Citation Nr: 21023891 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-19 039 DATE: April 21, 2021 ORDER Entitlement to an effective date earlier than March 31, 2016 for unspecified alcohol-related disorder is denied. Entitlement to an effective date earlier than March 31, 2016 for irritable bowel syndrome is denied. Entitlement to a rating in excess of 20 percent for lumbar degenerative disc disease prior to February 11, 2020 is denied. Entitlement to a rating in excess of 40 percent for lumbar degenerative disc disease and intervertebral disc syndrome (IVDS) since February 11, 2020 is denied. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy is denied. Entitlement to an initial rating in excess of 30 percent for irritable bowel syndrome is denied. Entitlement to an initial rating in excess of 30 percent for an unspecified alcohol-related disorder (now characterized as major depressive disorder with alcohol-related disorder) is denied. Entitlement to a compensable rating for residuals of bilateral inguinal hernia repair is denied. Entitlement to service connection for urinary frequency is denied. Entitlement to service connection for left knee strain is denied. Entitlement to service connection for right knee joint pain is denied. Entitlement to service connection for a left elbow condition is denied. Entitlement to service connection for right elbow tingling and numbness is denied. Entitlement to service connection for fatigue is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for cervical strain is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. VA received a completed application for service connection for unspecified alcohol-related disorder on March 31, 2016. 2. VA received a completed application for service connection for irritable bowel syndrome on March 31, 2016. 3. Prior to February 11, 2020, the Veteran’s lumbar degenerative disc disease is manifest by a combined range of motion not greater than 170 degrees. 4. Since February 11, 2020, the Veteran’s lumbar degenerative disc disease and IVDS is manifest by forward flexion 30 degrees or less or favorable ankylosis of the thoracolumbar spine. 5. The Veteran’s left lower extremity radiculopathy is manifest by no more than moderate incomplete paralysis. 6. The Veteran’s irritable bowel syndrome is assigned a 30 percent evaluation, the maximum rating authorized under Diagnostic Code (DC) 7319. 7. The severity, frequency, and duration of the Veteran’s major depressive disorder with alcohol use disorder did not more closely approximate occupational and social impairment with reduced reliability and productivity. 8. The severity, frequency, and duration of the Veteran’s symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 9. The Veteran’s postoperative bilateral inguinal hernias have not recurred. 10. The Veteran’s benign prostate hypertrophy and urinary frequency are not secondary to a service-connected disability, and are not otherwise related to an in-service injury or disease. 11. The Veteran’s left knee strain was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established or is attributable to intercurrent causes; and the disability is not otherwise etiologically related to an in-service injury or disease. 12. The Veteran’s right knee joint pain was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established or is attributable to intercurrent causes; and the disability is not otherwise etiologically related to an in-service injury or disease. 13. The preponderance of the evidence is against finding that left ulnar radiculopathy began during active service, or is otherwise related to an in-service injury or disease. 14. The preponderance of the evidence is against finding that right ulnar radiculopathy began during active service, or is otherwise related to an in-service injury or disease. 15. The preponderance of the evidence of record is against finding that the Veteran has had an undiagnosed illness, medically unexplained chronic multi-symptom illness, chronic fatigue syndrome, or other diagnosed fatigue disability at any time during or approximate to the pendency of the claim. 16. The preponderance of the evidence of record is against finding that the Veteran has had PTSD at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. Entitlement to an effective date prior to March 31, 2016 for the award of service connection for unspecified alcohol-related disorder is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 2. Entitlement to an effective date prior to March 31, 2016 for the award of service connection for irritable bowel syndrome is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 3. Prior to February 11, 2020, the criteria for a rating in excess of 20 percent for lumbar degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 4. From February 11, 2020, the criteria for a rating in excess of 40 percent for lumbar degenerative disc disease and IVDS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5243. 5. The criteria for a disability rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 6. The criteria for a disability rating in excess of 30 percent for IBS have not been met. 38 U.S.C. §§ 1155, 5107(b) 38 C.F.R. §§ 3.321 (b)(1), 4.1, 4.3, 4.7, 4.20, 4.114, Diagnostic Codes 7346-7319. 7. The criteria for a disability rating in excess of 30 percent prior to June 5, 2017 for major depressive disorder with alcohol use disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 8. The criteria for a compensable rating for residuals of bilateral inguinal hernia repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.114, Diagnostic Codes 7804-7338. 9. The criteria for service connection for urinary frequency due to service or service-connected lumbar spine disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 10. The criteria for service connection for left knee strain are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 11. The criteria for service connection for a right knee condition are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 12. The criteria for service connection for a left elbow condition, diagnosed as left ulnar radiculopathy, are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 13. The criteria for service connection for right elbow numbness and tingling, diagnosed as right ulnar radiculopathy, are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 14. The criteria for service connection for fatigue are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 15. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1984 to March 1988, and from September 1990 to July 1997, with service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2015 and July 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these claims for additional development in October 2018. Earlier Effective Date Generally, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Where a prior unappealed decision becomes final, the effective date of a subsequent award of service connection is the date of receipt of the subsequently filed application to reopen, and not the date of receipt of the original claim. Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005). Entitlement to an effective date earlier than March 31, 2016 for unspecified alcohol-related disorder Entitlement to an effective date earlier than March 31, 2016 for irritable bowel syndrome The Veteran contends that he should be assigned an earlier effective date for unspecified alcohol-related disorder and irritable bowel syndrome. VA received a completed VA Form 21-526b seeking service connection for several disabilities, to include an acquired psychiatric disorder and a gastrointestinal condition, on March 31, 2016. The form was signed on March 27, 2016. The RO properly treated this as a new claim for service connection. The Veteran had previously filed claims for a lumbar spine disability and left lower extremity radiculopathy, but the record does not reveal prior claims for a psychiatric or gastrointestinal disorder. There are no earlier, unadjudicated claims for service connection for unspecified alcohol-related disorder and irritable bowel syndrome. In a July 2017 rating decision, the RO granted service connection for unspecified alcohol-related disorder and irritable bowel syndrome effective March 31, 2016. The records clearly show that the Veteran’s claim was received on March 31, 2016. Under the facts of this case, March 31, 2016, is the earliest effective date allowed under VA law and regulation. 