Citation Nr: 21030014 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 20-26 249 DATE: May 17, 2021 ORDER Entitlement to a disability rating in excess of 70 percent for the Veteran's service-connected post-traumatic stress disorder (PTSD) with major depressive disorder (MDD) and alcohol use disorder, for the period on appeal, is denied. Entitlement to a disability rating in excess of 20 percent for the Veteran's service-connected prostate cancer, status post radical prostatectomy, for the period on appeal, is denied. Entitlement to a compensable disability rating for the Veteran's service-connected bilateral hearing loss is denied. Entitlement to a disability rating in excess of 10 percent, to include on an extraschedular basis, for the Veteran's service-connected tinnitus is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for the Veteran's service-connected right knee condition is remanded. Entitlement to a disability rating in excess of 10 percent for the Veteran's service-connected left knee condition is remanded. Entitlement to a compensable disability rating for the Veteran's service-connected erectile dysfunction is remanded. Entitlement to an effective date earlier than September 26, 2018, for the assignment of a 70 percent rating for the Veteran's service-connected PTSD is remanded. FINDINGS OF FACT 1. For the period on appeal, the severity, frequency, and duration of the Veteran's PTSD symptoms more closely approximate occupational and social impairment with deficiencies in most areas. 2. The competent and probative evidence demonstrates that throughout the period on appeal, the Veteran's prostate cancer residuals manifest in voiding dysfunction resulting in: urine leakage requiring absorbent materials which must be changed less than two times per day; and a daytime voiding interval between one and two hours with nighttime awakening to void between three to four times. 3. The Veteran's bilateral hearing loss is most closely approximated by a noncompensable, 0 percent disability rating. 4. The Veteran's tinnitus is not shown to have been so exceptional or unusual as to render impractical the application of the regular schedular standards for rating the disability. 5. The preponderance of the evidence establishes that the Veteran's GERD disability was not present until more than one year following his discharge from service and is not etiologically related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to a disability rating in excess of 70 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for establishing entitlement to a disability rating in excess of 20 percent for the Veteran's service-connected prostate cancer, status post radical prostatectomy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, Diagnostic Code 7528. 3. The criteria for establishing entitlement to a compensable disability rating for the Veteran's service-connected bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for establishing entitlement to a disability rating in excess of 10 percent, to include on an extraschedular basis, for the Veteran's service-connected tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.321, 4.85, Diagnostic Code 6260. 5. The criteria for establishing entitlement to service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1966 to August 1969 and from March 1991 to September 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2018 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In his June 2020 VA Form 9, the Veteran requested a videoconference hearing on the above issues. However, in February 2021, the Veteran through his representative waived his hearing request and asked that "no decision be made until the Veteran is able to submit evidence to substantiate his appeal." The Board sent the Veteran a March 2021 correspondence asking the Veteran's representative to clarify whether he was requesting an extension, how much time he was requesting, and giving him 30 days to respond. However, to date, neither the Veteran nor his representative has submitted a motion for extension or responded to the March 2021 communication. The Board reminds the Veteran that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, it was incumbent upon him to cooperate with the VA in developing his claims. As such, since the 30-day window has passed, the Board will proceed with adjudication of the Veteran's claims. The Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, with regard to the Veteran's claims. Increased RatingLegal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating will be assigned. See 38 C.F.R. § 4.7. In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must weigh against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. At 54). PTSDLegal Criteria The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. In pertinent part, a 70 percent disability 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); and inability to establish and maintain effective relationships. Finally, a 100 percent disability rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought process 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 memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Analysis For the reasons addressed below, the Board finds that a disability rating in excess of 70 percent for the Veteran's service-connected PTSD is not warranted during the period on appeal. Critically, the Board observes that the rating criteria for a 70 percent rating for PTSD with MDD indicates an array of symptoms, which are likely sufficient to cause impairment and deficiencies in most areas of life functioning, to include work, school, family relations, judgment, thinking, or mood. Such symptoms need not rise to the level of activity preclusion, but rather negatively influence or impact upon most areas of life functioning. A higher 100 percent rating is warranted when the evidence indicates total impairment. 