Citation Nr: 21028988 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 20-12 831 DATE: May 12, 2021 ORDER A disability rating in excess of 60 percent for total knee replacement with degenerative arthritis of the right knee ("right knee disability") is denied. A disability rating in excess of 20 percent for residual scars of the right knee is denied. A disability rating in excess of 10 percent for painful scar of the right knee is denied. A compensable rating for scars of the right knee is denied. A compensable rating for residual scars of the left lower extremity due to skin grafting is denied. A disability rating in excess of 10 percent for tinnitus is denied. Service connection for hypertension is denied. Service connection for bilateral hearing loss is denied. Service connection for gout is denied. Service connection for acid reflux is denied. An effective date earlier than March 30, 2017 for the assignment of a 60 percent rating for total knee replacement with degenerative arthritis of the right knee ("right knee disability") is denied. An effective date earlier than March 30, 2017 for the assignment of a 20 percent rating for residual scars of the right knee is denied. An effective date earlier than March 30, 2017 for the assignment of a 10 percent rating for painful scar of the right knee is denied. An effective date earlier than March 30, 2017 for the assignment of a noncompensable rating for scars of the right knee is denied. An effective date earlier than March 30, 2017 for the assignment of a 10 percent rating for tinnitus is denied. REMANDED Entitlement to service connection for left knee disability is remanded. FINDINGS OF FACT 1. The Veteran's status-post right total knee replacement has been manifested by chronic residuals consisting of severe painful motion or weakness in the right lower extremity. 2. Throughout the appeal period, the Veteran's residual scars of the right knee has manifested in underlying soft tissue damage measuring at least 77 cm2 but less than 465 cm2. 3. Throughout the appeal period, the Veteran's painful scar of the right knee has manifested in one scar that is painful, but not three or four scars that are unstable or painful. 4. Throughout the appeal period, the Veteran's scar of the right knee has not manifested in compensable symptoms. 5. Throughout the appeal period, the Veteran's residual scars of the left lower extremity due to skin grafting has not manifested in an area or areas of 929 cm2 or greater. 6. The Veteran is assigned a 10 percent rating for his service-connected tinnitus, the maximum schedular evaluation available for that disability. 7. The Veteran's current hypertension is not shown to have had its onset in service, within one year of separation from service, or is otherwise related to his service. 8. The Veteran's current bilateral hearing loss is not shown to have had its onset in service, within one year of separation from service, or is otherwise related to his service. 9. At no time during the appeal period has the Veteran had gout. 10. At no time during the appeal period has the Veteran had an acid reflux disability. 11. The RO granted service connection for right knee disability, residual scars of the right knee, painful scar of the right knee, scars of the right knee, and tinnitus in a rating decision issued in October 2017, with an assigned effective date of March 30, 2017, the date of the original claim. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 60 percent for total knee replacement with degenerative arthritis of the right knee are not met. 38 U.S.C.§§ 1155, 5107(b), 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5256, 5261, 5262. 2. The criteria for an initial rating in excess of 20 percent for residual scars of the right knee have not been met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7801. 3. The criteria for an initial rating in excess of 10 percent for painful scar of the right knee have not been met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7804. 4. The criteria for an initial compensable rating for scars of the right knee have not been met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7805. 5. The criteria for an initial compensable rating for residual scars of the left lower extremity due to skin grafting have not been met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7802. 6. There is no legal basis for the assignment of a schedular evaluation higher than 10 percent for tinnitus. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, Diagnostic Code 6260. 7. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.303, 3.304, 3.307, 3.309, 3.310. 8. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 9. The criteria for service connection for gout have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 10. The criteria for service connection for acid reflux disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 11. The criteria for an effective date earlier than March 30, 2017, for the grant of service connection for right knee disability have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 12. The criteria for an effective date earlier than March 30, 2017, for the grant of service connection for residual scars of the right knee have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 13. The criteria for an effective date earlier than March 30, 2017, for the grant of service connection for painful scar of the right knee have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 14. The criteria for an effective date earlier than March 30, 2017, for the grant of service connection for scars of the right knee have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 15. The criteria for an effective date earlier than March 30, 2017, for the grant of service connection for tinnitus have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset the Board notes that the undersigned Veteran's Law Judge granted the 120-day extension request of the Veteran's