38 U.S.C. § 5110 (a); 38 C.F.R. §§ 3.155 (b), 3.400 (b)(2). The pertinent legal authority governing effective dates in this case is specific, and the Board is bound by such authority. Unfortunately, there is no legal basis for an effective date earlier than March 31, 2016, for the grant of service connection for unspecified alcohol-related disorder and irritable bowel syndrome. Therefore, an effective date earlier than March 31, 2016 is not warranted. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. Entitlement to a rating in excess of 20 percent for lumbar degenerative disc disease Entitlement to a rating in excess of 40 percent for intervertebral disc syndrome (IVDS) The Veteran seeks a higher rating for his lumbar degenerative disc disease. In a July 2020 rating decision, the RO increased the evaluation for lumbar IVDS to 40 percent, effective February 11, 2020. The Veteran lumbar degenerative disc disease is assigned a 20 percent rating under Diagnostic Code (DC) 5242 prior to February 11, 2020, and a 40 percent rating under DC 5243 thereafter. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran’s lumbar spine disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243, for intervertebral disc syndrome (IVDS). Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. VA treatment records show complaints and treatment related to the Veteran’s back disability. These records do not include specific range of motion findings that support higher ratings for either appeal period. There is also no indication of ankylosis or incapacitating episodes due to IVDS. The Veteran was afforded a VA examination in August 2015. The Veteran reported back pain related to a fracture of the leg. He reported flare-ups, specifically that 10 days per month he was unable to perform sedentary tasks, and would apply heat. Range of motion testing revealed the following: flexion to 70 degrees; extension to 20 degrees; right and left lateral flexion to 20 degrees; and right and left lateral rotation to 20 degrees. The Veteran was able to perform repetitive use testing without any additional loss of motion. The Veteran did not have localized tenderness or pain on palpation or guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing was 5/5. Sensory examination revealed mild numbness of the left lower extremity, but was otherwise normal. The Board notes that the examiner did not offer an assessment of whether pain, weakness, fatigability, or incoordination limited the Veteran’s functional ability with repeated use over time or during flare-ups. However, the Board finds the examination adequate as the examiner reasoned that she was unable to determine his functional ability because the Veteran’s examination did not fit with her observations of his movement prior to starting the exam. The examiner indicated that ankylosis and IVDS were not present. Pursuant to the October 2018 Board remand, the Veteran was afforded a VA examination in February 2020. The Veteran reported low back pain. He indicated that he experienced flare ups 2 or 3 times per week, which were moderate to severe. Range of motion testing revealed the following: flexion to 15 degrees; extension to 20 degrees; right and left lateral flexion to 15 degrees; and right and left lateral rotation to 10 degrees. The Veteran was able to perform repetitive use testing without any additional loss of motion. Repeated use over time and estimated range of motion during flare-ups revealed the following: flexion to 30 degrees; extension to 5 degrees; right and left lateral flexion to 5 degrees; and right and left lateral rotation to 0 degrees. The Veteran had moderate localized paralumbar tenderness bilaterally at L2 through S1 on palpation. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing was 5/5 on the right and 4/5 on the left. The examiner indicated that IVDS was present; no episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician were noted. Ankylosis was not present. Prior to February 11, 2020, the preponderance of the evidence is against a rating in excess of 20 percent for lumbar degenerative disc disease under the General Rating Criteria. Diagnostic Code 5242, as noted above, provides ratings in excess of 20 percent where there is limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. However, at the August 2015 VA examination, flexion was 70 degrees with functional loss considered. There was no evidence of ankylosis or IVDS causing incapacitating episodes of at least six weeks. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to flare-ups of the thoracolumbar spine 10 days per month. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experiences flare-ups 10 days per month that he treats with a hot pad would not result in symptoms more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Since February 11, 2020, the preponderance of the evidence is against a rating in excess of 40 percent for lumbar degenerative disc disease under the General Rating Criteria. A higher rating is only available for unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. The Veteran does not contend, and the evidence does not show, any ankylosis of the spine. Indeed, at the February examination, the Veteran’s forward flexion during a flare-up was estimated at 30 degrees and the examiner affirmatively stated there is no ankylosis of the spine. The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for lumbar degenerative disc disease based on incapacitating episodes. The Veteran has IVDS, however, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. In this case, the February 2020 VA examiner found that the Veteran had not been prescribed bed rest by a physician for an acute episode related to his IVDS. Thus, the criteria for a rating in excess of 40 percent are not met. Regarding neurological impairment, the Veteran has already been granted service connection for left lower extremity radiculopathy and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Finally, the Board acknowledges that the rating criteria as to IVDS have been amended effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). The change to Diagnostic Code 5243 directs that the Code will be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root and to assign Code 5242 for all other disc diagnoses. Here, even if there was disc herniation with compression and/or irritation of the adjacent nerve root, application of Code 5243 does not result in a higher rating from the effective date of the amendment. Further discussion of this change is not required. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent for lumbar degenerative disc disease. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy The Veteran seeks an increased rating for left lower extremity radiculopathy. In a September 2015 rating decision, the RO continued the current 20 percent evaluation. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. The Veteran was afforded a VA examination in August 2015. Physical examination revealed mild numbness of the left lower extremity. However, other sensory examinations, reflex examinations, muscle strength testing, and straight leg testing were negative for signs and symptoms of radiculopathy. The examiner assessed mild left lower extremity radiculopathy involving the sciatic nerve. Pursuant to the October 2018 Board remand, the Veteran was afforded a VA examination in February 2020. Physical examination revealed reduced 4/5 strength in the left lower extremity. Sensory examination revealed decreased sensation in the left high and knee. Symptoms of mild intermittent pain, paresthesias, and numbness were noted. Straight leg testing was negative. The examiner assessed mild left lower extremity radiculopathy of the sciatic nerve. The Board finds that the left lower extremity radiculopathy most closely approximates moderate incomplete paralysis of the sciatic nerve due to symptoms of mild impairment of motor function and intermittent sensory disturbances and pain. Regarding impairment of motor functions, at the February 2020 VA examination, the Veteran had mildly reduced strength and normal reflexes. The Veteran reported