Citation Nr: 21025416 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-58 830A DATE: April 28, 2021 ISSUES 1. Entitlement to accrued benefits for service connection for bilateral hearing loss disability. 2. Entitlement to accrued benefits for service connection for a left knee disability, variously claimed as degenerative joint disease and arthritis. 3. Entitlement to accrued benefits for service connection for a right knee disability, variously claimed as degenerative joint disease and arthritis. 4. Entitlement to accrued benefits for service connection for dementia, claimed as secondary to claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD). 5. Entitlement to accrued benefits for service connection for hypertension, variously claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD), and to include as due to herbicide exposure. 6. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 50 percent prior to June 18, 2018. 7. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 70 percent from June 18, 2018. ORDER Entitlement to accrued benefits for service connection for bilateral hearing loss disability are granted. Entitlement to accrued benefits for service connection for a left knee disability, variously claimed as degenerative joint disease and arthritis are denied. Entitlement to accrued benefits for service connection for a right knee disability, variously claimed as degenerative joint disease and arthritis are denied. Entitlement to accrued benefits for service connection for dementia, claimed as secondary to claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD) are denied. Entitlement to accrued benefits for service connection for hypertension, variously claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD), and to include as due to herbicide exposure, are denied. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD) in excess of 50 percent prior to June 18, 2018 are denied. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD) in excess of 70 percent from June 18, 2018 are denied. FINDINGS OF FACT 1. Exposure to herbicide agents has been conceded. 2. The Veteran passed away in February 2021. 3. The competent, credible, and probative lay and medical evidence is in relative equipoise as to whether the Veteran’s bilateral hearing loss disability had its onset during service. 4. A left knee disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 5. A right knee disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 6. Dementia was not manifest in service, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 7. Hypertension was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 8. Prior to June 18, 2018, post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD) was manifested by occupational and social impairment with reduced reliability and productivity; with such symptoms as difficulty in adapting to work, difficulty in adapting to a worklike setting, difficulty in adapting to stressful circumstances, disturbances of motivation and mood, chronic sleep impairment, anxiety, suspiciousness, depressed mood, and mild memory loss. 9. The Veteran is currently assigned a total schedular rating effective June 18, 2018 by way of the November 2018 rating decision granting a total disability rating based on individual unemployability (TDIU) based on impairment due to PTSD. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the appellant’s favor, bilateral hearing loss disability was incurred in service. 38 U.S.C. § 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.385 (2018). 2. A left knee disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 3. A right knee disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. Dementia was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 5. Hypertension was not incurred in or aggravated by service, cardiovascular-renal disease may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 6. The criteria for accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 50 percent prior to June 18, 2018 have not been met or approximated. 38 U.S.C. § 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 3.400, 4.1, 4.126, 4.130, 4.2, 4.3, 4.7; Diagnostic Code (DC) 9411 (2018). 7. The appellant’s claim for accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 70 percent from June 18, 2018 is moot as a matter of law as he is already in receipt of a total rating. 38 U.S.C. §§ 7104, 1155; 38 C.F.R. §§ 3.340, 3.341, 4.1, 4.126, 4.130, 4.16, 4.2, 4.3, 4.7; Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1969 to January 1973. This matter is before the Board of Veterans Appeals (Board) on appeal from February 2015 and January 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. The record shows that the Veteran passed away in February 2021. The appellant is his surviving spouse. Her substitution was accepted by VA by way of a letter dated March 26, 2021 containing the relevant information. We will proceed accordingly. During the pendency of the appeals, an August 2018 rating decision granted an increased disability rating of 70 percent for PTSD to include MDD effective June 18, 2018. As the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, the claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). A November 2018 rating decision granted entitlement to a total disability rating based on individual unemployability (TDIU) and eligibility to Dependents' Educational Assistance. On January 23, 2020, VA received a copy of a DD-214. Highlighted in the remarks is, “SERVED IN VIETNAM.” (capitalization in original). Later, a May 2020 rating decision conceded herbicide exposure and granted service connection for arterioslerotic heart disease (ischemic heart disease) associated with agent orange exposure. Recently, the Veteran’s surviving spouse submitted several new claims, including a VA 21-534EZ Application for Dependency and Indemnity Compensation or Death Pension by a Surviving Spouse or Child, and a VA 21-530 Application for Burial Benefits. 38 C.F.R. § 3.155. These issues have not yet been adjudicated by the RO. Therefore, the Board does not have jurisdiction over them, and they are referred to the RO for appropriate action. 38 C.F.R. § 19.9(b). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). Significantly, a VA Form 646 Statement of Accredited Representative in Appealed Case dated May 13, 2019 is of record. The Veteran and his representative indicated that they rested the appeal on the answer to the statement of the case. He had no further argument. It contains clarifications of his theory of entitlement. For hypertension, the condition is claimed as a presumptive to agent orange exposure. For the left and right knees, these were allegedly injured as a result of the Veteran’s duties as an aircraft mechanic, having to fluctuate between his upper and lower extremities and bending of the knees. For bilateral hearing loss disability, he was surrounded by loud noises on a daily basis as part of his duties as an aircraft mechanic. The Board considered this and other lay evidence in reaching the decisions below. Next, a February 2020 VA 38 U.S.C. § 5103 Notice Response Letter is of record. The Veteran indicated, “I have enclosed all the remaining information or evidence that will support my claim, or I have no other information or evidence to give VA to support my claim. Please decide my claim as soon as possible.” The appellant in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection Claims for VA benefits do not survive a claimant’s death. However, a qualified survivor (including a spouse) may carry on the deceased veteran’s claim for benefits by submitting an application for accrued benefits within one year after the veteran’s death. 38 U.S.C. § 5121 (a), (c); 38 C.F.R. § 3.1000. Accrued benefits are “periodic monetary benefits... to which an individual was entitled at death under existing ratings or decisions or those based on evidence in the file at date of death.” Id. An accrued-benefits claim incorporates any prior final adjudication on claims brought by a Veteran, because it derives from the Veteran’s claims. An accrued benefits claim is, under the law, derivative of, and separate from, the Veteran’s claims. See Zevalkink v. Brown, 6 Vet. App. 483, 489-490 (1994), aff’d, 102 F.3d 1236 (Fed. Cir. 1996). Thus, in the adjudication of a claim for accrued benefits, the claimant is bound by the same legal requirements to which the Veteran would have been bound had he survived to have his claims finally decided. To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). We note that arthritis is a chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as “chronic.” See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to accrued benefits for service connection for bilateral hearing loss disability The Board incorporates its discussion from the sections above by reference. The determination of whether a Veteran has a hearing loss disability is governed by 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). By way of background, the December 1972 Report of Medical Examination disclosed a clinically normal evaluation of the ears – general, ear drums, head, and neurologic system. The whisper test was 15/15 in each ear, however, there are no audiometric test results from separation. In addition, the Veteran’s DD-214 reflects his military occupational specialty (MOS) as an Aircraft Mechanic. The Service Personnel Records (SPRs) support his contentions of occupational noise exposure in service. For example, a set of SPRs was received on October 3, 2014. The first page is Dated May 2, 1972 to November 1, 1972. The Veteran was assigned to the Power Plants shop of the Aircraft Division. It reads in part, “He has been asked to work around the clock during prop and engine changes.” The following page shows that the Veteran performed scheduled and unscheduled maintenance on propeller, fuel, and related systems. He also had watches and shore patrol duties. Additional SPRs are substantially the same. Next, of note, the Veteran filed his original claim for service connection for bilateral hearing loss disability received by VA on August 13, 2014. This was on a VA 21-4138 Statement in Support of Claim. It shows that the Veteran has bilateral hearing loss and tinnitus as a result of his military duties as an aircraft mechanic. He performed maintenance on E-2B power plants, and aircraft security. He reported that he had no hearing protection while on the flight deck. Next, in February 2015, the Veteran was afforded a VA audiological examination. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follow: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 30 45 LEFT 15 10 15 45 60 The average decibel loss is 28 in the right ear. The average decibel loss is 33 in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 92 percent in the left ear. The VA examiner diagnosed sensorineural hearing loss in the right ear and left ears, along with tinnitus. Next, the VA examiner opined that use of pure tone test results and the word recognition score was appropriate for this Veteran. The VA examiner opined that the test results are valid for rating purposes. However, the VA examiner ultimately could not render a nexus opinion for either ear without resorting to speculation. The VA examiner explained: In service hearing tests reviewed were; whisper test 15/15 at enlistment and discharge and pure tone testing indicating normal thresholds through 3000Hz. But did not test beyond 3000Hz. The available military tests of record cannot and did not determine status of hearing beyond 3000Hz. It would be speculation to suggest that Veteran had pre-existing high frequency hearing loss or that he sustained it during his service based on potential noise exposure in his MOS as Veteran states on history today that he always wore his ear protection when in proximity to aircraft engine noise. Following this opinion is a positive nexus opinion for tinnitus based upon military noise exposure. Later, a February 2015 rating decision denied service connection for bilateral hearing loss disability. Nevertheless, it granted service connection for tinnitus based upon the VA examiner’s separate positive nexus opinion. Additional evidence continued to be received, and the claim remained continuously on appeal. However, the January 2016 rating decision confirmed and continued the prior denial for bilateral hearing loss disability. Next, the April 23, 2016 VA 21-4138 Statement in Support of Claim shows in part that the Veteran worked as a jet mechanic while in service and was “constantly surrounded by loud noises.” Additional private treatment records include audiometric testing results from CSX Transportation, Inc. where the Veteran was employed after separation. The issue remains a nexus. The appellant contends that she is entitled to accrued benefits for service connection for bilateral hearing loss disability. The Veteran was competent to provide evidence of that which he experienced, including a history of noise exposure in service and difficulty hearing. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also observes that the Veteran was competent to report that his symptoms of hearing loss and tinnitus continued since service. There is only a whisper test from separation, combined with evidence of significant noise exposure. Therefore, the Board does not have a basis upon which to question or doubt the credibility of the Veteran’s lay contentions. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). To the extent the February 2015 VA examination could be construed as finding against bilateral hearing loss disability being directly attributable to service, the VA examiner’s opinion is inconsistent with the Veteran’s own noted competent and credible lay reporting of an onset in service. It is inconsistent with his prior statement that he was exposed to the flight line without noise exposure. The examination is also internally inconsistent in that the same reasoning for a positive nexus for tinnitus is not extended to bilateral hearing loss disability. There is no explanation for this. The Veteran reported exposure to the flight line and a power plant, and did not wear hearing protection. The fact that there was no hearing loss in service is not dispositive of the issue and an opinion based on the whisper test is inadequate. See Hensley, supra. There are no audiometric pure tone test results at separation upon which an examiner could definitively conclude that hearing was normal at separation. The VA examiner diagnosed hearing loss disability for VA purposes. He did not necessarily render a negative nexus opinion. Therefore, the VA examiner’s inconclusive opinions are entitled to moderate probative weight. Thus, the most probative evidence of record is the Veteran’s lay evidence, which is consistent with his series of lay statements. He experienced impairment later diagnosed as bilateral hearing loss disability. See Hensley, supra. We note that the Veteran’s descriptions of direct exposure to events in service, without hearing protection, have remained steady throughout the lengthy appeals period. They are remarkably consistent with the descriptions of his duties in the contemporaneous SPRs. At the very least, the evidence of record is in relative equipoise as to the onset of the Veteran’s bilateral hearing loss disability. Therefore, resolving reasonable doubt in the appellant’s favor, the Board finds that it is at least as likely as not that the Veteran’s bilateral hearing loss disability was incurred in service. He had bilateral hearing loss continuously since service. The appellant is therefore entitled to the benefit of the doubt. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, accrued benefits for service connection for bilateral hearing loss disability are warranted. 38 C.F.R. § 3.303 (d). 2. Entitlement to accrued benefits for service connection for a left knee disability, variously claimed as degenerative joint disease and arthritis 3. Entitlement to accrued benefits for service connection for a right knee disability, variously claimed as degenerative joint disease and arthritis The Board incorporates its discussion from the sections above by reference. We note that arthritis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the December 1972 Report of Medical Examination disclosed a clinically normal evaluation of the feet, lower extremities, and spine, other musculoskeletal system. Ongoing private treatment records from Dr. J. M. at the DeGraff Memorial Hospital show a past medical history of knee disability. For example, on page 5 of 17 is a past surgical history of right knee arthroscopy. This page is dated February 6, 2012. Later, a May 30, 2012 VA Primary Care Note shows that the Veteran was transferring care to VA from Dr. J. M. It shows that the Veteran has a prior medical history of bilateral arthroscopic knee surgery. The Primary Care Notes from an examination that day show bilateral knee and hip pain with exertion. Later, a July 9, 2013 VA treatment record disclosed bilateral knee pathology. It reads: 5. DJD of knees: I’m going to get x-rays and refer to physical therapy. Will consider corticosteroid injections in the future. He will return to see me in 6 months and have fasting blood work one week prior. He understands and agrees with the above plan. 7/12/2013 ADDENDUM STATUS: COMPLETED please let pt know that his knee xrays show arthritis and he should go schedule PT appt as soon as he gets the letter from them. Thanks. Subsequent VA active problem lists show, “DJD mainly of the knees which has been bothering him more.” A July 25, 2014 VA treatment record reads in part, “No edema. His knees have crepitations bilaterally, no effusion. He has erythematous scaling lesions between his toes.” It shows DJD of the bilateral knees which was bothering him more. Additional VA treatment records are substantially the same. The issue remains a nexus. An April 23, 2016 VA 21-4138 Statement in Support of Claim shows in part that the Veteran’s knee disabilities are a result of constant wear and tear that he endured while in service. Next, the aforementioned May 2019 VA 646 shows that the Veteran’s knee disabilities are the result of his duties as an aircraft mechanic in service, having to fluctuate between his upper and lower extremities, and bending of the knees. The appellant contends that she is entitled to accrued benefits for service connection for right and left knee disabilities. The Veteran was competent to provide evidence of that which he experienced, including his duties in service. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He was competent to report experiencing knee pain. He was competent to report when he began receiving treatment for the bilateral knees, that he had arthritis, and when degenerative changes of the right and left knees were first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the contemporaneous treatment records, including the STRs, and the VA treatment records. First, the separation examination is clinically normal for the feet, lower extremities, and spine, other musculoskeletal system. Following arthroscopy from his private treatment provider, the Veteran presented to VA on May 30, 2012. Subsequent imaging diagnosed DJD of both knees. Thus, the first documentation of the Veteran having a chronic knee disability was several years removed from separation. By way of the Veteran’s lay reporting to treatment providers, he experienced worsening knee pain after this point. The Board assigns substantial probative weight to the contemporaneous treatment records. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A right or left knee disability was not manifest in service or within one year from separation, and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report right and left knee pain, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. There are no reports of right or left knee disability, including due to pain, at separation. There is no imaging from service diagnosing arthritis. The Veteran’s theory of entitlement is largely based upon conclusory statements that right and left knee disabilities are attributable to his duties in service. However, the STRs from after reported in-service events disclosed a clinically normal examination of the lower extremities and musculoskeletal system. Furthermore, we note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). We have also considered the Veteran’s lay statements to the extent that he was competent to relate current pain in the right and left knees. However, they are outweighed by the medical evidence of record. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability.” The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Recently, in Wait v. Wilkie, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause “functional impairment of earning capacity,” and therefore meet the current disability requirement under Saunders. Wait v. Wilkie, 33 Vet. App. 8, 2020 U.S. App. Vet. Claims LEXIS 1609, 2020 WL 5200689. The CAVC held that, to meet the current disability requirement under Saunders, “there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person.” The CAVC clarified that the Board must make the factual determination whether the Veteran’s manifestations rose to the level of a functional impairment in earning capacity. In the instant case, however, there was no additional functional impairment due to pain alone as is addressed by Saunders related to service. It follows that the weight of the evidence is against any indication of a relationship to service for any neurological manifestations of a right or left knee disability. Therefore, even after considering Saunders, accrued benefits for service connection for a right or left knee disability are not warranted. The Board has considered multiple theories of entitlement, to include, direct service connection, presumptive service connection, and secondary service connection. Regardless of the theory, entitlement to accrued benefits for service connection for left and right knee disabilities are not warranted. The Board has assigned the most probative weight to the contemporaneous medical records, including the STRs. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. We considered Saunders. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, accrued benefits for service connection for a right and left knee disability are not warranted. 4. Entitlement to accrued benefits for service connection for dementia, claimed as secondary to claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD) The Board incorporates its discussion from the sections above by reference. By way of background, the December 1972 Report of Medical Examination disclosed a clinically normal evaluation of the head, psychiatric evaluation, and neurologic system. Years later, a January 28, 2014 VA Preventative Medicine Note is of record. It reads in part: Dementia Screen: Behavioral Trigger Review (To be completed by VA Staff) Is a “poor historian” or seems odd” – Response: No - O Points Often defers to a caregiver when asked questions? Response: No - O Points Has noticeable changes in behavior or dress, is inattentive in appearance or inappropriately dressed? Response: No - O Points 3. Fails to appear for scheduled appointments or comes at the wrong time or wrong day. Response: No - O Points Later that year, a July 31, 2014 VA Psychology Consultation is of record. The neuropsychologist concluded in part: This man showed significant problems with recalling a word list after a delay and with several timed attention and executive tests. Mr. [Veteran] endorsed prominent symptoms of depression, generalized anxiety, and PTSD. While some of his cognitive inefficiency may be related to PTSD, his conversational dysnomia is not typical of that disorder. Given his overall cognitive profile, risk factors for cerebrovascular disease, and report of recent onset tremor, he will be referred to Neurology for further evaluation. Additional VA and private treatment records are substantially the same. Later, a December 2015 VA Review Post Traumatic Stress Disorder Disability Benefits Questionnaire (DBQ) is of record. The VA examiner identified Mild Possible Vascular Neurocognitive Disorder. The comments read, “Possibly vascular disease related. This is a new diagnosis and the etiology was unclear to this examiner when reviewing neuropsychology and neurology notes but in those notes cerebrovascular risk factors were identified.” The April 23, 2016 VA 21-4138 Statement in Support of Claim shows in part that the Veteran was told by his doctor that dementia can sometimes be caused by stress, whereas in this case, it was caused by his PTSD. The statement does not say which doctor provided this opinion or include additional reasons and bases. Next, the Veteran was afforded a June 2018 VA PTSD examination with DBQ. The VA examiner identified Neurocognitive disorder due to Alzheimer’s disease. The VA examiner remarked: “Neurocognitive Disorder unspecified” was a proposed diagnosis listed on [R.] MD’s 4/24/18 VA psychiatric progress note which added, “He presented today with his wife with reports of having more difficulties with memory and word finding ability during speech. He gets frustrated due to these difficulties, also (when donepezil 23mgqd was continued by that psychiatrist then).” Also in June 2018, VA received a private treatment record from M. S.