attorney. The request was granted in September 2020 as the Veteran's attorney expressed their intent to submit additional evidence and a Brief in support of the claims on appeal. Unfortunately, to date, no Brief or additional evidence have been submitted. As such, the Board will proceed with appeal and consider the evidence of record. The Board recognizes that there are other issues on appeal. These issues are not yet certified following remand, and will be addressed in a separate opinion. The Veteran served on active duty in the Army from December 1963 to May 1966 and from May 1966 to March 1968. Increased Rating Right knee The Veteran filed a claim for service connection in March 2017. In an October 2017 rating decision, the Veteran was assigned a 60 percent disability rating, with an effective date of March 30, 2017. As such, the Board will assess as to whether a disability rating higher than 60 percent, as of March 2017, is warranted. Among other rating criteria, VA's rating schedule includes eight diagnostic codes applicable to evaluating knee and leg disabilities, six diagnostic codes for rating disabilities involving prosthetic implants and several diagnostic codes related to amputations of the lower extremity. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263, 5051 to 5056, and 5160 to 5173. The Veteran's right knee disability is rated as 60 percent disabling under Diagnostic Code 5055, as his disability is status-post total right knee replacement. Diagnostic Code 5055 lists the diagnostic criteria specifically applicable to knee replacement (prosthesis). Under Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. (The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. In Tedesco v. Wilkie, 2019 U.S. App. Vet. Claims LEXIS 1444 (Vet. App. August 16, 2019) the Court held that "severe painful motion" in the criteria for a 60 percent rating under Diagnostic Codes 5055 is not synonymous with "limitation of motion," although limitation of motion may be considered when evaluating painful motion. During the June 2017 VA Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) examination, the Veteran reported that his right knee problems worsened after service. He has had several visits to "Ortho" and "PT" and cortisone injections done without much help. He had surgery on his right meniscus in 1972 and developed a post op staph infection, which was treated aggressively. He had skin grafting using donor skin from his left thigh to close the infection wounds. Afterwards the problem resolved, and his right knee did well for several years. His right knee began acting up again in the 1980s and the pain became unbearable. He had an arthroscopy in 1985 followed by a total knee replacement several months later. He again had post op complications, this time it was a pulmonary embolism. His total knee replacement did not result in good range of motion and he underwent extensive "PT." Since that time, he had another right knee replacement for which records are not available. He described his current symptoms as daily pain and flare ups with moderate use. He would take opioid analgesics daily for the pain. He described the flare-ups as pain and stiffness with moderate use of such as walking and standing. He also described an unsteady gait, requiring a cane. The total knee joint replacement surgery date was listed as March 1985. The residuals were listed as chronic residuals consisting of severe painful motion or weakness. The date of the meniscectomy surgery was listed as 1972 and the residuals as extensive scarring due to post op infection. He would use a cane constantly. Imaging studies showed arthritis of the right knee. His right knee would impact his ability to sit, stand, and walk. Range of motion (ROM) was 0 to 100 degrees at flexion and 100 to 0 degrees at extension. Decreased ROM contributed to functional loss. Pain was noted during the examination, at flexion and extension. There was evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was pain laterally over the extensive scarring. There was objective evidence of crepitus. The Veteran could perform repetitive use testing with at least three repetitions, with no additional functional loss or range of motion noted. Muscle strength was normal. There was no muscle atrophy. There was no ankylosis indicated or history of recurrent subluxation or lateral instability. Joint stability testing was performed, and joint instability was not shown. The examiner concluded that the Veteran did not then nor ever had recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome, or any other tibial and or fibular impairment. The meniscal condition of the right side did not have any current symptoms. During a January 2019 medical visit with a private examiner the Veteran reported chronic pain of the knees. Upon review of the record, the Board finds that a 60 percent disability is warranted throughout the appeal period, but the preponderance of the evidence is against awarding a higher rating. The Veteran's total knee replacement of his right knee occurred in 1985. Temporary total rating of 100 percent is not warranted as the total knee replacement occurred in 1985, three decades before the service connection claim for right knee disability was filed. After the temporary total rating, 60 percent is the maximum schedular rating allowed under Diagnostic Code 5055 for knee replacement. 