that his left leg would periodically give out. Regarding sensory disturbance, the medical record shows pain, numbness, and decreased sensation. At the August 2015 and February 2020 VA examinations, physical examination revealed decreased sensation, and the examiners noted mild radicular symptoms of intermittent pain, paresthesia, and numbness. The Board finds that a rating in excess of 20 percent for the Veteran’s left lower extremity radiculopathy is not warranted. In this regard, the VA examination of record reveals that the Veteran had of paresthesias, numbness, and intermittent pain in the left lower extremity. However, the Board finds a rating in excess of 20 percent is not warranted as the Veteran’s symptoms have not been described as moderately severe. In fact, the VA examiners found that they were reflective of mild incomplete paralysis. Moreover, during the 2020 VA examination, the Veteran demonstrated mildly reduced strength, normal reflexes, and negative straight leg raises. In sum, the Board finds that the Veteran’s functional impairment resulting from his left lower extremity radiculopathy has been no more than moderate. Based on the above, the Board finds that the disability is primarily manifested by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for left lower extremity radiculopathy. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Entitlement to an initial rating in excess of 30 percent for irritable bowel syndrome The Veteran’s service-connected gastroenteritis with irritable bowel syndrome (IBS) has been assigned a 30 percent disability rating under 38 C.F.R. § 4.114, Diagnostic Code 7346-7319, for the entire period on appeal. This is the maximum schedular rating available for his disability. A 30 percent rating contemplates severe symptomatology, manifested by diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. The Veteran was afforded a VA examination for stomach conditions in August 2016. The Veteran reported he had been treated for reflux, but not gastric or duodenal problems. He reported stomach pain, which he described as mild to moderate. No signs or symptoms of any stomach condition was noted by the examiner. However, in the remarks the examiner noted periodic abdominal pain and mild nausea. The Veteran was afforded a VA examination for intestinal conditions in August 2016. The Veteran reported that he had developed abdominal pain, blood in stool, and diarrhea. He reported a colonoscopy in 2010, and had changed his diet. He reported persistent abdominal pain and diarrhea. The examiner noted symptoms of diarrhea 4 times per week and daily abdominal cramping. No episodes of bowel disturbance with abdominal distress, or exacerbations of the intestinal condition were noted by the examiner. No malnutrition or weight loss was noted by the examiner. The Veteran was afforded a VA examination in June 2017. The Veteran reported gastrointestinal symptoms and reflux disease for 15 years, which he treated with medication. He reported waking with regurgitation, but no symptoms during the day. He reported a 3- to 4-year history of constipation and diarrhea, with a history of rectal bleeding. The examiner noted symptoms of alternating diarrhea and constipation, with extreme constipation for 2-3 days and then diarrhea, along with occasional rectal bleeding. No malnutrition or weight loss attributable to an intestinal condition was noted by the examiner. The Veteran was afforded a VA examination in July 2017. The Veteran reported diarrhea and constipation symptoms since 1994. The examiner noted symptoms of alternating diarrhea and constipation, abdominal distension, and nausea. The Veteran had frequent episodes of bowel disturbance with abdominal distress, with 7 or more exacerbations of the intestinal condition within the previous 12 months. No weight loss or malnutrition was noted. No other pertinent clinical findings or symptoms were noted. The Veteran was afforded a VA examination in February 2020. The Veteran reported experiencing alternating constipation and diarrhea, as well as blood with bowel movements. He reported generally he had blood with most bowel movements, especially the larger and harder ones. The examiner noted symptoms of alternating diarrhea and constipation, anemia, and rectal bleeding after bowel movements. The Veteran had episodes of bowel disturbance with abdominal distress. The examiner noted 7 or more exacerbations within the previous 12 months, which he described as weekly bouts of diarrhea after varying degrees of constipation. No weight loss or malnutrition was noted. The examiner indicated that the varying degrees of constipation and blood with most of his bowel movements could be a nuisance and interrupt and interfere with his normal work routine when it occurs. As previously noted, the Veteran is in receipt of the maximum rating available under the applicable diagnostic code; there is no higher schedular rating that can be assigned by regulation. In a case such as this one where the law and not the evidence is dispositive, the claim is denied on a schedular basis because of the absence of legal merit or the lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Further, there is no evidence to suggest there is a better diagnostic code for application to the Veteran’s symptoms. The Board has considered evaluation under Diagnostic Codes 7399-7346 for gastroesophageal reflux disease (GERD). Under Code 7346, a higher 60 percent rating is only warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. VA examination reports and treatment records do not suggest the Veteran has experienced material weight loss, hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Thus, a higher rating under Code 7346 is not warranted. Based on the foregoing, the claim for a rating in excess of 30 percent for irritable bowel syndrome with associated GERD is denied. There are no additional expressly or reasonably raised issues on the record related to this claim. Entitlement to an initial rating in excess of 30 percent for major depressive disorder with alcohol use disorder The Veteran seeks an increased rating for his mood disorder. In a July 2017 rating decision, the RO granted service connection for unspecified alcohol use disorder with an evaluation of 30 percent effective March 31, 2016 through June 5, 2017. A July 2020 rating decision then added major depressive disorder to the award, noting a continued 30 percent rating effective June 5, 2017. The Veteran is rated 30 percent for his major depressive with alcohol use disorder throughout the period on appeal. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. VA treatment records reveal ongoing mental health treatment. A February 2019 consult noted a history of mood and sleep disorders, and an alcohol use disorder. The Veteran denied auditory or visual hallucinations, suicidal ideation, or homicidal ideation. In March 2016, the Veteran stated that he experienced anger, anxiety, chronic sleep problems, denial, depression, emotional numbing, guilt, heavy use of alcohol, isolation, memory loss, neglects family, nervousness, panic attacks, problems with communication, problems at work, sense of helplessness, substance abuse, unable to share feelings, and that he took medications for mental conditions. In December 2016, the Veteran asserted that he experienced insomnia, attention and concentration issues, irritability, and short-term memory loss. The Veteran was afforded a VA examination in April 2016. The Veteran was pleasant, open, and cooperative in the interview. He reported that he had been going to treatment at the OMAVAMHC, noting that he had been receiving treatment for an alcohol use disorder. The examiner diagnosed alcohol use disorder and unspecified alcohol-related disorder. Mental status examination revealed intact attention and concentration, depressed, angry, or anxious mood, intact insight and judgment, and intact recent and remote memory. The Veteran reported insomnia, that he would be up all night and has stretches where he can’t sleep. The examiner noted symptoms of depressed mood and anxiety. The examiner assessed occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was afforded a VA examination in June 2017. The Veteran reported that he did not leave the house often. He reported treatment