Citation Nr: 21024816 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 15-22 665 DATE: April 26, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating in excess of 20 percent for lumbar spine degenerative disc disease (DDD) is denied. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. Entitlement to a rating in excess of 10 percent for right knee psoriatic arthritis is denied. Entitlement to a rating in excess of 10 percent for left knee psoriatic arthritis is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran’s PTSD symptoms have not more closely approximate occupational and social impairment with deficiencies in most areas. 2. The Veteran’s lumbar spine DDD has not been manifested by forward flexion to 30 degrees or less or ankylosis of the thoracolumbar spine. 3. The Veteran’s GERD has been manifested by recurring epigastric distress with pyrosis and regurgitation; it has not been accompanied by substernal or arm or shoulder pain or productive of considerable impairment of health. 4. The Veteran’s right knee disability has been manifested by pain and flexion limited to 80 degrees; it has not been manifested by flexion limited to at least 45 degrees, limited extension, or ankylosis. 5. The Veteran’s left knee disability has been manifested by pain and flexion limited to 80 degrees; it has not been manifested by flexion limited to at least 45 degrees, limited extension, or ankylosis. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD with MDD 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 9411. 2. The criteria for a rating in excess of 20 percent for lumbar spine DDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 3. The criteria for a disability rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7346. 4. The criteria for a rating in excess of 10 percent for right knee psoriatic arthritis have not been met. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5002, 5003, 5260, 5261. 5. The criteria for a rating in excess of 10 percent for left knee psoriatic arthritis have not been met. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5002, 5003, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 1980 to July 1992. This matter is before the Board of Veterans’ Appeals (Board) following a Board Remand in March 2019. In October 2018, the Veteran testified at a Board hearing conducted by a Veterans Law Judge who is no longer employed by the Board. A transcript of that hearing is of record. In February 2021, the Board sent notice to the Veteran that the Judge who conducted his Board hearing was no longer employed by the Board and in accordance with 38 C.F.R. § 19.3(b) afforded the Veteran an additional opportunity to have a hearing before another Veterans Law Judge. The Veteran responded in February 2021 that he did not wish to have another hearing. As such, the Board will proceed based on the evidence of record. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection for acid reflux. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran is also requesting higher ratings for already established service-connected PTSD, lumbar spine DDD, and bilateral knee psoriatic arthritis. For these disabilities, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, “staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective February 7, 2021, VA’s Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38C.F.R. §4.71a). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3-2000 ; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, VA has made clear that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. As the Veteran’s claim was pending prior to February 7, 2021, the Board will consider entitlement under the prior regulations as well as the updated regulations from February 7, 2021 forward, applying the most favorable criteria for the Veteran. 1. Entitlement to a rating in excess of 50 percent for PTSD The Veteran contends that he is entitled to a higher rating for PTSD. The Veteran testified at his October 2018 Board hearing that he was reliving his trauma more often. 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 70 percent or higher. 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 include mental status examination from 2014 to 2020 which consistently indicate that the Veteran’s appearance, grooming, and speech were appropriate; that he often had poor attention span, concentration, and focus contributing to poor work performance; and that his thought content was absent auditory or visual hallucinations, a thought disorder, paranoid, suicidal, or homicidal ideations. On occasion, the Veteran reported fair to poor sleep. The Veteran underwent VA examination in August 2015 at which time the examiner noted that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity with symptoms of depressed mood, anxiety, suspiciousness, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relations, and difficulty in adapting to stressful circumstances. Mental status examination was unremarkable except for slightly constricted affect. The Veteran also described being irritable and snappy with others and that he frequently felt bad. The Veteran reported intermittent suicidal thoughts but no intent. The Veteran underwent VA examination in September 2019 at which time the examiner noted that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity with symptoms of depressed mood, anxiety, suspiciousness, and chronic sleep impairment. Mental status examination was unremarkable except for slightly constricted affect. The Veteran also described being irritable and snappy with others and that he frequently felt bad. The Veteran reported intermittent suicidal thoughts but no intent. The examiner noted that the Veteran presented to the appointment on time and exhibited adequate personal hygiene and appropriate dress; his affect was guarded and his mood was reported to be “anxious;” he was cooperative but slightly guarded and made good eye contact; he was alert and oriented; his speech was normal; his thought processes were linear and logical; and there was no evidence of a formal thought disorder or abnormal thought content. The competent evidence of record shows that the Veteran’s PTSD has been manifested by symptoms associated with a 50 percent rating such as anxiety and panic attacks and disturbances in motivation and mood, and reported intermittent suicidal ideation associated with a 70 percent rating. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. With respect to the Veteran’s reported suicidal ideation, VA treatment records indicate that the Veteran had infrequent thoughts “that it might be better if he was not around” after a distressing time in his life, in November 2010, when he was involved in a motor vehicle accident. The balance of the VA treatment records, however, demonstrate that the Veteran denied having suicidal thoughts. Thus, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 70 percent disability rating. Except for those incidents surrounding the motor vehicle accident, the Veteran consistently denied thoughts, intent, or a plan involving self-harm in existing treatment records. In addition, the record is absent any symptoms such as obsessional rituals, abnormal speech; near-continuous panic or depression, 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, and inability to establish and maintain effective relationships. The Board notes that the Veteran reported from January 2015 to 2020, that his level of support from friends and family was between 8-10/10. The record indicates that the Veteran has been married for more than 30 years; he has two sons and three granddaughters. VA treatment records indicate that over the years, the Veteran has enjoyed going on family trips and spending time with his family over holidays. At the August 2015 VA examination, the Veteran reported that he talked with his two sons regularly and had good relationships with his son and wife. He was also on good terms with his two brothers, had one good friend with whom he talked on the phone, and had recently reconnected with an old Army friend through email. At the September 2019 VA examination, with regard to social, marital, and family history, the Veteran noted that there was no significant change. As such, the Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. 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. 2. Entitlement to a rating in excess of 20 percent for lumbar spine DDD The Veteran contends that he is entitled to a higher rating for his lumbar spine DDD. The Veteran’s lumbar spine DDD has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5242 and 5243 were not to the rating schedule itself but added instruction to classify disabilities associated with IVDS under DC 5243 and all other intervertebral disc disabilities under 5242. As such, DC 5242 now reflects “Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)”; DC 5243 now reflects “Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve route; assign diagnostic code 5242 for all other disc diagnoses.” As such, the changes do not impact the general rating formula and evaluation of the disability under the pre- and post-February 7, 2021 regulations is not required. 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. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. 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). The Veteran underwent VA examination in August 2015 at which time it was noted that he was diagnosed as having lumbosacral strain in the 1980s. The Veteran reported that he had pain confined to the lower lumbar area that awakened him during the night three to four times a week as well as flare-ups of severe pain lasting two to four days about six times a year causing him to miss work. Physical examination demonstrated forward flexion to 60 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 15 degrees, and right and left lateral rotation to 5 degrees. There was pain with all motion, pain with weight bearing, and tenderness to palpation at superior aspects of sacroiliac joints bilaterally. The Veteran was unable to perform repetitive use testing as marked guarding ensued after second attempt precluding further range of motion attempts. The examiner noted that the Veteran’s level of guarding (severe) was inconsistent with a lumbar strain disorder and that he had a history of disc injury in a motor vehicle accident and the guarding was more consistent with that injury and its surgical residuals. Guarding resulted in abnormal gait or abnormal spinal contour. The examiner was unable to say without mere speculation if pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups as it required assessment by untrain observer. The examiner noted that the Veteran’s lumbar spine disability interfered with sitting and standing. Muscle strength testing was normal, deep tendon reflexes were absent bilaterally at the knee and ankle, sensory examination was normal, and he was unable to perform straight leg raising. There was no radiculopathy pain or any symptoms of radiculopathy, no ankylosis, and no IVDS. The Veteran had a scar which was not painful, unstable, or equal to or greater than six square inches. The examiner noted that x-rays showed arthritis and residuals of lumbar surgery after motor vehicle accident. The Veteran underwent VA examination in September 2019 at which time it was noted that he was diagnosed as having lumbar spine DDD in 1991. The Veteran reported daily low back pain that occurred with any bending, lifting 20 pounds, sitting a half hour, and all types of movement. The Veteran denied radicular symptoms and noted that he took tramadol as needed. Physical examination demonstrated forward flexion to 50 degrees and extension, right and left lateral flexion, and right and lateral rotation to 10 degrees. There was pain with all motion. There was no additional loss of function or range of motion on repetitive use testing; and the examiner estimated that there would be no additional loss of motion after repetitive use over time. The Veteran denied flare-up; and there was no physical evidence of guarding or muscle spasm. The examiner noted that the Veteran’s lumbar spine DDD caused interference with sitting and increased pain. Muscle strength, reflex, and sensory examinations were all normal. Straight leg raising was negative bilaterally; and there was no radiculopathy pain or any symptoms of radiculopathy, ankylosis, or IVDS. The examiner noted that the Veteran’s lumbar spine condition impacted his ability to work as there could be no bending, lifting, or carrying more than 25 pounds, and no strenuous movement of the low back. There was no objective evidence of pain on non-weight bearing, and passive range of motion exercise could not be performed or was not medically appropriate. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for lumbar spine DDD. The Board acknowledges the Veteran’s reports of functional loss due to pain; however, even considering the Veteran’s lay reports of symptoms and noted functional loss, such would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The August 2015 VA examiner was unable to say without mere speculation if pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups; the September 2019 VA examiner found no additional loss of function or range of motion on repetitive use testing and estimated that there would be no additional loss of motion after repetitive use over time. In addition, the lay and medical evidence of record is against a finding that the Veteran has any neurological abnormality associated with his spine disability. There was no signs or symptoms of radiculopathy at either VA examination. Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for lumbar spine DDD. 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. 3. Entitlement to an initial rating in excess of 10 percent for GERD The Veteran contends that he is entitled to a higher rating for his GERD. At the October 2018 Board hearing, the Veteran testified that he could hardly eat anything without it coming back up if he did not take his medication in the morning. The Veteran’s GERD is rated by analogy to 38 C.F.R. § 4.114, Diagnostic Code 7346, for hiatal hernia. Pursuant to DC 7346, a 10 percent disability rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The maximum 60 percent evaluation is 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. The Veteran underwent VA examination in January 2017 at which time he reported daily severe reflux with intermittent nausea (four or more times a year lasting for less than one day), flatus, and fecal urgency. The examiner noted that the Veteran was prescribed pantoprazole daily. The Veteran underwent VA examination in September 2019 at which time he was diagnosed as having GERD in 1992. The Veteran reported daily heartburn for which he takes Prilosec and tums as needed. The Veteran reported pyrosis, reflux, and regurgitation but denied dysphagia. The Veteran’s GERD has been productive persistently recurring epigastric distress with pyrosis and regurgitation; it has not been productive of dysphagia or accompanied by substernal or arm or shoulder pain, or productive of considerable impairment of health. VA treatment records from 2016 to 2020 show stable weight and no evidence that GERD has caused any hematemesis, melena, or anemia. Accordingly, the Veteran’s GERD manifested in two or more symptoms for the 30 percent evaluation of less severity throughout the appeal period, corresponding to the criteria for a 10 percent rating under Diagnostic Code 7346. A higher 30 percent rating under DC 7346 is not warranted. 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. 4. Entitlement to a rating in excess of 10 percent for right knee psoriatic arthritis 5. Entitlement to a rating in excess of 10 percent for left knee psoriatic arthritis The Veteran seeks higher ratings for his bilateral knee psoriatic arthritis. At his October 2018 Board hearing, the Veteran testified that his knees had gotten worse and that he was getting injections every two to three months in both knees. The Veteran’s right and left knee psoriatic arthritis have each been rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5002. Under Diagnostic Code 5002, rheumatoid arthritis is rated as an active process or based on chronic residuals such as limitation of motion or ankylosis. The ratings for the active process may not be combined with the residual ratings for limitation of motion or ankylosis. The higher evaluation will be assigned. Id. and Note. As an active process, rheumatoid arthritis is assigned a 20 percent rating for one or two exacerbations a year in a well-established diagnosis. A 40 percent rating is assigned for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent rating is assigned when the severity is less than the 100 percent criteria, but there is weight loss and anemia productive of severe impairment of health, or severely incapacitating exacerbations occurring four or more times a year or a less number over prolonged periods. A 100 percent rating is assigned when there are constitutional manifestations associated with active joint involvement that are totally incapacitating. Id. Chronic residuals of psoriatic arthritis such as limitation of motion or ankylosis are rated under the appropriate diagnostic codes for the specific joints. Where the limitation of motion of the specified joint or joints involved is noncompensable under the specific diagnostic codes, a rating of 10 percent is assigned for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. For the purpose of rating disability from arthritis, the knees are considered major joints. 38 C.F.R. § 4.45(f). The record indicates that the Veteran’s psoriatic arthritis is an active process. In addition to his knees, he has been assigned ratings for chronic residuals of limitation of motion in thumb and finger of both hands, with six digits evaluated as 10 percent disabling and four digits evaluated as zero percent disabling. See 38 C.F.R. §§ 4.25, 4.26. Thus, in order for assignment of a rating higher than the combined rating plus the bilateral factor for the orthopedic manifestations of the Veteran’s psoriatic arthritis of the knees and hands, there needs to be evidence that the psoriatic arthritis was manifested by weight loss, anemia, or severe impairment of health or by severely incapacitating exacerbations occurring 4 or more times per year. Therefore, the Veteran’s service-connected chronic residuals of psoriatic arthritis of the knees are best rated under the limitation of motion codes for the knees. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant diagnostic codes for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. In this case, the evidence may warrant separate ratings for limitation of flexion and limitation of extension. Under Diagnostic Code 5260, a 10 percent or higher rating for limitation of flexion of the leg (knee) requires flexion limited to at least 45 degrees. Under Diagnostic Code 5261, a 10 percent or higher rating for limitation of extension of the leg (knee) requires extension limited to at least 10 degrees. 38 C.F.R. § 4.71a. The Veteran underwent VA examination in June 2013 at which time he reported pain, stiffness, limited range of motion, and difficulty with bending and prolonged standing. Physical examination demonstrated flexion to 80 degrees with pain at 80 degrees and extension to zero degrees for both knees. Repetitive use testing did not result in additional limitation of motion. The examiner noted that the Veteran had less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, and interference with sitting, standing, and weightbearing. The Veteran underwent VA examination in September 2019 at which time he reported pain with stairs, pain with walking 10 minutes, and an inability to squat. The Veteran reported periodic cortisone injections and taking tramadol as needed. Physical examination demonstrated flexion to 90 degrees and extension to zero degrees with pain on both motions for both knees. There was no additional loss of function or range of motion on repetitive use testing; and the examiner estimated that there would be no additional loss of motion after repetitive use over time. The Veteran denied flare-up. The examiner noted that the Veteran had disturbance of locomotion caused by increased pain in both knees. There was no ankylosis. The Board finds that the preponderance of the evidence is against ratings in excess of 10 percent for right and left knee psoriatic arthritis. The Board acknowledges the Veteran’s lay reports of symptoms and that there was less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, and interference with sitting, standing, and weightbearing in both knees. However, even considering the functional loss, such would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. At their worst, the Veteran’s knees showed flexion to 80 degrees. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for ratings in excess of 10 percent for right and left knee psoriatic arthritis. 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. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea The Veteran contends that his sleep apnea had an onset in service and is likely related to hazardous environmental exposures while serving in the Gulf War. The Veteran underwent VA Persian Gulf War examination in December 2010 at which time the veteran reported difficulty falling and staying asleep and intermittent headaches since returning from desert storm in 1991. The Veteran reported daytime somnolence. The examiner noted positive history of sleep apnea with related symptoms of daytime hypersomnolence, snoring, and sleep disruption. The Veteran was diagnosed as having possible OSA with tension headaches with symptoms of fatigue, headaches, sleep disturbances. The Veteran testified at the October 2018 Board hearing that his wife said that before he went to Iraq, he never snored or stopped breathing in his sleep. The Veteran’s wife testified, “Why he -- he was sleeping okay, then since he came back in ’91, and he was snoring pretty badly, and a lot of times he stopped breathing, and I had to kick him or nudge him, and then he just was gasping for air. He’d just do that, and so I had to do that pretty often, and I slept many times on the couch because of his problem.” The Veteran underwent VA examination in September 2019 at which time the examiner noted that the Veteran had a history of EDS [Ehlers-Danlos syndrome], snoring, and apnea started after he returned from Iraq in 1991; however he did not have a sleep study until 2016. The examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by claimed in-service injury, event, or illness. The examiner noted that the Veteran claimed to have symptoms of sleep apnea since 1991 but due to a lack of documentation in his records of an ongoing problem and because he was diagnosed more than 25 years after the onset of symptoms, he did not feel that current sleep apnea syndrome began during service. In this case, the VA examiner relied on the lack of documentation and dismissing without explanation the lay statements of the Veteran and his wife regarding symptoms during service after returning from deployment. On remand, a medical opinion should be obtained addressing the origins of the Veteran’s sleep apnea that considers the competent lay statements of the Veteran and his wife. The matter is REMANDED for the following action: Obtain a medical opinion from a physician with appropriate expertise in diagnosing and treatment sleep apnea. After review of the record, the reviewing physician is asked to answer the following question: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea disability had its onset in, or is otherwise related to the Veteran’s period of active duty service? In providing this opinion, the physician must consider and comment upon the lay assertions of the Veteran’s wife that since returning from Iraq, the Veteran began “snoring pretty badly, and a lot of times he stopped breathing.” The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. Robert N. Scarduzio Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Olson, Patricia 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.