38 C.F.R. § 4.71a. Because Diagnostic Code 5055 in VA's rating schedule pertains specifically to evaluations of total knee replacement disabilities, the Veteran's disability will not be rated by analogy to any of the other diagnostic codes. See Copeland v. McDonald, 27 Vet. App. 333, at 337 (2015). Even if it were possible to rate by analogy, the Veteran's right knee disability would remain at 60 percent. Other than the assignment of a temporary 100 percent evaluation for one year following the implantation of a prosthesis, a 60 percent disability rating is the highest rating that can be assigned pursuant to the eight diagnostic codes applicable to the evaluation of knee and leg disabilities, in addition to the six diagnostic codes for rating disabilities involving prosthetic implants. See 38 C.F.R. § 4.71a, diagnostic codes 5256 to 5263 and 5051 to 5056. Lastly, the Board recognizes that the Veteran has scarring related to his right knee disability. However, he is separately rated for these scars and these increased rating claims are also on appeal and will be discussed below. The Board notes that Diagnostic Code 5055 suggests rating intermediate degrees of symptoms by analogy under 5256, 5261, or 5262. However, as stated above, the Veteran in receipt of the maximum rating for the residuals of his disability and to rate intermediate degrees of symptoms under 5256, 5261, or 5262 would only allow for a 30 percent rating. Neither the Veteran nor his representative provided any evidence as to how and or why he thinks his symptoms warrant a higher rating. Regardless, the Veteran is not competent to assess the level of severity of the residuals of his right knee disability. Further, for the residuals of his status-post right total knee replacement, the Veteran is in receipt of the maximum rating allowed under Diagnostic Code 5055. The Board recognizes that the Veteran's right knee has caused him pain and impacts his ability to engage in certain physical activities. However, this is contemplated by the currently assigned 60 percent disability rating. Given the foregoing, the Board finds that a disability rating higher than 60 percent for status-post total knee replacement of the right knee is denied. Scars Legal Criteria During the pendency of the appeal, the criteria for evaluating certain disabilities of the skin were revised, effective August 13, 2018. See 38 C.F.R. § 4.118, (Diagnostic Codes 7801, 7802, 7805, and 7806). The amended regulations are only applicable to claims received on or after August 13, 2018, or where a claimant requests readjudication under the new criteria. See 83 Fed. Reg. 32592 (August 13, 2018) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805, 7806). The Veteran has not specifically requested consideration under the revised criteria of Codes 7801, 7802, 7805, or 7806. However, it is VA's intent that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. As such, and even though the amended regulations are not substantially different from the prior versions and would not result in a different outcome, the Board will consider both versions. Under the amended criteria which became effective on August 13, 2018, Diagnostic Code 7804 was not changed. As such, the Board will discuss this code first. Under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, with a maximum 30 percent rating warranted for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). If one or more scars are both unstable and painful, 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (2). Scars can receive separate evaluations under Diagnostic Codes 7800, 7801, 7802, and 7805, despite also being rated under Diagnostic Code 7804. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (3). Criteria effective prior to the August 13, 2018 revision Under Diagnostic Code 7801, a 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear, at least 6 square inches (39 square centimeters). Id. A 20 percent rating is warranted when these scars cover area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating is warranted when these scars cover an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A higher rating, and the maximum rating is available for deep and linear scars that affect a larger area, measuring at least 144 square inches. A deep scar is one associated with underlying soft tissue damage. See 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1). Under Diagnostic Code 7802, a maximum 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are superficial (not associated with soft tissue damage) and nonlinear, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. Id. Under Diagnostic Code 7805, any other scars, including linear scars, are to be rated based on any disabling effects and the appropriate diagnostic code for such effects. Diagnostic Code 7805 directs that any disabling effect(s) not considered in Diagnostic Codes 7801 through 7804 should be evaluated under the appropriate diagnostic code. This instruction essentially directs that scars may be rated for the functional impairment caused by the scar. Criteria effective from August 13, 2018 After the revision, Diagnostic Code 7801 amended the notes, but the criteria for this code remained the same. The six zones of the body are defined as each extremity, anterior trunk, and posterior trunk. See 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1). A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. See 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2). Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. After the revision, Diagnostic Code 7802 amended the notes, but the criteria for this code remained the same. Note (1) now reads: For the purposes of Diagnostic Code 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) now reads: A separate evaluation may be assigned for each affected zone of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. After the revision, Diagnostic Code 7805 removed the parentheses but the rating criteria for this code remained the same. The parentheses which noted that linear scars were included was removed. Evidence The Veteran was afforded two VA examinations during the appeal period. The June 2017 VA examiner concluded that there were no scars or disfigurement of the head, face, or neck. There was one scar that is painful. The pain was described as sharp pain when the scar is stretched with normal activity. None of the scars of the trunk or extremities were unstable, with frequent loss of covering of skin over the scar. None of the scars