for major depression, sleeping difficulty, and when he could fall asleep staying in bed for 3 to 4 days. The examiner diagnosed unspecified alcohol-related disorder. Mental status examination revealed intact attention and concentration, “useless, indifferent” mood, difficulty sleeping, intact memory, and normal reasoning ability. No specific symptoms were noted by the examiner. The examiner assessed a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran was afforded a VA examination in February 2020. The Veteran reported supportive therapy since 2018. He reported feelings of guilt, worthlessness, and hopelessness. The examiner diagnosed alcohol use disorder and major depressive disorder. The examiner noted symptoms of depressed mood, and chronic sleep impairment. Mental status examination revealed logical and goal-oriented speech, cooperative behavior, good concentration and attention, and good judgment and insight. The Veteran described his mood as “indifferent.” The examiner assessed occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. VA treatment records, the VA examinations, and the Veteran’s lay statements show that the Veteran’s alcohol use disorder and/or major depressive disorder was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, and chronic sleep impairment), and symptoms associated with a 50 percent rating (possibly irritability, thinking/attention issues, low energy and anhedonia). He also had symptoms that are not listed with a specific rating, such as reportedly weird dreams. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. The weird dreams reported by the Veteran are similar to or related to the Veteran’s chronic sleep impairment, which is contemplated by the assigned 30 percent rating. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 30 percent rating. Though the Board acknowledges the Veteran’s report of irritability, attention and concentration issues, isolation, the April 2016 VA examiner estimated that the Veteran’s mental disorder would result in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner’s professional assessment of the Veteran’s overall mental functioning is consistent with the currently assigned disability rating. The later examinations notably assessed milder symptoms, consistent with either a noncompensable or 10 percent disability rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 30 percent rating. The criteria for a 50 percent or higher rating are not met and the appeal must be denied. Entitlement to a compensable rating for residuals of bilateral inguinal hernia repair The Veteran seeks a compensable rating for residuals of a bilateral inguinal hernia repair. The Veteran’s inguinal hernia is rated noncompensable pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7804-7338. Under Code 7338, a noncompensable evaluation is appropriate if the hernia is small, reducible, or without true hernia protrusion; or where it is not operated, but remediable. A 10 percent evaluation is warranted if a hernia is postoperative recurrent, readily reducible and well-supported by truss or belt. A 30 percent evaluation is warranted for a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss, or not readily reducible. A maximum schedular evaluation of 60 percent is warranted for a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. A Note following Code 7338 provides that a 10 percent evaluation should be added for bilateral involvement, provided that the second hernia is compensable. This means that the more severely disabling hernia is to be evaluated, and 10 percent only, added for the second hernia, if the latter is of compensable degree. The Veteran was afforded a VA examination in June 2017. The Veteran reported a history of bilateral hernia surgery in 1993 and 1995. He reported feeling bulging of the right side when he was constipated with pain in the right groin area. No hernia was detected on physical examination. No other pertinent physical findings, complications, conditions, signs, or symptoms related to inguinal hernia were noted by the examiner. No post-surgical scars were noted. There was no indication for a supporting belt. Pursuant to the 2018 Board remand, the Veteran was afforded a VA examination in February 2020. The Veteran reported having discomfort and bulging in the inguinal area back in the early 1990’s. He stated he had recently noticed some bulging and groin discomfort when lifting heavier objects. On examination, there was no true hernia protrusion on the right side, and no hernia detected on the left side. There was no indication for a supporting belt. A right inguinal hernia scar was noted that was 5.2 cm x 0.3 cm. The examiner stated that the Veteran’s hernia did not impact his ability to work. The examiner noted that some of the left sided discomfort may be related to a separate finding of epididymitis. The Board finds that a compensable rating for right inguinal hernia is not warranted. Pursuant to Code 7338, a compensable rating for a postoperative inguinal hernia requires it to be recurrent, readily reducible and well-supported by truss or belt. An additional 10 percent evaluation for bilateral involvement can be assigned, but only if one of the hernias is compensable. Such findings are not shown in this case. There is no doubt to be resolved; the assignment of a compensable rating pursuant to DC 7338 is not warranted. Service Connection 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). Objective indications of a qualifying chronic disability include both signs and symptoms, in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs and symptoms include, but are not limited to, fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and change in the veteran’s appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). The term MUCMI refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is “medically unexplained,” that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant’s case. Id. at 291. Entitlement to service connection for urinary frequency The Veteran seeks service connection for urinary frequency. He asserts that his urinary frequency symptoms are related to his service-connected lumbar spine disability. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of benign prostate hypertrophy, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of urinary frequency began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records are silent for complaints, diagnosis, or treatment related to urinary frequency or urinary issues. In May 2016, a VA examiner opined the Veteran’s urinary frequency is less likely proximately due to or aggravated by his service connected lumbar spine disability. The examiner explained that the Veteran’s records were silent for any spinal cord compression or cauda equina syndrome. The Veteran’s radiographic evidence for his back was noted as mild. The examiner concluded that there was no evidence that the Veteran’s back had affected his bladder function. Thus, the examiner concluded it was less likely that the current service-connected degenerative disc disease has caused any urinary frequency and there was also no evidence of any aggravation. In an October 2017 addendum opinion, the examiner opined that the exact cause of the Veteran’s urinary frequency complaint remained to be determined. The examiner explained that there were no medical records of the complaints, and that no workups had ever been performed. The examiner noted that the Veteran had multiple medical, mental health, and social comorbidities that could easily play into urinary tract disorders. Regardless, the examiner found that urinary frequency was a symptom with numerous possible etiologies. Pursuant to the Board’s remand, the Veteran was afforded a VA examination in February 2020 to clarify the nature and etiology of the urinary symptoms. The examiner diagnosed benign prostate hypertrophy (BPH). The examiner opined that the Veteran’s BPH was less likely related to service. The examiner explained that BPH was a common cause of urinary frequency in men. BPH was a gradual enlargement of the prostate gland that almost all men experience, some with effects on their urinary pattern, some not. He has had those effects causing slowing of his urinary stream and more frequent urination. There was nothing in his