38 C.F.R. § 4.103, Diagnostic Code 9411. The symptoms considered in determining the level of impairment under the Rating Schedule for PTSD are not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Mauerhan, 16 Vet. App. 436. Throughout the period on appeal, the Veteran's VA treatment records reflect that he has received consistent treatment for his psychiatric disabilities. Further, the Veteran was afforded a VA PTSD examination in December 2018. The Veteran also submitted a private psychological opinion dated March 2021. Noted symptoms were: traumatic nightmares; intense or prolonged distress as well as marked physiologic reactivity after exposure to traumatic reminders; avoidance; negative emotional state; markedly diminished interests; alienation; constricted affect; irritable behavior; hypervigilance; exaggerated startle response; problems with concentration; chronic sleep impairment; depressed mood; anxiety; suspiciousness; mild memory loss, such as forgetting names, directions or recent events; circumstantial, circumlocutory or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or work like setting; suicidal ideation; impaired impulse control; suspiciousness; and obsessional rituals which interfere with routine activities. There are no reports that the Veteran is unable to handle his own finances or participate in activities of daily living. Additionally, there are no reports that the Veteran experiences homicidal ideation. The December 2018 examiner found the Veteran to have occupational and social impairment with reduced reliability and productivity, while the March 2021 examiner found the Veteran's psychiatric disabilities caused him difficulties in most areas. After having resolved all reasonable doubt in favor of the Veteran, the Board has determined that a 70 percent rating is warranted for the entire period on appeal, but no higher. In this regard, the Board finds that due to the symptoms summarized above his service-connected PTSD has most nearly approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. In sum, the evidence shows the Veteran has experienced several significant symptoms and impairments, which include: impaired impulse control, depressed mood, significant relationship problems, chronic dysfunctional sleep, disturbances of mood and motivation, difficulty with adapting to stressful circumstances including work and worklike setting, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. Throughout this period, the weight of the evidence supports a finding that the Veteran's PTSD manifested as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. However, the Board finds that the signs and symptoms associated with his service-connected PTSD do not more nearly approximate total social and occupational impairment. In this regard, for example, there is no evidence of delusions, homicidal ideations, or grossly inappropriate behavior. He has been able to perform activities of daily living and is competent to handle his own finances. Additionally, the evidence does not show the Veteran experiences memory impairments of such severity that he forgets names of close relatives, his own occupation, or his own name. In short, despite the Veteran's symptoms, he has not exhibited the type of emotional and cognitive impairment reserved for a total rating. 38 C.F.R. § 4.130, DC 9411. Based on the foregoing, for the period on appeal, the preponderance of the evidence is against the assignment of a higher, 100 percent, rating for the Veteran's service-connected PTSD. 38 C.F.R. § 3.102. The Board has applied the benefit of the doubt where appropriate. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Consideration has been given to assigning a staged rating; however, the evidence does not suggest that the severity has fluctuated during the period of this appeal, so a staged rating is not appropriate for this claim. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Prostate CancerLegal Criteria The Veteran's prostate cancer, status post prostatectomy, is rated pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7528, for malignant neoplasms of the genitourinary system or postoperative residuals. Diagnostic Code 7528 instructs to rate as voiding dysfunction or renal dysfunction, whichever is predominant. The criteria for voiding dysfunction and renal dysfunction are found in § 4.115a. Initially, the Veteran has not been shown to have renal dysfunction. As such, the Veteran's residuals are most appropriately rated under voiding dysfunction. Under 38 C.F.R. § 4.115a, voiding dysfunction can be rated according to urine leakage, frequency, or obstructed voiding. Regarding urine leakage, a 60 percent rating is warranted for requiring the use of an appliance or wearing of absorbent materials which must be changed more than four times per day. A 40 percent rating is warranted for requiring the wearing of absorbent materials which must be changed two to four times per day. A 20 percent rating for voiding dysfunction is warranted for requiring the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. Voiding dysfunction that manifests as urinary frequency warrants a 40 percent rating when daytime voiding intervals are less than one hour or awakening to void (nocturia) occurs five or more times per night. A 20 percent rating contemplates daytime voiding intervals between one and two hours, or nocturia occurs three to four times per night. A 10 percent rating is warranted when daytime voiding intervals are between two and three hours, or nocturia occurs twice per night. Id. Voiding dysfunction that manifests as obstructed