of the trunk or extremities were due to burns. There were no scars of the bilateral upper extremities. There were four scars of the right knee. The first scar was described as linear and deep set/puckered with associated suture scars to either side on the right thigh laterally from near the hip downwards to above the knee. It measured 16 cm x 1cm (16 cm2). The second scar was described as connected to the first scar above the knee and extending below the knee laterally, scarring on the skin graft site, rectangular, slightly pigmented, depressed below surrounding skin surface and shiny. It was tender to palpation and movement. It measured 20 cm x 4 cm (80 cm2). The third scar was described as a linear surgical scar anterior patella from quadriceps to "shin." It measured 31 cm x 1.50 cm (46.5 cm2). The fourth scar was described as linear surgical scar at lateral knee. It measured 9 cm x. 0.20 cm (1.8cm2). There were three scars of the left lower extremity. The three scars were described as three precise rows of skin graft harvest site scars on the left lateral thigh, superficial and hypopigmented, non-linear, each measuring 20 cm x 3 cm (60 cm2). Neither the anterior trunk nor posterior trunk were affected. The approximate total area for the superficial nonlinear scar areas for the trunks and extremities of the left lower extremity was 180 cm2. The approximate total area for the superficial non-linear scar areas for the trunks and extremities of the left lower extremity was 180 cm2. The approximate total area for the deep non-linear scar areas for the trunks and extremities of the left lower extremity was 144.3 cm2. The scars did not result in limitation of function, did not have any pertinent physical findings, complications, signs, or symptoms, or impact the Veteran's ability to work. The examiner concluded that although the right knee skin graft scar caused pain it did not impact the Veteran's ability to work. The August 2019 VA examiner concluded that there were no scars or disfigurement of the head, face, or neck. There was one scar that was painful. The pain was described as sharp and occasional dull pain, continually, worse if sleeping on that side. It would get worse when his pants brushed against it. None of the scars of the trunk or extremities were unstable, with frequent loss of covering of skin over the scar. None of the scars of the trunk or extremities were due to burns. There were no scars of the bilateral upper extremities. There were three scars of the right knee. The first scar was described as a large vertical scar with large area of bone graft, measuring 46 cm x 6 cm (276 cm2). This scar was tender to palpation. The second scar was described as a large vertical scar over patella from "TKR", measuring 31 cm x 1 cm (31 cm2). The third scar was described as vertical scar medial patella and lower leg from cartilage, measuring 8 cm x 1 cm (8 cm2). All three scars had underlying soft tissue damage. The approximate total area for the underlying tissue damage for the scars of the right lower extremity was 315 cm2. There was one scar of the left lower extremity. The scar had underlying soft tissue damage, measuring 18 x 1 cm (18 cm2). Neither the anterior trunk nor posterior trunk were affected. The approximate total area for the underlying tissue damage for the scar of the left lower extremity was 18 cm2. The scars did result in limitation of function. Specifically, the scars of the right lower extremity caused some hinderance with walking as the scars were painful and movement pulled on the scars. The scars did not have any pertinent physical findings, complications, signs, or symptoms. The scars did impact the Veteran's ability to work. The functional impact was described as daily disturbance from pain, impact on walking. Analysis- Right knee The Veteran is separately rated for scars related to his total arthoplasty of the right knee. By way of filing, the Veteran contends that his right knee scars warrant higher ratings. Neither he nor his representative provided any evidence as to how and or why the Veteran thinks his symptoms warrant higher ratings. The Board will analyze each rating to see if higher ratings are warranted for each disability as of March 2017. After considering the evidence of record in light of the applicable rating criteria, the Board finds that the preponderance of the evidence is against the assignment of higher ratings for scars of the right knee. The Veteran's scar is rated under Diagnostic Code 7801 and has been assigned a 20 percent rating, as the RO found the second surgical scar in the June 2017 VA report to be deep and nonlinear and measure 80.0 cm2. To warrant a higher rating under this diagnostic code the Veteran's deep and nonlinear scar needs to cover an area or areas of at least 465 cm2. The June 2017 VA examination reflects a measurement of 80.0 cm2, consistent with the currently assigned 20 percent rating. The August 2019 VA examination report also reflects a measurement of 80.0 cm2. As the VA examination reports do not indicate a measurement of a scar of the right knee of at least 465 cm2, a rating in excess of 20 percent under Diagnostic Code 7801 is not warranted at any time during the appeal period, even when considering the current criteria and the criteria prior to August 13, 2018. A disability rating in excess of 20 percent for residual scars of the right knee is denied. The Veteran's scar is rated under Diagnostic Code 7804 and has been assigned a 10 percent rating, as the RO found that there was one surgical scar that was painful. To warrant a higher rating under this diagnostic code the Veteran needs to have at least three scars that are unstable or painful. Both the June 2017 and August 2019 VA examination reports reflect one painful scar of the right knee, consistent with currently assigned 10 percent rating. As the medical records of evidence to include the VA examination reports do not indicate at least three scars of