clinical record to suggest some other cause of his problem. Thus, the examiner concluded the condition was less likely incurred in or caused by active service. The examiner further opined that the Veteran’s urinary frequency symptoms were less likely than not proximately caused or aggravated by his service-connected disabilities. The examiner explained that BPH was a common cause of urinary frequency in men. The Veteran had those effects causing slowing of his urinary stream and more frequent urination. However, neither his physical exam or his MRI’s demonstrate any evidence of sufficient bony spine distortion or nerve or spinal cord compromise of the type or at the level that would account for any influence on his bladder or urinary frequency. Further, the examiner noted that the Veteran’s back problems pre-dated his BPH symptoms by at least 11 years. The examiner found that there was no logical anatomic or physiological mechanism demonstrable in past studies or imaging that would account for any aggravating influence or effect on his bladder function by his service-connected low back disability and left lower extremity radiculopathy. The Board finds the February 2020 VA examiner’s opinion the most probative evidence of record. The February 2020 VA examiner opined that the Veteran’s BPH was not at least as likely as not related to an injury in service or to his service-connected lumbar spine and left lower extremity radiculopathy, supporting his opinion with explanation and citation to the evidence. The VA examiner specifically explained that there was no logical anatomic or physiologic mechanism demonstrable on this Veteran that would account for any aggravating influence or effect on his bladder function by his service-connected lumbar spine and left lower extremity radiculopathy. The examiner’s opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his urinary frequency is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Moreover, the Board gives more probative weight to the February 2020 VA medical opinion. In sum, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply and service connection for urinary frequency and/or BPH is not warranted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Entitlement to service connection for left knee strain The Veteran seeks service connection for left knee strain. Here, the Veteran had active service in the Persian Gulf and Arabian Sea between September 1990 and July 1997. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). A February 2020 VA examination shows the Veteran has a diagnosis of patellofemoral pain syndrome. Because the Veteran’s patellofemoral pain syndrome is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). A February 2020 VA examination found that the Veteran’s patellofemoral pain syndrome has a clear and specific etiology and pathophysiology. With respect to the etiology of the Veteran’s patellofemoral pain syndrome, the examiner explained that the Veteran’s left knee disability was the result of a fall injury in 2017. The examiner noted that there was no previous history of left knee problems prior to the 2017 fall injury. The examiner explained that the fall led to the symptoms of patellofemoral pain syndrome that the Veteran had at the examination. With respect to the pathophysiology of the Veteran’s patellofemoral pain syndrome, the clinician explained that trauma to the Veteran’s left kneecap, or patella, caused post-traumatic pain syndrome. The Board finds this opinion probative because the examiner clearly identified the etiological injury that caused the Veteran’s left knee disability, as well as the specific patella trauma that led to the symptoms of patellofemoral pain syndrome. Accordingly, as both the etiology and the pathophysiology of the Veteran’s patellofemoral pain syndrome are fully understood, it is not considered a MUCMI and presumptive service connection is not warranted. Thus, the question for the Board turns to whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records show the Veteran sought treatment for left knee pain. In May 1983, the Veteran reported left knee pain 1 day after marching. Treatment providers assessed nonserious strain, and gave the Veteran an ace wrap and Tylenol. In November 1986, the Veteran sought treatment for left ankle and left knee pain. Swelling was noted in the foot and ankle. A November 1986 orthopedic note showed a left tibia fracture, with the left leg was immobilized for 10 months as a result. A March 1997 report of medical examination noted normal clinical lower extremity findings. In a March 1997 report of medical history, the Veteran denied trick or locked knee. The Veteran was afforded a VA examination in June 2017. The Veteran reported that his left knee started to bother him in the past 5 to 6 years, with insidious onset. Pain was noted at the kneecap and the back of the knee. The examiner diagnosed left knee strain. The examiner opined in a July 2017 addendum that the left knee condition was less likely than not related to service. The examiner noted that the Veteran was seen for left knee strain, and that physical therapy showed post tibia-fibula fracture in November 1986. An earlier July 2012 VA examination noted that the Veteran was service-connected for a left tibia-fibula fracture with leg length discrepancy. However, no left knee pain was noted at the 2012 VA examination. The examiner concluded that the medical records showed an instance of a complaint of left knee pain with a diagnosis of strain during service, which the examiner explained is a self-limited condition. Given the records at separation and after service, the examiner concluded there was no indication of a chronic knee condition related to service. However, as noted in the Board remand, the examiner did not fully address whether the Veteran’s left knee condition was related to his service-connected low back condition, service-connected left lower extremity radiculopathy, or service in Southwest Asia. Pursuant to the Board remand, the Veteran was afforded a VA examination in February 2020. The Veteran reported pain and swelling in both knees after a fall in 2017. The examiner diagnosed left patellofemoral pain syndrome. The examiner opined the claimed condition is less likely than not related to service, to include environmental hazards in Southwest Asia. The examiner explained that the Veteran’s knee was injured in a fall in 2017, when his leg gave out and he fell landing on his knees and both elbows. The examiner indicated that he was aware of no logical medical explanation for how toxic exposures would somehow cause left knee pain or patellar pain. The examiner opined that the patellofemoral pain syndrome was less likely than not caused by his service-connected low back disability, and/or tibia-fibular fractures. The examiner explained that the Veteran has experienced back symptoms dating back to at least 1997, and that his tibia-fibular fracture was in 1985. The examiner noted that the Veteran had not had, by his own history, any left knee problems until after his fall injury in 2017. Since that fall, the Veteran had had some degree of knee symptoms related to the patellofemoral pain caused by the fall. The examiner concluded that there was nothing in his medical record to show left knee symptoms prior to the fall injury, or to relate any knee problems to the Veteran’s service-connected back or lower extremity conditions. The examiner further opined that the Veteran’s knee problem had only been present for 3 years, and that the Veteran’s knee problem was not aggravated by a service-connected disability. The examiner explained that the Veteran’s knee problems had not progressed since 2017. The examiner noted that knee problems normally get worse with age, but to say it had been aggravated beyond its normal progression was not possible since it had only been present for 2 to 3 years and had not demonstrably progressed. Thus, the examiner concluded that the left knee condition had not been aggravated beyond its normal progression by a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of patellofemoral pain syndrome, and evidence shows that left knee strain and exposure to environmental hazards in Southwest Asia occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of patellofemoral