voiding warrants a 30 percent rating when urinary retention requires intermittent or continuous catheterization. A 10 percent rating contemplates marked obstructive symptomatology, such as hesitancy, slow or weak stream, decreased force of stream, with any one or combination of the following: (1) post-void residuals greater than 150 cc.; (2) uroflowmetry; markedly diminished peak flow rate, less than 10 cc./second; (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A noncompensable rating is warranted when obstructive symptomatology with or without stricture disease requires dilatation one to two times per year. Analysis For the reasons addressed below, the Board finds that a disability rating in excess of 20 percent for the Veteran's service-connected prostate disability is not warranted during the period on appeal. The Veteran's VA treatment notes indicate that he has received treatment for his prostate condition throughout the period on appeal. Specifically, the Board notes a November 2018 urinary incontinence screen which indicated the Veteran reported urinary incontinence within the prior 12 months; a January 2019 treatment note where the Veteran reported waking up two to three times per night to urinate; and a November 2019 urinary incontinence screen where the Veteran denied urinary incontinence in the prior 12 month period. In December 2018, the Veteran was afforded a VA Prostate Cancer examination to assess the severity of his disability. The Veteran's prostate cancer was noted to be in remission as he had undergone a radical prostatectomy. The examiner noted that the Veteran had voiding dysfunction that caused urine leakage which required absorbent material which must be changed less than 2 times per day. The Veteran's voiding dysfunction did not require the use of an appliance. The voiding dysfunction caused increased urinary frequency with a daytime voiding interval between 1 and 2 hours and nighttime awakening to void 3 to 4 times. The Veteran's voiding dysfunction caused signs or symptoms of obstructed voiding, though none of the symptoms were marked. The Veteran did not have a history of recurrent symptomatic urinary tract of kidney infections. After a review of the evidence, the Board finds that a rating in excess of 20 percent is not warranted at any time during the appeal. The VA examination, as well as the VA treatment records, do not document any complaints of continual urine leakage or urinary incontinence requiring the use of an appliance or wearing absorbent materials which must be changed two to four times per day, as required for a 40 percent rating based on voiding dysfunction. Additionally, the evidence of record does not demonstrate that the Veteran has a daytime voiding interval of less than one hour or awakens to void more than five times a night, as required for a 40 percent rating under urinary frequency. Further, the Veteran's obstructed voiding does not require intermittent or continuous catheterization as required for a higher 30 percent rating under obstructed voiding. For the entire rating period on appeal, all possible diagnostic codes were considered, but the Veteran could not receive a higher disability rating for his prostate cancer condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7528. The Board has applied the benefit of the doubt where appropriate. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Consideration has been given to assigning a staged rating; however, the evidence does not suggest that the severity has fluctuated during the period of this appeal, so a staged rating is not appropriate for this claim. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Bilateral Hearing Loss The severity of hearing loss is determined by comparing audiometric test results with the specific criteria. 38 C.F.R. § 4.85, Diagnostic Codes 6100 through 6110. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. The Rating Schedule allows for such audiometric test results to be translated into a numeric designation ranging from Level I to Level XI, in order to evaluate the degree of disability from service-connected defective hearing. The Veteran is seeking ratings in excess of those already assigned to his service-connected bilateral hearing loss. VA treatment notes indicate that the Veteran has received treatment for his bilateral hearing loss, including wearing hearing aids. However, these treatment records do not provide adequate audiological tests or findings to rate the Veteran's hearing loss disability. Additionally, the Veteran has not claimed, and the evidence does not show, that his hearing has worsened since his last VA examination. As there are no additional audiological tests or findings in the record that differ significantly from, or are worse than, the below cited VA examination, the Board will focus its discussion below cited examination. In December 2018, the Veteran underwent a VA audiological examination, which revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 AVG (1000-4000) RIGHT 20 25 55 70 70 55 LEFT 25 25 50 60 65 50 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 76 percent in the left ear. Applying the December 2018 audiometric results to the Rating Schedule reveals a numeric designation of Level II for the Veteran's right ear and Level IV for the Veteran's left ear. See C.F.R. § 4.85, Table VI, Diagnostic Code 6100. Applying these numeric designations to Table VII results in a noncompensable rating from this examination. See 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. The Board acknowledges the Veteran's lay statements regarding experiencing difficulty hearing. However, disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Thus, based on the audiometric findings of record, a compensable rating for bilateral hearing loss is not warranted, and the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Tinnitus VA's rating schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under those circumstances, where the schedular evaluations are found to be inadequate, a veteran may be awarded a rating higher than that encompassed by the schedular criteria. 