the right knee that are painful or unstable, a rating in excess of 10 percent under Diagnostic Code 7804 is not warranted at any time during the appeal period. A disability rating in excess of 10 percent for painful scar of the right knee is denied. The Veteran's remaining scars have been rated under Diagnostic Code 7805 and has been assigned a noncompensable rating, as the RO found that the scars were superficial, nonlinear, and not painful or unstable. Diagnostic Code 7805 directs that any disabling effect(s) not considered in Diagnostic Codes 7801 through 7804 should be evaluated under the appropriate diagnostic code. This instruction essentially directs that scars may be rated for the functional impairment caused by the scar. As the remaining scars did not warrant compensable ratings under Diagnostic Codes 7801 through 7804, application of Diagnostic Code 7805 is proper. However, under 38 C.F.R. § 4.31 a noncompensable rating shall be assigned where the schedule (the diagnostic code) does not provide a zero evaluation and a compensable evaluation is not met. Both the June 2017 and August 2019 VA examination reports reflect one painful scar, which is separately rated as 10 percent, and one scar measuring 80.0 cm2, which is separately rated as 20 percent disabling with neither of the remaining scars warranting a compensable rating under any of the other applicable codes. The Board recognizes that the July 2017 report states that the right knee skin graft scar causes pain, but the report also clearly stated that it does not impact his ability to work, nor did it result in limitation of function. The Board also recognizes that the August 2019 report reflects that the scars did result in limitation of function and did impact his ability to work as they are painful and hinder walking. Besides the report stating the disability as "scars" and not "scar", a complete read of the report shows that there is only one painful scar of the right knee, which has been separately rated. Also, the report clearly stated that the scars did not have any pertinent physical findings, complications, signs, or symptoms not yet contemplated. Given the aforementioned, even when considering both the current criteria and the criteria prior to August 13, 2018, the Board finds that there are no disabling effect(s) not considered in Diagnostic Codes 7801 through 7804, to include any functional impairment not already contemplated. A compensable disability rating under Diagnostic Code 7805 for scar(s) of the right knee is denied. Analysis-Left knee By way of filing, the Veteran contends that his left knee scar or scars warrant a compensable rating. Neither he nor his representative provided any evidence as to how and or why the Veteran thinks his symptoms warrant a higher rating. After considering the evidence of record in light of the applicable rating criteria, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for the Veteran's scar of the left knee. The scar is not of the head, face, or neck so Diagnostic Code 7800 is not for application The Veteran's scar is rated under Diagnostic Code 7802 and has been assigned a noncompensable rating, as the RO found that the scars were superficial, nonlinear, and not painful or unstable. To warrant a higher rating under this diagnostic code the Veteran's scar needs to measure at least 929 cm2. Both the June 2017 and August 2019 VA examination reports illustrate that the scar or scars of the left knee were not painful, unstable, or deep. The reports reflected that at most they measured 60 cm2, all consistent with a noncompensable rating. Even when considering the current criteria and the criteria effective prior to August 13, 2018, a compensable rating is not warranted under Diagnostic Code 7802. Additionally, the scar does not impact his ability to work and the probative evidence does not indicate any disabling effects not considered. As such, a separate or compensable rating is not warranted based on any other provision of the rating schedule, to include Diagnostic Code 7805, at any time during the period of appeal. As the preponderance of the evidence is against the assignment of a compensable rating, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. Tinnitus The Veteran was awarded service connection for tinnitus in a May 2017 rating decision and a 10 percent evaluation was assigned. Neither he nor his representative provided any evidence as to how and or why the Veteran thinks his symptoms warrant a higher rating. As will be discussed below, the claim must be denied as a matter of law as the Veteran is in receipt of the maximum rating. The Veteran's tinnitus is rated as 10 percent disabling under Diagnostic Code 6260. Under 38 C.F.R. § 4.87, Diagnostic Code 6260, there is no provision for assignment of a rating in excess of 10 percent for tinnitus. Only a single evaluation may be assigned, whether the sound is perceived in one ear, both ears, or in the head. Id. at Note (2). In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit concluded that 38 C.F.R. § 4.25(b) and 38 C.F.R. § 4.87, Diagnostic Code 6260, limit a Veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. A higher evaluation for tinnitus is not available. The Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for that disability. 