pain syndrome began during service or is otherwise related to an in-service injury, event, or disease. Taken together, the July 2017 and February 2020 VA examiners’ opinions establish that the Veteran’s left knee strain or patellofemoral pain syndrome is not at least as likely as not related to an in-service injury, event, or disease, including exposure to environmental hazards and secondary to service-connected back and lower extremity disabilities. The July 2017 VA examiner opined that the Veteran’s left knee strain was less likely than not related to in-service tibia-fibular fracture and in-service left knee pain, while the February 2020 VA examiner opined that the Veteran’s patellofemoral pain syndrome was not at least as likely as not related to degenerative disc disease and exposure to environmental hazards in Southwest Asia. The combined rationale was that the Veteran’s in-service left knee strain was self-limiting, that there was no mechanism to relate knee pain to environmental exposure, the Veteran’s current patellofemoral pain syndrome was related to a 2017 fall, and that his knee disability had not demonstrably progressed and thus there was no evidence the left knee condition had been aggravated beyond its normal progression. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his left knee disability is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships, pathology, and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the 2017 and 2020 VA examiners’ opinions. In sum, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply and service connection for a left knee condition is not warranted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Entitlement to service connection for right knee joint pain The Veteran seeks service connection for right knee joint pain. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current right knee disability, and evidence shows that the Veteran served in the Persian Gulf and Arabian Sea, the preponderance of the evidence weighs against finding that the Veteran’s right knee disability began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records are silent for complaints, diagnosis, or treatment for a right knee disability. A March 1997 report of medical examination at separation is silent for right knee abnormalities, and the Veteran’s March 1997 report of medical history showed the Veteran denied lock or trick knee. VA treatment records reflect that the Veteran fell in November 2016. The Veteran reported that he had fallen when his leg gave out. He reported ongoing joint pain and swelling. The Veteran was afforded a VA examination in June 2017. The Veteran reported left knee pain for the previous 5 to 6 years. He reported pain at the kneecap and back of knee. However, no specific report or diagnosis was made with respect to the right knee. Pursuant to the Board remand, the Veteran was afforded a VA examination in February 2020. The Veteran reported that he fell in 2017. He indicated that his left leg gave out, injuring his knees, neck, and both elbows. He reported ongoing pain and swelling of the left knee, with aggravation of these symptoms if walking on slopes or climbing stairs. The examiner opined that the right knee condition is less likely than not caused by his service-connected low back or tibia-fibular fracture. The examiner explained that the Veteran did not have any knee problems until he fell in 2017. The examiner indicated that the Veteran’s right knee condition had resolved after the initial injury. Even if still present, the examiner opined that right knee condition started after a fall injury, about 20 years after the Veteran began to have back troubles. The examiner concluded that neither the Veteran’s history nor his medical record indicated any possible causal relationship from his back condition leading to his knee problem. The examiner further opined that since the condition had resolved, it was not possible to establish aggravation of the condition. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his right knee disability is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the February 2020 VA examiner’s opinion. In sum, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply and service connection for a right knee condition is not warranted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Entitlement to service connection for a left elbow condition The Veteran seeks service connection for a left elbow condition. Here, the Veteran had active service in the Persian Gulf and Arabian Sea between September 1990 and July 1997. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). A February 2020 VA examination shows the Veteran has a diagnosis of left ulnar radiculopathy. As the Veteran’s left ulnar radiculopathy is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). A February 2020 VA opinion indicates that the Veteran’s left ulnar radiculopathy has a clear and specific understood etiology. With respect to the etiology of the Veteran’s ulnar radiculopathy, the clinician explained that the Veteran fell in 2017, injuring both of his elbows. With respect to the pathophysiology of the Veteran’s ulnar radiculopathy, the clinician explained when the Veteran fell, he bruised the ulnar groove area where the ulnar nerve is located, which led to intermittent numbness in the left hand that had partially improved with physical therapy. The examiner also noted signs of epicondylitis on examination, but that these were not pertinent to the current claim because they do not cause numbness and tingling. The Board finds this opinion probative because the examiner clearly related the Veteran’s right elbow condition to a specific right elbow injury in 2017. The examiner further explained that the Veteran injured his ulnar groove, and that this injury resulted in ongoing residual numbness and tingling. Accordingly, as both the etiology and the pathophysiology of the Veteran’s right ulnar radiculopathy are fully understood, it is not considered a MUCMI and presumptive service connection is not warranted. Stewart v. Wilkie, 30 Vet. App. 383 (2018). Thus, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records are silent for complaints, diagnosis, or treatment of a left elbow condition. A March 1997 report of medical examination noted a burn scar of the left hand, but indicated normal upper extremity findings. VA treatment notes reflect that the Veteran fell in November 2016. The Veteran reported that it felt like his leg just gave out. He reported ongoing back trouble, and complaints of pain in the left arm. The Veteran was afforded a VA examination in August 2017. The Veteran reported that his left leg gave out, and that he fell on his left elbow. The Veteran reported daily elbow pain. The examiner diagnosed biceps tendonitis. The examiner opined that the left elbow condition is most probably related to a hyper-flexion of the left elbow. This injury is not typical for a fall on the left elbow as reported. Pursuant to the 2018 Board remand, the Veteran was afforded a VA examination in February 2020. The examiner noted the Veteran fell in 2017, after his left leg gave out. As a result of this fall, he landed on his left knee and both elbows. He reported numbness and tingling into his hands, which had gradually gotten better after physical therapy but had not gone away completely in his left elbow. The examiner diagnosed ulnar radiculopathy. The Board concludes that, while the Veteran has a current diagnosis of left ulnar radiculopathy, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of left ulnar radiculopathy began during service or is otherwise related to an in-service injury, event, or disease. The February 2020 VA examiner opined that the Veteran’s left ulnar radiculopathy is less likely than not related to any exposures during active service in the Persian Gulf. Instead, the examiner opined that the Veteran’s left ulnar radiculopathy is related to an injury of the ulnar groove after a fall in 2017. The examiner explained that there was no mechanism by which a single nerve would be affected by some toxic effect or exposure. The examiner further noted that there was no documentation of any problem with the left elbow until after the Veteran fell in 2017. The examiner concluded the Veteran’s left elbow condition is less likely than not incurred in or caused by service. The examiner further opined that the Veteran’s left elbow disability is less likely than not secondary to his service-connected low back disability or left lower extremity radiculopathy. The examiner explained the nerves of the lumbar cord, where the Veteran’s back arthritis is noted, do not in any way “go to” and are not related to the upper extremities. Therefore, physiologically, the examiner concluded there was no way in which any kind of low back or lumbar spine disability could impair the upper extremity nerves or upper extremity function. The examiner further concluded that there was no way mechanistically for the back disorder to aggravate the Veteran’s arm condition beyond its normal progression. While the Veteran believes his left elbow condition is related to exposures during service in Southwest Asia, he is not shown to have the experience, training, or knowledge necessary to provide a competent etiology opinion. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The competent evidence demonstrates that the Veteran’s left ulnar radiculopathy is due to a post-service injury. In sum, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply and service connection for a left elbow condition is not warranted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Entitlement to service connection for right elbow tingling and numbness The Veteran seeks service connection for right elbow tingling and numbness. Here, the Veteran had active service in the Persian Gulf and Arabian Sea between September 1990 and July 1997. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). Pursuant to the Board remand, the Veteran was afforded a VA examination in February 2020. The February 2020 VA examination shows the Veteran has a diagnosis of right ulnar radiculopathy. As the Veteran’s right ulnar radiculopathy is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). The February 2020 VA examination indicates that the Veteran’s right ulnar radiculopathy has a fully understood etiology and pathophysiology. With respect to the etiology of the Veteran’s ulnar radiculopathy the clinician explained the Veteran fell in 2017, impacting his elbow. The examiner noted that the Veteran bruised the ulnar groove area where the ulnar nerve is located, leading to the intermittent numbness in his right hand and fingers. This was partially resolved with physical therapy, but was still present to a mild degree, at least enough to be a nuisance. Thus, the examiner concluded that the Veteran’s fall, and the resulting physiological injury to the ulnar groove, resulted in the current ulnar radiculopathy condition. The Board finds this opinion probative because the examiner clearly related the Veteran’s right elbow condition to a specific right elbow injury in 2017. The examiner further explained that the Veteran injured his ulnar groove, and that this injury resulted in ongoing residual numbness and tingling. Accordingly, as both the etiology and the pathophysiology of the Veteran’s right ulnar radiculopathy are fully understood, it is not considered a MUCMI and presumptive service connection is not warranted. Thus, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of right ulnar radiculopathy, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The February 2020 VA examiner opined that the Veteran’s right ulnar radiculopathy is less likely than not related to any exposures during active service in the Persian Gulf. Instead, the examiner opined that the Veteran’s right ulnar radiculopathy is related to an injury of the ulnar groove after a fall in 2017. The examiner explained that there was no mechanism by which a single nerve would be affected by some toxic effect or exposure. The examiner further noted that there was no documentation of any problem with the right elbow until after the Veteran fell in 2017. The examiner concluded the Veteran’s right elbow condition is less likely than not incurred in or caused by service. While the Veteran believes the right elbow numbness and tingling is related to exposures during service in Southwest Asia, he is not shown to have the experience, training, or knowledge necessary to provide a competent etiology opinion. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The competent evidence demonstrates that the Veteran’s right ulnar radiculopathy is due to a post-service injury. In sum, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply and service connection for a right elbow condition is not warranted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Entitlement to service connection for fatigue The Veteran seeks service connection for fatigue. He contends his fatigue is related to service in the Persian Gulf. Here, the Veteran had active service in the Persian Gulf and Arabian Sea between September 1990 and July 1997. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The evidence does not, however, show objective indications of a qualifying chronic disability. The Veteran was afforded a VA examination in April 2017. The Veteran reported a history of fatigue, muscle weakness, and joint pains. The examiner opined that the Veteran’s fatigue could easily be related to the myriad of medical diagnoses that he has. The examiner further explained that it was not possible to separate the symptoms out and determine specific etiologies, when all of the Veteran’s medical and social and mental comorbidities are factored in. The Veteran was afforded a VA examination in February 2020. The examiner found that the Veteran did not have a diagnosis of chronic fatigue syndrome. The examiner further indicated that the Veteran’s disability pattern was not an undiagnosed illness, medically unexplained chronic multi-symptom illness of unknown etiology, chronic multi-symptom illness with a partially explained etiology, or disease with a clear and specific etiology and diagnosis. The examiner explained that the Veteran’s chronic fatigue was a symptom of multiple other conditions discussed in the exam, but was not in itself an illness. As the Veteran does not have objective indications of a qualifying chronic disability, service connection pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 is not warranted. The Board concludes that the Veteran does not have a current diagnosis of chronic fatigue syndrome and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In February 2020, a VA examiner evaluated the Veteran and determined that, while he experiences fatigue symptoms, he did not have a diagnosis of chronic fatigue syndrome, or other illness. Rather, the examiner explained that the Veteran’s fatigue was a symptom of other diagnosed disabilities. The examiner specifically noted that the fatigue was a symptom of anemia, back pain, gastroesophageal reflux disease (GERD), chronic alcohol abuse, and depression. Thus, the examiner concluded that there was no diagnosis in itself, to include chronic fatigue syndrome. While VA medical records from November 2016 contain symptoms of fatigue, there is no indication of a specific diagnosis or assessment of chronic fatigue syndrome. Consequently, the Board gives more probative weight to the February 2020 VA examiner’s clinical findings. While the Veteran believes he has a current diagnosis of chronic fatigue, undiagnosed illness, or medically unexplained multi-symptom illness, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Because there is no evidence of currently diagnosed chronic fatigue syndrome, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the benefit of the doubt doctrine does not apply; the appeal in this matter must be denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) The Veteran seeks service connection for PTSD. The threshold question is whether the Veteran is currently diagnosed with PTSD. Brammer v. Derwinski, 3 Vet. App. 223 (1992); 38 C.F.R. § 3.304 (f). The Board concludes that the Veteran does not have a current diagnosis of PTSD and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In April 2016, June 2017, and February 2020 VA examiners evaluated the Veteran and determined that, while he experiences psychiatric symptoms, he did not have a diagnosis of PTSD. Rather, he was diagnosed with alcohol related mood or depressive disorder. While VA medical records from February 