38 C.F.R. § 3.321(b)(1). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. Id.; see also Fanning v. Brown, 4 Vet. App. 225, 229 (1993); 38 C.F.R. § 3.321(b)(1). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The Veteran initially became service-connected for tinnitus in the December 2018 rating decision on appeal. His condition was evaluated as 10 percent disabling, effective September 26, 2018. Under DC 6260, 10 percent is the maximum schedular rating available for tinnitus. 38 C.F.R. § 4.87. Nonetheless, the Veteran contends he is entitled to extraschedular consideration for his tinnitus. His description intermittent ringing in his ear has been taken into consideration by the rating criteria because ringing of the ears is the definition of tinnitus, as shown by Dorland's Illustrated Medical Dictionary, which defines tinnitus as a noise in the ears, such as ringing, buzzing, roaring, or clicking. 1930 (32nd ed. 2012). The Board finds the Veteran's tinnitus is contemplated, and may be properly evaluated, by the schedular criteria. See Long v. Wilkie, No. 16-1537 (Vet. App. Dec. 30, 2020); Doucette v. Shulkin, 28 Vet. App. 366 (2017). Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 114-15 (2008). The Board acknowledges the Veteran's assertion that his tinnitus is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible evidence in this regard. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds, however, that neither the lay or medical evidence demonstrates that the criteria for an extraschedular rating have been met. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Accordingly, the rating assigned for the Veteran's tinnitus accurately reflects the degree of his service-connected tinnitus. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, DC 6260. Under the current facts, the Veteran has not asserted, and the evidence of record has not suggested or raised, any such effect or impact of his tinnitus that creates such an exceptional circumstance to render the schedular rating criteria inadequate. The Veteran's claim for a disability rating in excess of 10 percent for service-connected tinnitus, therefore, is denied. Service ConnectionLegal Criteria Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In determining whether service connection is warranted for a disability, 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 preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). GERD The Veteran contends that his claimed GERD is the result of his active duty service. The Board notes that the Veteran is currently diagnosed with GERD and Barrett's esophagus. See December 2018 VA Esophageal Conditions examination. Therefore, the central issue that must be resolved is whether the Veteran's current disability originated in service or are otherwise related to service. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Veteran has a currently diagnosed GERD disability, competent medical evidence of record does not support that this disability was incurred in service or otherwise related to service. The Veteran's service treatment records (STRs) contain no complaints, treatment, or diagnosis of this condition. There are no treatment records for this condition while the Veteran was in service, and no medical examiner has given an opinion linking the Veteran's current disability to his active duty service. The Board does note that the Veteran's STRs do contain a February 1968 complaint of viral gastroenteritis, and a June 1968 report of diarrhea. However, as noted above, there is no diagnosed GERD or other similar conditions while in service. The Veteran submitted private treatment records which indicated he was first diagnosed with a Barrett's esophagus in May 2017 and had been taking omeprazole since 2015. The Veteran was provided with a December 2018 VA Esophageal and Intestinal conditions examinations. The examiner confirmed the Veteran was diagnosed with GERD and Barrett's Esophagus. During the examination the Veteran stated that the date of onset for his symptoms was unknown, and the claimed condition began gradually with heartburn and has gotten worse over time. The examiner noted that the Veteran's Barrett's esophagus was diagnosed by biopsies during a May 2017 upper endoscopy. Further, the examiner noted the Veteran underwent other diagnostic studies in July 2018 and February 2014. The examiner opined that the Veteran's condition was less likely than not (less than a 50 percent probability) etiologically related to his active duty service. The rationale provided was that a review of the medical records showed the Veteran had an in-service diagnosis of viral gastroenteritis in February 1968, and diarrhea for 2 days in June 1968. The examiner noted that GERD is not caused by gastroenteritis, and that the Veteran's STRs are silent for any complaints of chronic indigestion or abdominal pain while in active duty. Therefore, the examiner opined it is less likely than not that the Veteran's GERD is related to his active duty service. The Board weighs the above-mentioned VA examination, against the Veteran's lay contentions that his GERD is due to service. While the Veteran is competent to testify to his symptoms, he is not competent to provide a medical opinion as to the etiology of his disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not indicated when his symptoms began, and the medical