examination is not enough to require a remand for a new examination; however, treatment records show that the Veteran has neck pain has worsened since the August 2016 VA examination. See VA treatment records. VA’s duty to assist includes providing a new medical examination when a veteran assert’s or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). Moreover, in the August 2016 VA examination, the Veteran reported flare-ups of his cervical spine disability; however, the examiner failed to provide an estimate of loss of ROM during a flare-up. As discussed above, to comply with Sharp, VA examiners must obtain information from the Veteran as to the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. It also requires that VA examiners estimate the additional loss of range of motion (ROM) during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. If an estimate cannot be provided without resorting to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Accordingly, a more contemporaneous VA examination is required to provide a current picture of the Veteran’s cervical spine disability at issue on appeal. 38 C.F.R §§ 3.326, 3.327 (2019). 4. Entitlement to rating in excess of 20 percent disabling for service-connected lumbar spine DDD is remanded. Similarly, the Veteran was last afforded a lumbar spine examination in August 2016. Since the August 2016, the Veteran has reported increased chronic lower back pain along with BLE radiculopathy. See VA treatment records. VA’s duty to assist includes providing a new medical examination when a veteran assert’s or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). Additionally, in the August 2016 VA examination, the Veteran reported flare-ups of his lumbar spine DDD, but the examiner failed to provide an estimate on the additional loss of ROM during a flare-up. As this issue is being remanded for a current VA examination, the examination should comport to Sharp and Correia. Accordingly, a more contemporaneous VA examination is required to provide a current picture of the Veteran’s lumbar spine disability at issue on appeal. 38 C.F.R §§ 3.326, 3.327 (2019). 5. Entitlement to a compensable rating for service-connected costochondritis claimed as pectoral popping is remanded. Here, the Veteran contends that he is entitled to a compensable rating for his costochondritis. Based on the evidence, a remand is necessary. The Veteran, through his attorney, argued that his costochondritis is rated under an incorrect diagnostic code. The Veteran contends that his costochondritis should be rated under § 4.71a, as opposed to §4.73 (muscle injuries). The assignment of a particular DC is “completely dependent on the facts of a particular case” and the Board can choose the code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). In this instance, the November 2019 VA examination showed that the Veteran’s costochondritis was not an injury to a muscle group of the shoulder girdle or arm, forearm, hand, foot, leg, pelvic girdle, thigh, torso or neck. Based on the examination, the Veteran’s condition was not applicable to any of the muscle groups under § 4.73. The Veteran reported ongoing intermittent pain that had worsened. He explained that left side chest wall pain that felt like a tendon. The Veteran was unable to perform a push up or lift weights and he reported that pushing or pulling caused pain. Evidently, the Veteran’s condition results in some functional limitation but the particular effect of his condition is not clear. Accordingly, a remand is necessary for the Veteran to undergo a VA examination to determine the current severity and functional impact/limitation of his costochondritis. The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, obtain a VA addendum medical opinion to determine the nature and etiology of the Veteran’s OSA. If an opinion cannot be obtained without an examination, then a VA examination should be afforded to the Veteran. 3. Additionally, afford the Veteran a VA examination to determine the etiology of his claimed chronic sinusitis, if diagnosed. A discussion to reconcile the conflicting medical evidence on whether the Veteran has chronic sinusitis is also requested. The VA examiner should address the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s chronic sinusitis, if diagnosed, had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service. (b.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s OSA is caused by the medications taken for his service-connected disabilities. (c.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s OSA is aggravated (i.e. worsened beyond normal progression) by the medications taken for his service-connected disabilities. (d.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s OSA is caused by his service-connected psychiatric disorder. (e.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s OSA is aggravated (i.e. worsened beyond normal progression) by his service-connected psychiatric disorder. (f.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s obesity was caused by his lumbar spine disability. (g.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s obesity was aggravated (i.e. worsened beyond normal progression) by his lumbar spine disability. (h.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s OSA was caused by or would not have occurred but for his obesity. 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 against it. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as “any increase in disability.” See Allen v. Brown, 7 Vet. App. 439, 448 (1995). 4. Additionally, schedule the Veteran for VA examinations to determine the current severity of his: (a) cervical spine disability; (b) lumbar spine disability; and (c) costochondritis. 5. For the cervical and lumbar spine examinations, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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. To the extent possible, the examiner should identify any symptoms and functional impairments due to the cervical and lumbar spine disabilities. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment 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). A copy of this REMAND must also be provided to the VA examiner. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. (Continued on the next page)   6. The examiner should cite to the medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 7. After undertaking any additional development deemed necessary, the AOJ must readjudicate the claims on appeal. If any claim remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board. R.R. WATKINS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Umo, 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.