Citation Nr: 21028363 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-03 641A DATE: May 11, 2021 ORDER Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder is denied. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus, type II is denied. Entitlement to an initial compensable rating for erectile dysfunction is denied. REMANDED Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disability has not exhibited total occupational and social impairment. 2. Management of the Veteran's service-connected diabetes mellitus requires insulin and restricted diet; however, it does not also require regulation of activities. 3. The Veteran's service-connected erectile dysfunction is not manifested by penis deformity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for an initial rating in excess of 20 percent for diabetes mellitus, type II have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.119, Diagnostic Code (DC) 7913. 3. The criteria for an initial compensable rating for erectile dysfunction have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.115(b), Diagnostic Codes (DC) 7599-7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1966 to August 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded these and other claims in December 2018. With respect to the remanded claims seeking entitlement to higher ratings for service-connected peripheral neuropathy of the right and left lower extremities and entitlement to Automobile or other conveyance and Specially Adapted Housing, in view of rating decisions assigning a 100 percent rating for the loss of use of both feet due to peripheral neuropathy under 38 C.F.R. § 4.63 and approving entitlement to Automobile or other conveyance and Specially Adapted Housing benefits, these claims have been satisfied to the maximum extent possible and no further contentions were asserted by the representative of the Veteran in his brief of April 2021. Parenthetically, the Board would note that if that loss of use had been rated separately with a maximum of 40 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5167 and then combined pursuant to 38 C.F.R. § 4.25, this would have actually resulted in a combined rating of 70 percent. Increased rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder The Veteran is presently service connected for posttraumatic stress disorder (PTSD). In a Rating Decision dated January 2015, the Veteran was granted a rating of 70 percent and a March 2015 rating decision established that the rating is effective as of April 6, 2014. In August 2015, the Veteran filed a claim requesting an increased rating for his PTSD, which was denied in a December 2015 rating decision. The Veteran disagreed with that rating within a year, in November 2016. The Veteran's service-connected psychiatric disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the applicable diagnostic criteria, 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 ideations; 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 the veteran's personal appearance and hygiene; difficulty in adapting to stressful circumstances (including in work or work like settings); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the evidence shows 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; and/or memory loss for names of close relatives, his or her own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed and other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board acknowledges that symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Id., at 442. In adjudicating a claim for a higher rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id., at 443. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of examination. See 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely based on social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The Veteran and his representative assert that he is entitled to an initial rating in excess of 70 percent for his PTSD. The Veteran was evaluated for his PTSD symptoms by a VA examiner in January 2015. During that examination, the Veteran was diagnosed with PTSD. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported symptoms such as depressed mood anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in being able to establish and maintain effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; and the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Based on this evaluation, the Veteran was rated at 70 percent. The Board finds that the VA examination in the record is probative and should be considered competent evidence of record. The Veteran was subsequently evaluated for his PTSD symptoms by another VA examiner in September 2015. During that examination, the Veteran was diagnosed with PTSD. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that since the last VA examination, he has continued to be chronically anxious, has flashbacks of accident, depression, alcohol abuse with hospitalization, bad temper, irritability, hyper-alertness, difficulty falling asleep, sits in the house all day, avoids people, and has had breakups with his girlfriend leading to his living in his car at times since he has no place of his own. The Veteran additionally reported symptoms such as depressed mood; anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including at work or a worklike setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; and the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran was afforded another evaluation for his PTSD symptoms by another VA examiner in August 2017. During that examination, the Veteran was diagnosed with PTSD. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that since the last VA examination, he suffered the loss of his longterm girlfriend of 12 years in June 2016, at which time she had cardiac operations and then strokes. Since her death, he has gotten worse without her and has become totally isolative. The Veteran has been in touch with his older son and now lives with his son and his family, consisting of his wife and son. The Veteran reported symptoms such as depressed mood; anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran was afforded yet another evaluation for his PTSD symptoms by a VA examiner in November 2019. During that examination, the Veteran was diagnosed with PTSD. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. At this time, the Veteran reported symptoms such as depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; impaired judgement; inability to establish and maintain effective relationships; and impaired impulse control, such as unprovoked irritability with periods of violence. The Board also reviewed the Veteran's treatment records. These records indicate that, aside from his immediate family, the Veteran is isolated and stays in his room most of the time. Additionally, there are substantial stresses in the Veteran's life, as his son has been diagnosed with a rare form of cancer. That, coupled with the loss of his longtime girlfriend, have left the Veteran with increased symptomology and causes unresolved grief issues, fear of loss, increased isolation, anxiety, sleep impairment, urges to drink alcohol, increased irritability, hypervigilance, decreased motivation, and anhedonia. The VA examinations all agree that the Veteran's PTSD has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which is consistent with the Veteran's current disability rating of 70 percent. The Board also notes that the treatment records endorsed symptoms that are also consistent with occupational and social impairment with deficiencies in most areas, and therefore consistent with a 70 percent disability rating. The Board finds that although the intensity of the individual symptoms varied, the chronic nature of the duration and frequency of his PTSD symptoms reflect the severity of the Veteran's PTSD which most nearly approximates a 70 percent rating. The Board does not find that the evidence more nearly approximates a finding that the Veteran's PTSD symptoms result in total occupational and social impairment. First, there is no evidence of record that the Veteran suffered from symptoms such as gross impairment in thought or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Moreover, the Veteran has not contended on appeal that he suffers from such symptoms. As noted above, while the Veteran is noted to potentially have a total occupational impairment due to his psychiatric disability, his social impairment does not rise to the level of a total social impairment. Although the loss of his long-time girlfriend and thereafter the need to move in with his son no doubt produced even greater symptoms then he would otherwise have experienced, his familial and social capabilities have apparently allowed him to maintain at least some close relationships over the course of the time frame on appeal, which the Board does not find consistent with a total social impairment. Therefore, the Board finds that the evidence of record more nearly approximates an 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability of the Veteran 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. While the Board is very sympathetic to the Veteran's substantial stresses that undoubtably impacts his psychiatric disability, the Board finds that the Veteran's does not have a total occupational and social impairment. Accordingly, for all the foregoing reasons, the Board finds that the Veteran is not entitled to an initial rating of 100 percent for his PTSD. 38 U.S.C. § 5107. 2. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus, type II The Veteran is presently service connected for diabetes mellitus, type II. In a Rating Decision dated March 2015, the Veteran was granted a rating of 20 percent and the rating is effective as of April 6, 2014. In August 2015, the Veteran filed a claim requesting an increased rating for his diabetes mellitus, which was denied in a December 2015 rating decision. The Veteran disagreed with that rating within a year, in November 2016. The Veteran's service-connected diabetes mellitus, type II, is evaluated pursuant to 38 C.F.R. § 4.119, DC 7913. Under this criteria, diabetes mellitus requiring more than once-daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is assigned a 100 percent disability rating. 38 C.F.R. § 4.119, DC 7913. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated, is assigned a 60 percent disability rating. Id. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities is assigned a 40 percent disability rating. Id. The Board notes that the term "regulation of activities" is defined in DC 7913 as "avoidance of strenuous occupational and recreational activities." In Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007), the Court held that medical evidence is required to show that occupational and recreational activities have been restricted. Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet warrants a 20 percent evaluation. Id. In addition, the regulations stipulate that compensable complications of diabetes are to be evaluated separately, with noncompensable complications to be considered as part of the diabetic process under DC 7913. Id. at Note (1). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO, DC 7913. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). DC 7913 is deemed by the Board to be the most appropriate code, primarily because it pertains specifically to the disability at issue (diabetes mellitus) and also because it provides specific guidance as to how symptoms of this disability are to be evaluated. The Board can identify nothing in the evidence to suggest that another diagnostic code would be more appropriate, and the Veteran has not requested that another diagnostic code should be used. Accordingly, the Board concludes that the Veteran is appropriately rated under DC 7913, with reference to other diagnostic codes as required by the diagnostic criteria set forth therein. The Veteran received a diabetes mellitus VA examination in January 2015, and the examiner noted that the Veteran's treatment for his diagnosed diabetes mellitus involved prescribed oral hypoglycemic agent and required use of insulin. He was not treating his disability with regulation of activities as part of medical management of his diabetes mellitus. The examiner further noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and there were zero episodes of ketoacidosis requiring hospitalization over the past 12 months. The examiner noted that the Veteran had recognized complications of diabetes mellitus, including diabetic peripheral neuropathy and erectile dysfunction. The examiner did not address whether the Veteran's diabetes mellitus impacts his ability to work. The Veteran received another diabetes mellitus VA examination in September 2015, and the examiner noted that the Veteran's treatment for his diagnosed diabetes mellitus involved prescribed oral hypoglycemic agent and required use of insulin. He was not treating his disability with regulation of activities as part of medical management of his diabetes mellitus. The examiner further noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and there were zero episodes of ketoacidosis requiring hospitalization over the past 12 months. The examiner noted that the Veteran had recognized complications of diabetes mellitus, including diabetic peripheral neuropathy and erectile dysfunction. The examiner concluded that the Veteran's diabetes mellitus does not impact his ability to work. The Veteran received yet another diabetes mellitus VA examination in August 2017, and the examiner noted that the Veteran's treatment for his diagnosed diabetes mellitus involved prescribed oral hypoglycemic agent. He was not treating his disability with regulation of activities as part of medical management of his diabetes mellitus. The examiner further noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and there were zero episodes of ketoacidosis requiring hospitalization over the past 12 months. The examiner noted that the Veteran had recognized complications of diabetes mellitus, including diabetic peripheral neuropathy and erectile dysfunction. The examiner concluded that the Veteran's diabetes mellitus does not impact his ability to work. The Veteran received a more recent diabetes mellitus VA examination in November 2019, and the examiner noted that the Veteran's treatment for his diagnosed diabetes mellitus involved prescribed oral hypoglycemic agent and required use of insulin. He was not treating his disability with regulation of activities as part of medical management of his diabetes mellitus. The examiner further noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and there were zero episodes of ketoacidosis requiring hospitalization over the past 12 months. The examiner noted that the Veteran had recognized complications of diabetes mellitus, including diabetic peripheral neuropathy and erectile dysfunction. The examiner concluded that the Veteran's diabetes mellitus does impact his ability to work, as the Veteran cannot walk because his feet and toes are numb, and "he cannot balance well," noting an instance when the Veteran fell downtown at the post office. The Board also notes that the Veteran's diabetes mellitus does not appear to be under control, as his blood sugars are considerably higher than average. Accordingly, the medical evidence of record demonstrates that the Veteran required insulin injections daily, oral medication, and (arguably, while not noted) a restricted diet. Crucially, all of the VA examiners specifically indicated that the Veteran's activities are not limited for medical management of his diabetes mellitus. See Camacho, supra. at 365. In sum, the Board finds that the evidence is against a disability rating in excess of the 20 percent rating presently assigned for diabetes mellitus. While the use of insulin and a restricted diet is shown, the evidence does not support a finding that the Veteran's diabetes mellitus is manifested by a regulation of his recreational and occupational activities by a physician. Moreover, while he is shown to have almost consistent hyperglycemia, he has not been hospitalized for such. For these reasons, there is no basis upon which to assign an increased disability rating for his diabetes mellitus. Therefore, the Board finds that no basis exists for the assignment of a rating in excess of 20 percent for diabetes mellitus under DC 7913. 3. Entitlement to an initial compensable rating for erectile dysfunction The Veteran is presently service connected for erectile dysfunction. In a Rating Decision dated March 2015, the Veteran was granted a rating of noncompensable disability rating and the rating is effective as of April 6, 2014. In August 2015, the Veteran filed a claim requesting an increased rating for his erectile dysfunction, which was denied in a December 2015 rating decision. The Veteran disagreed with that rating within a year, in November 2016. The Veteran's service-connected diabetes mellitus, type II, is evaluated pursuant to 38 C.F.R. § 4.155(b), Diagnostic Code 7599-7522. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. An unlisted disease, injury, or residual condition is rated by analogy with the first two digits selected from that part of the rating schedule that most closely identifies the part or system of the body involved; the last two digits will be "99" for all unlisted conditions. In this case, "7599" is for disabilities of the genitourinary system. Under Diagnostic Code 7522, a 20 percent rating is appropriate for a deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. A January 2015 VA male reproductive systems examination indicates that the Veteran does not have a voiding dysfunction and has erectile dysfunction. The Veteran reported that he had been having trouble with erections for about the last 5 years or so; and noted that he is not using any medication for this condition. A September 2015 VA male reproductive systems examination indicates that the Veteran does not have a voiding dysfunction and has erectile dysfunction. The Veteran reported that since the last VA examination, he is unable to get an erection and noted that he is not using any medication for this condition. An August 2017 VA male reproductive systems examination indicates that the Veteran does not have a voiding dysfunction and has erectile dysfunction. The Veteran reported gradual and progressive loss of ability to achieve an erection, he now suffers from complete loss of erectile function. A November 2019 VA male reproductive systems examination indicates that the Veteran does not have a voiding dysfunction and has erectile dysfunction. The Veteran reported that since the last VA examination, he is unable to get an erection and noted that he is not using any medication for this condition. The Board recognizes the Veteran's contention that he has a total loss of sexual function. However, there is no evidence of a penis deformity, as required by DC 7522. In order to receive a compensable rating under DC 7522 there must not only be erectile dysfunction (impotence), but there must also be competent evidence of a penile deformity. The Board further notes that the Veteran is already in receipt of special monthly compensation based on the loss of use of a creative organ pursuant to 38 U.S.C. § 1114(k), effective from April 6, 2014. Accordingly, the Board finds that a preponderance of the evidence is against the claim. The Board has considered the applicability of the benefit of the doubt doctrine, but because the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b). REASONS FOR REMAND Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. The Veteran claims that he has degenerative disc disease of the lumbar spine which was caused by the Veteran's service-connected left knee and hip disabilities. Regrettably, a remand is necessary for further evidentiary development of the Veteran's appeal. The Veteran was provided a VA examination in January 2020. This examination confirmed the Veteran's diagnosis of degenerative disc disease of the lumbar spine and concluded that the Veteran's disability was less likely than not proximately due to or the result of the Veteran's service-connected left knee and hip disabilities. The rationale provided for this opinion is that the lumbar spine is only weakly related with the left hip and left knee, and that the left knee replacement surgery took place after he already had back pain, therefore it did not preexist it. However, the examiner seems unaware that the Veteran's left knee disability originated prior to his knee replacement and may have caused or aggravated his lumbar spine prior to the surgery. The examiner also seems to have expected a record noting correlation and used the lack of documentation of a correlation as a basis to deny such. The Board finds that this opinion is inadequate and does not address the Veteran's contentions of a potential link between his diagnosed disability and his service-connected left knee and hip disabilities. As the Veteran's lay statements, and treatment records indicate that the Veteran has a disability that could be related to a service-connected disability, the Board finds that another medical opinion is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). Specifically, a remand is required to afford the Veteran an addendum opinion or another VA examination so as to determine the nature, etiology, and severity for spondylosis of the lumbar spine. The matter is REMANDED for the following action: 1. The Veteran must be afforded either an addendum opinion, or if additional examination is deemed warranted, a new VA examination by an examiner with appropriate expertise to determine the nature, etiology, and severity of the Veteran's diagnosed lumbar spine disability. Any and all studies, tests, and evaluations that are deemed necessary should be performed. The claims folder, including a copy of this remand, should be reviewed by the examiner. The examination report should note review of these records, and the VA and private treatment records. The examiner should then provide an opinion as to whether it is at least as likely as not (i.e. a probability of 50 percent or greater) that the Veteran's diagnosed spondylosis of the lumbar spine is caused or aggravated by one of the Veteran's service-connected disabilities. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner is advised that the Veteran is considered competent to be able to report injuries and symptoms, and that his reports must be considered in formulating the requested opinions. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. R. Montalvo, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.