records in the file do not indicate a diagnosis of GERD until many years after the Veteran left active service. As such, the Board finds the VA examinations, which opined against a link between the Veteran's currently diagnosed GERD disability and his service, to be of high probative value. Additionally, the Board again notes that the Veteran was not diagnosed with this condition until years after he left active duty service. In light of the above discussion, there is no evidence that the Veteran sought treatment for or was diagnosed with a stomach condition or GERD while in service, or within a year after service, and there is no medical opinion in the record linking his current disability to his active duty service. Therefore, the Veteran's claim must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. REASONS FOR REMAND Bilateral Knees The Board notes that the last VA examination in connection with the Veteran's service-connected bilateral knee disabilities was conducted 3 years ago in December 2018. Additionally, the Board notes that the Veteran's VA treatment records indicate that he underwent a knee surgery in March 2020. This is evidence of potential worsening of his service-connected knee conditions. Given the length of time since the last examination, and the potential worsening of the Veteran's claimed conditions, a remand is warranted for a contemporaneous examination. Further, the Board notes, that treatment records regarding the Veteran's knee surgery are not in the claims file. As these records may contain information that is pertinent to the Veteran's claims on appeal, the RO must attempt to obtain/locate them. Erectile Dysfunction Where the VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran claims that he is entitled to a compensable evaluation for erectile dysfunction, but neither the Veteran nor his representative have provided any specific contentions as to why a compensable evaluation should be established. The Veteran's VA treatment records show a diagnosis and treatment for erectile dysfunction but show no indication of a penile deformity. In a December 2018 VA Prostate Cancer examination, the examiner noted the Veteran experienced erectile dysfunction. However, no examination of the Veteran's penis was conducted to determine if deformity was present. The Boards finds that the VA examination is inadequate as the examiner did not fully examine the Veteran. The Board finds that examination of the Veteran's penis is relevant since the presence of penile deformity is required to obtain a compensable schedular rating. It is noted that entitlement to special monthly compensation based on loss of use of a creative organ has been previously established. Accordingly, to ensure VA has met its duty to assist, remand is required to obtain an adequate examination. Earlier effective date for PTSD 70 percent rating In a December 2019 notice of disagreement, the Veteran expressed disagreement with the effective date of his claim. The AOJ issued a statement of the case (SOC) in May 2020 addressing the Veteran's increased rating claim. The Veteran in an October 2020 Appellant Brief indicated that he is still seeking entitlement to an earlier effective date for the 70 percent rating for his PTSD. However, the AOJ has yet to issue a Statement of the Case (SOC) with regard to the Veteran's earlier effective date claim. A remand is therefore necessary. Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. The AOJ must issue a Statement of the Case (SOC) addressing the Veteran's earlier effective date claim for entitlement to TDIU. The Veteran is hereby notified that, following the receipt of the SOC concerning this issue, he must file a timely substantive appeal if he desires appellate review by the Board. If, and only if, the Veteran files a timely substantive appeal, the AOJ should return these issues to the Board for appellate review. 2. Next, undertake appropriate development to obtain any outstanding records pertinent to the Veteran's issues on appeal. Specifically, the RO should attempt to obtain/locate the Veteran's treatment records regarding his March 2020 knee surgery. 3. Then, schedule the Veteran for an appropriate VA examination, with an examiner who has yet to examine the Veteran, to determine the current nature and severity of his bilateral knee disabilities. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed (a.) The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. (b.) The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If the Veteran is not currently experiencing a flare-up, then based on relevant information elicited from the Veteran, a review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran's functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran. (c.) To the extent possible, the examiner should identify any symptoms and functional impairments due to the bilateral knee disabilities and comment on the effect of these disabilities on any occupational functioning and activities of daily living. (d.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner does not have the knowledge or training. The examiner must provide a complete rationale for all proffered opinions. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete answer as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. (Continued on the next page) 4. Next, schedule the Veteran for a VA genitourinary examination to determine the current severity of service-connected erectile dysfunction. Specifically, the examiner should examine the Veteran's penis and indicate whether the Veteran's erectile dysfunction is manifested by penile deformity. J. TUNIS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Gresham 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.