38 C.F.R. § 4.87, Diagnostic Code 6260. As there is no legal basis upon which to award a higher evaluation, to include separate schedular ratings for tinnitus in each ear, the Veteran's claim for an increased disability rating must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Service Connection Generally, to establish direct service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Depending on the evidence and the contentions of record in a particular case, lay evidence can be competent and sufficient to establish a diagnosis and medical etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), including cardiovascular-renal disease (to include hypertension) and organic diseases of the nervous system (to include sensorineural hearing loss) may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board has reviewed the entire record, with an emphasis on the evidence relevant to this appeal. Hence, the Board will summarize the relevant evidence as appropriate and the analysis below will focus specifically on what the evidence shows or fails to show in the present claims. Hypertension As there are private treatment records dated December 2016, September 2017, and August 2019 that list essential (primary) hypertension as a diagnosis, there is a current diagnosis of hypertension. Upon review of the record, there is no probative evidence to indicate a correlation between the Veteran's hypertension and his military service. The private treatment records indicate treatment related to hypertension, but with no indication of its etiology. The enlistment examination and separation examination reflect blood pressure readings of 130/94 (systolic/diastolic) and 120/84 respectively (systolic/diastolic). These readings may reflect elevated, as well as a high blood pressure when looking at the diastolic at entrance. See https://www.cdc.gov/bloodpressure/about.htm and https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. However, these readings alone do not equate to an in-service diagnosis of hypertension. Also, of note, the Veteran's blood pressure improved when comparing the readings at entrance and at separation. Service treatment records do not show any complaints of or treatment for hypertension. Neither the Veteran, nor his representative, have provided any statements or details describing how the Veteran's hypertension is related to service. Therefore, the Board finds that the second element, an in-service incurrence or aggravation of a disease or injury, has not been met. In addition, there is no competent evidence of record to indicate a link between his current hypertension and his military service. A preponderance of the evidence is against his claim for service connection. There is no medical opinion of record regarding his hypertension. A medical opinion is not required because the record before the Board does not indicate that this disability has a causal connection to or is associated with his active military service or secondary to any service-connected disability. There is no indication beyond the filing of the claim by the Veteran of an event, injury, or disease in service to which the claimed disability may be associated. Accordingly, as hypertension is not shown to be causally or etiologically related to any disease, or injury in service and that it did not manifest to a compensable degree within one year of the Veteran's discharge from service, service connection for hypertension is not warranted. The preponderance of the evidence is against the Veteran's claim and the doctrine of reasonable doubt is not applicable in the instant appeal. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990); 38 C.F.R. § 3.102. Bilateral hearing loss With respect to claims for service connection for hearing loss, the United States Court of Appeals for Veterans Claims (Court) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further opined that 38 C.F.R. § 3.385, discussed below, then operates to establish when a hearing loss disability can be service connected. Id. at 159. 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, 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. By way of filing, the Veteran contends that service connection is warranted for his bilateral hearing loss. Neither he nor his representative provided any evidence as to how and or why the Veteran thinks his service caused his hearing loss. A review of the Veteran's service treatment records does not show audiometric testing showing a bilateral hearing loss disability for VA purposes. These records do show a couple of audiograms with some threshold shifts, but they do not rise to a level to be considered a disability for VA purposes. See 38 C.F.R. § 3.385. Additionally, the most recent service treatment audiogram dated March 1968 reflects improvement in hearing. Lastly there is no indication of complaints of or treatment for hearing loss or symptoms related to such. According to the Veteran's DD Forms 214, his primary specialty in service was as a "comm sen specialist", "opns co.", and a supply specialist. As will be discussed below, the record shows a current hearing loss disability. Thus, the main question before the Board is whether the Veteran's current bilateral hearing loss is attributable to an event, injury, or disease incurred during active duty. The Veteran was afforded a VA audiological examination in April 2017, during which puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 AVG RIGHT 25 25 40 65 70 50 LEFT 30 25 45 65 70 51 Maryland CNC speech discrimination testing showed recognition of 88 percent in the right ear and 72 percent the left ear. The examiner indicated that the Veteran had sensorineural hearing loss in the frequency range of 500 to 4000 Hz, bilaterally. The examiner stated that the Veteran's hearing loss is not at least as likely as not caused by or a result of an event in military service. The rationale provided was that the Veteran's records show two audiologic examinations which were performed in December 1963 and March 1968. Both tests revealed normal hearing with no permanent, significant threshold shifts being observed. Therefore, given that the Veteran's hearing was normal at entrance and exit with no observable threshold shifts, it is less likely than not that the Veteran's hearing loss was caused/initiated by a military event. It must be noted that the Veteran does have a history of occupational noise exposure through work in the mills and with heavy equipment after separation from the military. The examiner also noted in his report that the Veteran's "MOS" in the military were teletype operator in Europe, currier service in Vietnam and support for the first infantry (armorer) in Vietnam. These carry a low-high probability rating for exposure to harmful military noise. The Veteran self-reported being exposed to aircraft, explosions, and firefights. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for hearing loss. Although the evidence shows that the Veteran has bilateral hearing loss disability by VA standards, the most probative evidence of record demonstrates that this disability is not related to his service. The Veteran is competent to report problems hearing, when those symptoms began, and what he believes caused these problems and symptoms. However, the Veteran, as a lay person, is not competent to attribute his hearing loss to any instance of his military service, as he has not demonstrated that he is an expert in determining the etiology of hearing loss or tinnitus. The April 2017 VA audiologist is a trained medical professional who interpreted the service audiograms and service treatment records and determined there was no evidence of symptoms related to hearing loss while in service. The rationale provided in the VA opinion is based on in person examination of the Veteran, the Veteran's reporting, a complete review of the file, and the medical expertise of VA audiologist. Therefore, the Boards places great probative value on it. This is considered more probative than the Veteran's filing of the claim. Additionally, of note, the Veteran has not provided any lay assertions relating his hearing loss. The Board acknowledges that a VA examination regarding ear disabilities was performed in October 2017. However, the focus of that examination was to evaluate the Veteran for disabilities related to vestibular and infections conditions. Additionally, although the report reflects that an audiological examination was performed, the April 2017 VA examination already provided the thresholds needed to show a current hearing loss disability. Accordingly, as hearing loss is not shown to be causally or etiologically related to any disease, or injury in service and that it did not manifest to a compensable degree within one year of the Veteran's discharge from service, service connection for hearing loss is not warranted. In reaching this decision, the Board considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hearing loss. Thus, that doctrine is not applicable in the instant appeal, and the Veteran's claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Gout; Acid reflux The Veteran contends that he has gout and acid reflux. As per his filing, he contends that these disabilities warrant service connection. Upon review of the record, there is no probative evidence to indicate a current diagnosis of the claimed disabilities or residuals thereof. The Veteran's service treatment records indicate that he was healthy upon entrance. Service treatment records do not indicate treatment for gout and acid reflux. Also, there is no indication of treatment for or symptoms of the claimed disabilities. There are two private treatment records that fall outside the appeal period that makes mere mention of gout. The January 2011 record reads "sounds like it was probably gout attack" and the May 2011 record reads "question of a gout flare-up." These two records are vague and do not equate to a competent medical diagnosis gout, let alone a competent diagnosis of a current disability of gout. There are no records of evidence to indicate treatment for or a diagnosis of acid reflux. The Veteran is competent to report that he experienced symptoms related to a gout or acid reflux. However, he is not competent to self-diagnose the claimed disabilities. The Veteran, as a lay person, does not have the education, training, or experience to diagnose the claimed disabilities, or residuals of these disabilities or opine as to the etiology of any current related illness. "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a); see also Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Additionally, the Veteran has not provided any medical evidence within the appeal period to indicate any current diagnosis, let alone any statements to illustrate how it is he believes his claimed disabilities are related to service. There is no medical opinion of record regarding his claimed gout and acid reflux. VA examinations are not warranted, as the record before the Board does not show gout or acid reflux related to an event, injury, or disease in service. A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of a current disability, there can be no valid claim. The totality of the competent evidence does not reflect that the Veteran has or has had a diagnosis of gout or acid reflux. Therefore, the Veteran's claims must be denied. The preponderance of the evidence is against the Veteran's claims and the doctrine of reasonable doubt is not applicable in the instant appeal. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990); 38 C.F.R. § 3.102. Effective Date The statutory guidelines for the determination of an effective date of an award are set forth in 38 U.S.C. § 5110. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is the latter. 38 C.F.R. § 3.400. Under 38 C.F.R. § 3.400(b)(2)(i), the effective date for a grant of direct service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date is the date of receipt of claim, or date entitlement arose, whichever is later. Under 38 C.F.R. § 3.400(b)(2)(ii), the effective date for presumptive service connection will be the date entitlement arose, if a claim is received within one year after separation from active service. VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments are only effective for claims and appeals filed on or after March 24, 2015. As the claims in this case were filed after that date, the amendments are applicable in this instance and the regulations in effect prior to March 24, 2015 will not be applied. The Board recognizes that an increased rating claim is subject to the more specific criteria under 38 U.S.C. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2). However, as will be discussed below, the claims on appeal stem from original claims and therefore are not considered new claims for an increased disability rating for the purposes of the application of the more specific criteria. The RO granted service connection for total knee replacement with degenerative arthritis of the right knee, residual scars of the right knee, painful scar of the right knee, scars of the right knee, and tinnitus in an October 2017 rating decision, assigning each disability an effective date of March 30, 2017the date VA received the claim. Neither the Veteran nor his representative provided any statements, contentions, or argument as to why the Veteran feels an earlier effective date is warranted for these specific disabilities. Upon review of the record, there is nothing to indicate that claims for a right knee disability, scars of the right knee, or tinnitus were filed prior to March 30, 2017. Aside from the November 2017 notice of disagreement (NOD), there is nothing in the file to even hint that an earlier effective date for any of these disabilities is warranted. The fully developed claim was submitted on March 30, 2017. There is no indication that the Veteran filed a claim prior to March 30, 2017. The Veteran filed his claims for service connection on March 30, 2017. Thus, the proper effective date, given that none of the exceptions to the general rule noted above apply, is March 30, 2017. The Board acknowledges that the Veteran checked the boxes off in the November 2017 NOD to indicate his belief that an effective date earlier than March 30, 2017 is warranted for his right knee disability, scars of the right knee, and tinnitus. However, the Board is precluded by statute and regulation from assigning an effective date prior to March 30, 2017, for the grant of service connection for right knee disability, scars of the right knee, and tinnitus. The earliest date that the Veteran expressed an intent to file a claim for service connection is March 30, 2017, the presently assigned effective date. Thus, March 30, 2017 is the appropriate effective date, because even if the date that the entitlement arose was found to precede it, the later of the two dates controls. REASONS FOR REMAND The Veteran has been afforded one VA examination, in June 2017. A review of the examination report indicates that there is no current disability related to the left knee. The report also notes the Veteran reported that his left knee is not a problem at all. However, the report illustrates abnormal or outside of normal range, evidence of pain with weight bearing, and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. In addition, under Saunders v. Wilkie, "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability." To establish the presence of a disability, a veteran will need to show that his pain reaches the level of a functional impairment of earning capacity." 886 F.3d 1356 (Fed. Cir. 2018). The same VA examiner provided an opinion about the left knee. He opined that the left knee disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, the only rationale provided was that the Veteran does not have a left knee problem. Despite listing the December 1963 service treatment record that showed there was pain in the left knee in the evidence comments in the report, the VA examiner failed to account for this when providing rationale. Additionally, a complete review of the record shows another service treatment record that mentions the left knee and that Veteran received treatment for his left knee and even had a diagnosis of osteoarthritis in 1985. Accordingly, a new VA examination is necessary in order to confirm any current diagnoses and to obtain an opinion regarding functional impairment. The matter is REMANDED for the following action: Schedule an appropriate VA examination to determine the nature and etiology of the Veteran's claimed left knee disability, preferably with an examiner other than the one that performed the June 2017 VA examination. The examiner should identify all current disabilities of the left knee found at any time during the appeal period (from March 2017). Note: pain in it of itself may constitute a disability for VA purposes if it results in functional impairment. If a medical diagnosis cannot be given, the examiner must state whether the Veteran has any functional impairment, such as loss of range of motion, pain, or instability. For each diagnosed knee disability or finding of functional impairment, the examiner should provide an opinion regarding whether it is at least as likely as not that the disability manifested during active service; or is otherwise related to an event, injury, or disease incurred during active service. Review of the entire file is required. The examiner is advised that there are records that show chronic knee pain, consideration of a "TKA" operation of the left knee and a 1985 diagnosis of traumatic osteoarthritis of the left knee. In providing this opinion, the examiner is asked to specifically address in the examination report the following service treatment records: (a.) The December 1963 service treatment indicating a painful knee (VBMS, document labeled STR-Medical, receipt date April 2, 1982 page 14 of 57). (b.) The February 1968 service treatment indicating pain in the knee and effusion in both knees (VBMS, document labeled STR-Medical, receipt date April 2, 1982 page 42 of 61). The examiner is advised that the Veteran and his lay witnesses are competent to report observable symptoms. The examiner is further advised that the mere absence of treatment records is not wholly dispositive as to whether the reported symptoms are credible. Any opinion offered must be supported by a complete rationale. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Talamantes 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.