-R., M.D. It shows that the physician is familiar with the Veteran’s medical conditions and medical history. It does not specifically show that the claims file was reviewed. The psychiatrist indicated that the Veteran’s PTSD, neurocognitive disorder unspecific, and dementia, are more likely than not related to PSTD. The psychiatrist indicated that the findings were based on a clinical face to face interview and a mental health status examination from 2017 which showed that an unspecified neurocognitive disorder is likely Alzheimer’s versus vascular dementia. The psychiatrist prescribed related medication. The medical opinion was signed on June 23, 2018. The appellant contends that she is entitled to accrued benefits for service connection for dementia. The Veteran was competent to provide evidence of that which he experienced, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). More specifically, the Veteran was competent to report difficulty with memory and word finding ability during speech. The Veteran was competent to relate what he had been told by a professional. He was competent to report when he began receiving treatment for psychiatric difficulties, and when an unspecified neurocognitive disorder was identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinions as to the diagnosis and cause of a dementia disability are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran had medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the STRs, and the VA examinations. First, the separation examination is clinically normal for the head, psychiatric evaluation, and neurologic system. Early VA treatment records do not initially show dementia upon screening. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the detailed opinions of the VA examiners. In December 2015, the VA examiner identified Mild Possible Vascular Neurocognitive Disorder. The June 2018 VA examiner confirmed such impairment due to Alzheimer’s disease. We note that if the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, the Board assigns the most probative weight to the findings of the VA examiners. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A dementia disability was not manifest in service or within one year from separation, and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report memory difficulty, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as organic disease of the nervous system or cardiovascular renal disease, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented medical complaints of memory difficulty decades after discharge. The December 2015 VA examiner wrote, “This is a new diagnosis...” This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that “evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran’s health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service”). In short, the most probative evidence is the clinically normal STRs upon discharge and VA examinations. The most probative evidence establishes a remote onset of possible mild neurological impairment several years after discharge. Additionally, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). In Martinez-Bodon v. Wilkie, No. 18-3721, the United States Court of Appeals for Veterans Claims (CAVC) expanded the Federal Circuit’s decision in Saunders in finding it is not limited to pain. Rather, the definition of “disability” in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) includes any “condition” that results in “functional impairment of earning capacity,” including a psychiatric condition. The CAVC also held that VA has the authority to adopt and apply its rating schedule and has used this authority (in 38 C.F.R. §§ 4.125 and 4.130) to limit compensation for psychiatric disabilities to those with a DSM-5 diagnosis. In the instant case, however, there is no additional impairment related to service. It follows that the weight of the evidence is against any indication of a relationship to service for any claimed neurological manifestations of a dementia disability. Next, it appears another theory of entitlement to service connection for dementia is one of secondary service connection. More specifically, he contends that dementia is secondary to his service-connected PTSD with MDD. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that the preponderance of the evidence does not link dementia, however diagnosed, to PTSD to include MDD. First, although was competent to report what he has been told by his physician, the limited report of a relationship between the two disabilities in the VA 21-4138 is not sufficient. The June 2018 VA examiner attributed any neurocognitive disorder to Alzheimer’s disease. Even assuming claimed dementia can be liberally construed as diagnosed Alzheimer’s disease, though we do not concede this, the weight of the evidence is still against any relationship to service-connected PTSD. The June 2018 medical opinion from M. S.-R., M.D. itself is not conclusive. It lists several conditions, including dementia, before the nexus opinion check box. There is not a complete rationale citing to evidence in the claims file. Second, in contrast, the July 31, 2014 VA neuropsychologist opined, “While some of his cognitive inefficiency may be related to PTSD, his conversational dysnomia is not typical of that disorder.” Consistently, the December 2015 VA examiner wrote, “This is a new diagnosis and the etiology was unclear to this examiner when reviewing neuropsychology and neurology notes but in those notes cerebrovascular risk factors were identified.” The June 2018 VA examiner implicitly attributed the “Neurocognitive disorder (as) due to Alzheimer’s disease.” The wording of the diagnosis suggests a distinct etiology from PTSD. In sum, the weight of the evidence suggests that dementia is less likely than not proximately due to, the result of, or aggravated by any service connected disability. The Board has considered multiple theories of entitlement, to include, direct service connection, presumptive service connection, and secondary service connection. Regardless of the theory, entitlement to accrued benefits for service connection for dementia is not warranted. The Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the VA medical opinions. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no nexus to PTSD or other service-connected disability. 38 C.F.R. § 3.310. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, accrued benefits for service connection for dementia are not warranted. 