2019 contain a finding of PTSD listed in the Veteran’s active problem list, there is no indication of specific diagnostic criteria. Instead, the statement appears to be based on the Veteran’s self-reported medical history. Consequently, the Board gives more probative weight to the April 2016, June 2017, and February 2020 VA examiners’ clinical findings which determined the Veteran did not meet the diagnostic criteria for PTSD. While the Veteran believes he has a current diagnosis of PTSD, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Because there is no evidence of currently diagnosed PTSD, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the benefit of the doubt doctrine does not apply; the appeal in this matter must be denied. REASONS FOR REMAND Entitlement to service connection for cervical strain The Veteran seeks service connection for cervical strain. In October 2018, the Board remanded the claim for an addendum opinion. The Veteran underwent a VA examination in February 2020. The examiner opined that the Veteran’s neck condition is less likely than not incurred or caused by the claimed in-service injury, event, or illness. The examiner indicated that there was no documented history of neck problems, and that the Veteran’s history did not suggest any neck problems until he fell in 2017. Therefore, the examiner concluded the Veteran’s current cervical strain is less likely than not related to service. The Board finds the opinion inadequate as it was based solely on the absence of medical documentation. See Dalton v. Peake, 21 Vet. App. 23 (2007). Further, a VA examination report dated August 2016 reflects that the Veteran reported neck pain prior to his 2017 fall injury. Accordingly, an addendum opinion that properly considers the relevant lay evidence must be obtained. Entitlement to service connection for sleep apnea The Veteran seeks service connection for sleep apnea. He contends his sleep apnea is secondary to his service-connected gastroesophageal reflux disease (GERD) and/or alcohol use disorder. Alternatively, he contends that his sleep apnea is the result of his service in Southwest Asia during the applicable time period. In the October 2018 decision, the Board noted that the Veteran was a Persian Gulf veteran and, therefore, the provisions of 38 C.F.R. § 3.317 were applicable to these claims. The Board found that additional notice under § 3.317 needed to be provided, but no additional development with respect to a VA addendum was directed. A June 2017 VA examiner had found the Veteran’s sleep apnea diagnosis had a known etiology and was not associated with environmental exposures in Southwest Asia. Since then, the U.S. Court of Appeals for Veterans Claims (Court) issued Stewart v. Wilkie, 30 Vet. App. 383 (2018), which stated that an adequate medical opinion should address both the etiology and pathophysiology of a multisymptom illness. This inquiry is veteran-specific with regard to both factors. Accordingly, remand is required for a supplemental medical opinion that complies with Stewart. Entitlement to service connection for headaches The Veteran seeks service connection for headaches. He contends that his headaches are the result of his service in Southwest Asia during the applicable time period. In the October 2018 decision, the Board noted that the Veteran was a Persian Gulf veteran and, therefore, the provisions of 38 C.F.R. § 3.317 were applicable to these claims. The Board found that additional notice under § 3.317 needed to be provided. A February 2020 VA examiner found the Veteran’s migraine headaches diagnosis had a known etiology and was not associated with environmental exposures in Southwest Asia, but did not clearly address the pathophysiology of the Veteran’s migraine headaches in the opinion or the associated examination report. Since then, the U.S. Court of Appeals for Veterans Claims (Court) issued Stewart v. Wilkie, 30 Vet. App. 383 (2018), which stated that an adequate medical opinion should address both the etiology and pathophysiology of a multisymptom illness. This inquiry is veteran-specific with regard to both factors. Accordingly, remand is required for a supplemental medical opinion that complies with Stewart. Service connection for hearing loss is remanded. Service connection for tinnitus is remanded. In 2018, the Board remanded the Veteran’s claims for a new VA examination because the Veteran submitted medical literature indicating that noise exposure may result in delayed onset hearing loss. The examiner was asked to provide a complete rationale and directed attention to the submitted medical literature. A January 2020 VA examiner provided negative etiological opinions, noting that there was no shifting in hearing sensitivity during service, hearing sensitivity within normal limits at separation, and that the Institute of Medicine stated that there was no scientific basis to conclude that permanent hearing loss directly attributable to noise exposure will develop long after such noise exposure. Therefore, there was no scientific basis on which to conclude that the current hearing loss was caused by or the result of military service. The examiner also provided a negative opinion concerning tinnitus, noting in part that the medical literature did not support late onset noise-induced tinnitus. The Board finds that the opinions are inadequate. The examiner appears to rely on one study, but does not discuss the medical literature submitted by the Veteran. Remand is required. Entitlement to TDIU is remanded. Finally, the TDIU claim remains inextricably intertwined with the above claims for service connection. Accordingly, the Board finds that it cannot be adjudicated until the AOJ completes the directed development of the service connection claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s cervical strain is at least as likely as not related to active service. A detailed rationale must be provided for the opinion rendered. 2. Schedule the Veteran for an examination to determine the nature and etiology of his sleep apnea. The examiner must review the entire claims file, including a copy of this remand. The examiner is asked to provide responses to the following: A) Is the etiology of the Veteran’s sleep apnea (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the etiology of the disease or disability population as a whole. B) Is the pathophysiology of the Veteran’s sleep apnea (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. C) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s sleep apnea was incurred in, or is otherwise related to, his active service? A complete rationale must be provided for all opinions expressed. 3. Schedule the Veteran for an examination to determine the nature and etiology of his migraine headaches. The examiner must review the entire claims file, including a copy of this remand. The examiner is asked to provide responses to the following: D) Is the etiology of the Veteran’s migraine headaches (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the etiology of the disease or disability population as a whole. E) Is the pathophysiology of the Veteran’s migraine headaches (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s migraine headaches were incurred in, or is otherwise related to, his active service? A complete rationale must be provided for all opinions expressed. 4. Request an appropriate VA medical examiner on the likely etiology of the Veteran’s bilateral hearing loss disability and tinnitus. The claims folder must be made available for review. Based on a review of the record, the examiner should address the following: Is it at least as likely as not that the Veteran’s bilateral hearing loss disability was incurred in or related to service? In rendering the opinion, the examiner must consider all lay and medical evidence, including the submitted medical literature by the Veteran and his reports of noise exposure during service. 5. After taking any additional development deemed necessary, readjudicate the issues on appeal. If any benefit sought remain denied, issue a supplemental statement of the case and return the matters to the Board, if otherwise in order. JESSICA SEAY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Lauritzen, 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.