5. Entitlement to accrued benefits for service connection for hypertension, variously claimed as secondary to service-connected post-traumatic stress disorder (PTSD) to include major depressive disorder (MDD), and to include as due to herbicide exposure The Board incorporates its discussion from the sections above by reference. “Hypertension” refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland’s Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104, DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. A disease specified in paragraph (2) of this subsection becoming manifest as specified in that paragraph in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; and (B) each additional disease (if any) that (i) the Secretary determines in regulations prescribed under this section warrants a presumption of service-connection by reason of having positive association with exposure to an herbicide agent, and (ii) becomes manifest within the period (if any) prescribed in such regulations in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and while so serving was exposed to that herbicide agent, shall be considered to have been incurred in or aggravated by such service, notwithstanding that there is no record of evidence of such disease during the period of such service. 38 U.S.C. §§ 1116 (a)(1). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. §§ 3.307 (a)(6)(iii). For the purposes of this section, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307 (a)(6)(i). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of §3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of §3.307(d) are also satisfied. AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin’s disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). For purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309 (e), Note 2. The diseases listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early-onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a)(6)(ii). VA has determined there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27630-27641 (2003). By way of legal background, an April 1, 2020 VA Memorandum shows that herbicide exposure is conceded. The subsequent May 2020 rating decision reads in part: USS Saratoga was in the territorial sea of Vietnam from May 22, 1972 through May 20, 1972and on December 7, 1972. Service personnel records document you were assigned to the Carrier Airborne Early Warning Squadron 123 (VAW-123) during this time and VAW-123 was attached to the USS Saratoga. Therefore, exposure to herbicides is conceded based on your nautical service in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019, Public Law 116-23. The Board observes that in Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). By way of evidentiary history, the Service Treatment Records (STRs) include a December 1972 Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the vascular system and heart. The examiner indicated that the Veteran was qualified for release. Ongoing private treatment records from Dr. J. M. at the DeGraff Memorial Hospital show a past medical history of hypertension. For example, a February 27, 2012 private treatment record shows an assessment of “Hypertension Benign.” Similarly, VA treatment records show remote impressions of hypertension from several decades after separation. For example, a May 30, 2012 VA Primary Care Note is of record. The Veteran presented to the Upstate New York Health Care System (HCS) “To become established for hypertension, CAD, COPD.” It shows a prior medical history of hypertension. The relevant plan was for him to continue with medications. A February 7, 2020 VA Emergency Department Note contains a CPRS Computerized Problem List. It shows a diagnosis of benign essential hypertension from the Upstate New York Health Care System (HCS). Additional VA treatment records are substantially the same. The issue remains a nexus. Next, on April 23, 2016 VA received a VA 21-4138 Statement in Support of Claim. It shows in part that the Veteran “believes that his hypertensin is a result of his PTSD as well.” The Board has construed this as a theory of secondary service connection. Later, in the aforementioned VA Form 646, the Veteran through his representative asserted that hypertension is claimed as a presumptive condition to agent orange exposure. The appellant contends that she is entitled to accrued benefits for service connection for hypertension. The Veteran was competent to provide evidence of that which he experienced, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran was competent to relate what he had been told by a professional. The Veteran was competent to report when he began receiving treatment for hypertension, and when it was identified by medical treatment providers. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the contemporaneous treatment records, including the Service Treatment Records (STRs) and subsequent treatment records. The STRs disclosed a clinically normal examination of several relevant systems. There is no other documentation of hypertension in service. Approximately 40 years after discharge, VA and private treatment records show the remote onset of benign hypertension well controlled by medication in 2012. The hurdle of a remote diagnosis is not discussed in the Veteran’s Notice of Disagreement (NOD) and VA Form 9. The Board assigns substantial probative weight to the contemporaneous treatment records. Regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Hypertension was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being diagnosed with renal cell carcinoma, the Veteran’s and appellant’s own lay opinions regarding identifying a potential chronic disease entity pale in probative weight when compared to the objective medical evidence of record. Specifically, regarding the presumptive period of one year, the Board is sympathic to the appellant. However, we are bound by the governing regulations showing in part, “[A] disabling hypertension within the 1-year period will be given the same benefit of service connection as any of the chronic diseases listed.” 38 C.F.R. § 3.309 (a). In short, the most probative evidence establishes that the Veteran developed hypertension several decades after discharge. An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records does not demonstrate such continuity. Next, we consider direct and presumptive theories as they relate to conceded herbicide exposure. VA’s Secretary has determined that there is no positive association between exposure to herbicide agents and any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003). Accordingly, although herbicide exposure was conceded, the presumptive provisions of 38 U.S.C. § 1116 have no applicability in this matter. Hypertension is not such a presumptive condition. In addition, despite several years on appeal, there is no competent and probative evidence linking hypertension to herbicide exposure. See Combee, supra. Next, another theory of entitlement to service connection for a hypertension is one of secondary service connection. More specifically, he contends that hypertension is secondary to his service-connected PTSD with MDD. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that a there is no competent and probative evidence linking hypertension to any psychiatric disability. Although competent to report what he has been told by his physician, the limited report in the VA 21-4138 is not sufficient to establish such a link. It does not contain or cite to a medical opinion with complete reasons and bases for such a conclusion. There is no other competent and probative evidence linking hypertension to service connected disability. Therefore, we find that hypertension is not related to service, and is less likely than not proximately due to, the result of, or aggravated by any service connected disability. The Board has considered multiple theories of entitlement, to include, direct service connection, presumptive service connection, secondary service connection, and a connection based upon Agent Orange exposure. Regardless of the theory, entitlement to accrued benefits for service connection for hypertension are not warranted. The Board has assigned the most probative weight to the contemporaneous medical records, including the STRs. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. We also considered conceded exposure to agent orange. The most probative evidence establishes the remote onset of any hypertension unrelated to events in service. There is also no nexus to PTSD or other service-connected disability. 38 C.F.R. § 3.310. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, accrued benefits for service connection for hypertension are not warranted. Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability ratings have been previously staged. As discussed below, the same stages and their respective ratings are still warranted. 6. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 50 percent prior to June 18, 2018 7. Entitlement to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 70 percent from June 18, 2018 The Board incorporates its discussion from the sections above by reference. PTSD with MDD is currently rated at 50 percent prior to June 18, 2018 and 70 percent effective June 18, 2018, pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. DC 9411 and other DC’s addressing psychiatric disabilities are addressed under the General Rating Formula for Mental Disorders. Ratings are assigned according to the manifestation of particular symptoms. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The such symptoms as language means for example, and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The appellant asserts that the current 50 percent and 70 percent ratings for PTSD do not accurately depict the severity of the disability during the respective stages. By way of background, the Veteran was afforded a December 2013 VA PTSD examination. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner identified PTSD chronic severe. The VA examiner indicated that the disability is best summarized by, “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining relationships, and difficulty in adapting to stressful circumstances. The Veteran denied any current active suicidal or homicidal ideation. Next, the Veteran was afforded a February 2015 VA PTSD examination. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA psychologist documented, “The veteran reports that his PTSD symptoms have not improved. For the first time, his friends at a recent annual camp event, told him they witnessed him waking up screaming and swinging at something while he continued to sleep.” The VA examiner indicated that the disability is best summarized by, “Occupational and social impairment with reduced reliability and productivity.” Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining relationships, and difficulty in adapting to stressful circumstances. The psychologist remarked in part: Regarding work functioning, the veteran recalls that in the past he would forget to complete a task and that other workers would comment on this asking when he would be done. In later years, he recalls that his work performance was slower. He reports he became more anxious and more easily stressed on the job. In the past several years he has had increasing difficulty in conversation; i.e., stumbling over words. Months later, in December 2015, the Veteran was afforded a VA PTSD examination. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner documented, “The veteran has remained in retirement since the last examination. The veteran volunteers three hours a month for an annual charity event.” The VA examiner indicated that PTSD is best summarized by, “Occupational and social impairment with reduced reliability and productivity.” The VA psychologist indicated symptoms including depressed mood, anxiety, chronic sleep impairment, mild memory loss, impairment of short and long term memory, difficulty in understanding complex commands, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances. Later, the Veteran was afforded a June 18, 2018 VA PTSD examination. This is the date when there was evidence of a change. The VA examiner identified that PTSD is best summarized by, “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” The Veteran denied having any current active suicidal or homicidal ideation. We discuss this stage beginning June 18, 2018 further below. Later, an October 2018 VA addendum medical opinion shows that the Veteran has total occupational and social impairment due to PTSD. Ongoing VA and private treatment records are substantially the same. The appellant contends that she is entitled to accrued benefits for an increased disability evaluation for post-traumatic stress disorder (PTSD) to include major depressive disorder in excess of 50 percent prior June 18, 2018, and in excess of 70 percent thereafter. Diagnostic Code (DC) 9411, 38 C.F.R. § 4.130. The weight of competent lay and medical evidence indicates that a higher evaluation is not warranted. Generally, the Veteran was competent to report his feelings, including agitation, anger, and nightmares. He was competent to report that he has been diagnosed with PTSD with MDD. The Veteran competently endorsed symptoms of difficulties related to his mood, sleep, social interaction, and memory. The Board assigns significant probative weight to the Veteran’s lay reports of his symptoms, including those exhibited at the time of the VA examinations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Prior to June 18, 2018 PTSD with MDD is currently rated at 50 percent under Diagnostic Code (DC) 9411, 38 C.F.R. § 4.130. This was based upon difficulty in adapting to work, difficulty in adapting to a worklike setting, difficulty in adapting to stressful circumstances, disturbances of motivation and mood, chronic sleep impairment, anxiety, suspiciousness, depressed mood, and mild memory loss. A higher evaluation is not warranted unless there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. We assign the most probative weight to the VA examination results. The December 2013 VA PTSD examination shows symptoms including depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining relationships, and difficulty in adapting to stressful circumstances. Relatively consistently, at the February 2015 VA PTSD examination, symptoms remained depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining relationships, and difficulty in adapting to stressful circumstances. The VA examiner remarked, “In the past several years he has had increasing difficulty in conversation; i.e., stumbling over words.” Months later, in December 2015, the VA psychologist indicated symptoms including depressed mood, anxiety, chronic sleep impairment, mild memory loss, impairment of short and long term memory, difficulty in understanding complex commands, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances. Still, there was no indication of suicidal or homicidal ideation. The VA examiners did not find panic attacks that occur weekly or less often, or panic attacks that occur more than once per week. There was no impaired impulse control. Both of the February 2015 and December 2015 VA examiners indicated that PSTD is best summarized by occupational and social impairment with reduced reliability and productivity. To the extent the December 2013 VA examiner summarized that there is more severe impairment, the identified symptoms were not so severe that a higher rating is warranted. Furthermore, the summarized indication of his overall impairment is outweighed by the other two VA examinations and a consideration of the documented areas of impairment. Lastly, the level of impairment identified in 2015 was notably from after the disease was reported to have progressed. Here, we have assigned the most probative weight to the clinical findings of the VA examiners, including the Veteran’s reported symptomatology. The Board finds that the most probative evidence shows that PTSD is most closely approximated by a 50 percent rating prior to June 18, 2018. On this date, there was a change in severity of the Veteran’s symptoms, as discussed further below. We note that generally, an evaluation of 50 percent is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The Veteran’s level of impairment prior to June 18, 2018 fits such criteria. While the Veteran’s symptoms waxed and waned across the appeal period, the Board finds that the evidence of record, taken together, describes a consistent picture of symptomatology associated with the Veteran’s PTSD with MDD. He had increasing difficulty with memory, but his disability picture was still indicative of moderate impairment of social and occupational functioning. He was able to volunteer in a limited capacity. The Board has assigned substantial probative weight to the clinical findings of the VA examiners. Their summaries of the Veteran’s disability picture were offered based upon medical expertise. In addition, there is not sufficient evidence that the Veteran’s anxiety, depression, and sleep disturbance were of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating than the current 50 percent evaluation. See Bankhead v. Shulkin, No. 15-2404, slip op. at 10 (U.S. Vet. App. Mar. 27, 2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Therefore, prior to June 18, 2018, PTSD to include MDD is most closely approximated by occupational and social impairment with reduced reliability and productivity; with such symptoms as difficulty in adapting to work, difficulty in adapting to a worklike setting, difficulty in adapting to stressful circumstances, disturbances of motivation and mood, chronic sleep impairment, anxiety, suspiciousness, depressed mood, and mild memory loss. It follows that the preponderance of the evidence is against the assignment of a rating in excess of the currently assigned 50 percent rating prior to June 18, 2018. Turning to the period from June 18, 2018, this is the date when there was evidence of a change. The Veteran is already in receipt of a total schedular rating by way of the grant of a total disability rating based on individual unemployability (TDIU). See November 2018 Rating decision. This was primary based upon the severity of his PTSD. As questions of a total rating are rendered moot, with no remaining questions of law or fact to decide. See 38 U.S.C. §§ 5110, 7104; Sabonis v. Brown, 6 Vet. App. 426 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit). The TDIU is more favorable to the appellant than the 70 percent disability rating for PTSD. It follows that there is no higher rating possible from June 18, 2018. Thus, the claim must be denied as a matter of law. Put differently, the Veteran is now already in receipt of the full benefit sought. Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board is very sympathetic to the appellant’s circumstances and the emotional hardship that she has endured in the loss of her husband, the Veteran. Unfortunately, the Board finds that the preponderance of the evidence is against the claims for accrued benefits, and as such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, 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.