Citation Nr: 21030030 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-38 114 DATE: May 17, 2021 ORDER Entitlement to an effective date earlier than October 28, 2014, for the grant of service connection for major depressive disorder is denied. Entitlement to an initial rating of 40 percent for right lower extremity venous insufficiency is granted from July 10, 2013, to July 1, 2019. Entitlement to initial ratings in excess of 40 percent prior to July 2, 2019, and in excess of 10 percent from that date for right lower extremity venous insufficiency is denied. Entitlement to a rating in excess of 10 percent prior to February 28, 2012; in excess of 20 percent from that date to July 9, 2013; and in excess of 10 percent from July 10, 2013, for right knee traumatic arthritis is denied. Entitlement to a rating of 10 percent for right knee instability is granted from July 10, 2013. Entitlement to a rating in excess of 10 percent for right knee instability is denied. Entitlement to a separate rating of 10 percent for right knee traumatic arthritis based on symptomatic meniscectomy is granted from February 28, 2012. Entitlement to an initial rating in excess of 10 percent prior to July 10, 2013, and to a compensable initial rating from that date for right knee surgical scars is denied. Entitlement to a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012 is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for delayed ejaculation is granted. REMANDED Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to July 27, 2018, is remanded. FINDINGS OF FACT 1. No communication was received from the Veteran prior to October 28, 2014, that reasonably can be interpreted as an informal or formal claim for entitlement to service connection for major depressive disorder or another acquired psychiatric disability. 2. Affording the Veteran the benefit of the doubt, during the entire relevant period prior to July 2, 2019, his right lower extremity venous insufficiency was manifested by persistent edema and stasis pigmentation or eczema. 3. The Veteran's right lower extremity venous insufficiency was manifested by persistent edema and statis pigmentation or eczema prior to July 2, 2019, and by intermittent edema or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity, from that date. 4. The Veteran's traumatic knee arthritis was manifested by extension limited to 15 degrees from February 28, 2012, to July 9, 2013, and by painful but noncompensable limited motion prior to February 28, 2012, and from July 10, 2013. 5. Affording the Veteran the benefit of the doubt, his right knee instability was slight throughout the relevant period. 6. The Veteran's right knee traumatic arthritis is manifested by a history of meniscectomy, which has caused symptoms not otherwise compensated through the Veteran's other ratings for the disability since February 28, 2012, the date of the claim for an increased rating. 7. For the period prior to July 10, 2013, the evidence does not show that the Veteran's right knee surgical scars manifested in more than one painful or unstable scar, in a scar that was both painful and unstable, in underlying soft tissue damage with an area of at least 39 square centimeters, in a scar with an area of at least 929 square centimeters, or in a scar with other disabling effects. 8. During the period beginning July 10, 2013, Veteran's service-connected right knee scars were not associated with underlying soft tissue damage having an area of at least 39 square centimeters, did not have an area or areas of at least 929 square centimeters, were not unstable or painful, and did not cause any other disabling effects. 9. The Veteran did not require at least one month of convalescence following admission for his pulmonary embolism in 2012. 10. The preponderance of the evidence of record is against finding that the Veteran has had a left knee disability at any time during or proximate to the pendency of the claim. 11. Affording the Veteran the benefit of the doubt, his delayed ejaculation began during his active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to October 28, 2014, for the grant of service connection for major depressive disorder have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107, 5110, 7104; 38 C.F.R. §§ 3.155, 3.160 (2014); 38 C.F.R. §§ 3.1(p), 3.102, 3.156(c), 3.159, 3.400. 2. The criteria for entitlement to an initial rating of 40 percent from July 10, 2013, to July 1, 2019, for right lower extremity venous insufficiency have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.104, Diagnostic Code 7121. 3. The criteria for entitlement to initial ratings in excess of 40 percent prior to July 10, 2019, and in excess of 10 percent from that date for right lower extremity venous insufficiency have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.104, Diagnostic Code 7121. 4. The criteria for entitlement to a rating in excess of 10 percent prior to February 28, 2012; in excess of 20 percent from that date to July 9, 2013; and in excess of 10 percent from July 10, 2013, for right knee traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5010-5260. 5. The criteria for entitlement to a rating of 10 percent for right knee instability have been met from July 10, 2013. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. 6. The criteria for entitlement to a rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. 7. The criteria for entitlement to a separate rating of 10 percent for right knee traumatic arthritis based on symptomatic meniscectomy have been met from February 28, 2012. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5259. 8. The criteria for entitlement to a rating in excess of 10 percent prior to July 10, 2013, and to a compensable rating from that date for right knee surgical scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7804. 9. The criteria for entitlement to a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.30. 10. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 11. The criteria for entitlement to service connection for delayed ejaculation have been met. 38 U.S.C. §§ 1110, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1995 to April 2001. In December 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board issued a decision in February 2020 that remanded the issues pertaining to entitlement to an earlier effective date for the grant of service connection for major depressive disorder; to service connection for a gastrointestinal condition, sexual dysfunction, and a left knee condition; to increased ratings for the service-connected right lower extremity venous insufficiency, right knee disability, and right knee scars; to a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012; and to a TDIU prior to July 27, 2018. Relevant to the issues denied herein, the remand directed the Agency of Original Jurisdiction (AOJ) to issue the Veteran a statement of the case as to the earlier effective date issue and readjudicate the appeal based on the expanded record. The AOJ substantially completed those actions. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Of note, following issuance of the statement of the case as to the earlier effective date issue, the Veteran submitted a timely substantive appeal as to that issue. Therefore, the issue is appropriately before the Board at this time. The February 2020 Board decision also granted the Veteran entitlement to service connection for a pulmonary embolism. The AOJ implemented that decision in a May 2020 rating decision that also assigned a noncompensable initial rating for the disability. In July 2020, the Veteran, through his representative, submitted a supplemental claim seeking a higher initial rating for the disability. In an October 2020 rating decision, the AOJ granted an initial rating of 60 percent for the disability. To date, the Veteran has not appealed that issue to the Board. Nevertheless, a February 2021 supplemental statement of the case for the present appeal included the issue of "Entitlement to an evaluation in excess of 0 percent for pulmonary embolism." The Veteran's representative submitted a response to the supplemental statement of the case in April 2021 that includes that issue. However, because the Veteran has not initiated an appeal of the issue by submitting a timely notice of disagreement, the issue is not before the Board at this time despite it being included in the February 2021 supplemental statement of the case and despite the representative's apparent belief that the issue is before the Board. See 38 C.F.R. §§ 20.201, 20.202; see also Percy v. Shinseki, 23 Vet. App. 37 (2009). The Veteran's representative has submitted several briefs that include general allegations that the examinations of record are inadequate for decision-making purposes. The briefs do not describe any specific deficiencies in the examinations. The Veteran has also submitted statements that allege in similarly general terms that the VA examinations of record are "faulty" or otherwise inadequate for decision-making purposes. The Board has reviewed the evidence of record and finds that the VA examinations afforded to the Veteran are adequate for decision-making purposes because they provide the information necessary to render a full decision as to the issues decided herein. Neither the Veteran nor his representative has raised any other issues with regard to the duty to notify or duty to assist as they pertain to the issues denied in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). In that regard, the Board notes that the development directed in the Remand section below pertains to the remanded issues, and there is no indication that evidence developed as part of those actions may be relevant to the issues denied in this decision. The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues decided in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Effective Date Issue 1. Entitlement to an effective date earlier than October 28, 2014, for the grant of service connection for major depressive disorder The Veteran seeks entitlement to an effective date prior to October 28, 2014, for the grant of service connection for major depressive disorder. He has not identified a more appropriate effective date. In a statement included with the notice of disagreement as to the issue, the Veteran's representative wrote, "In support of this contention, we submit an excerpt from his VA treatment from his VA treatment records." The VA treatment records submitted with that statement show treatment for mental health complaints from March to November 2013. The effective date for a grant of service connection is the day following the date of 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 the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b); 38 C.F.R. § 3.400(b). Regulations that were in effect prior to March 24, 2015, required that an informal claim "must identify the benefit sought." See 38 C.F.R. §§ 3.155, 3.160 (2014). The regulations also provided that a claim may be either a formal or informal written communication "requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) (2014). The regulations in effect since March 24, 2015, require that claims be submitted on an application form prescribed by the Secretary. They do not allow for informal claims not submitted on such a form. See 38 C.F.R. §§ 3.155, 3.160 (2015). The Board will apply the regulations in effect prior to March 24, 2015, to communications received during that period. Thus, the essential elements for any claim, whether formal or informal, are "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79 (2009). VA must look to all communications from a claimant that may be interpreted as applications or claims, formal and informal, for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). However, VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. Brannon v. West, 12 Vet. App. 32, 35 (1998); Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). Turning to the evidence of record, the Board has reviewed the communications from the Veteran received prior to October 28, 2014, and concludes that none can reasonably be interpreted as an informal or formal claim for entitlement to service connection for major depressive disorder or another acquired psychiatric disability. The formal claims for service connection submitted prior to October 28, 2014, do not list major depressive disorder or another acquired psychiatric disability as a disability for which service connection was being sought. In addition, no communication from the Veteran received prior to October 28, 2014, contains a statement requesting a determination of entitlement, or evidencing a belief in entitlement, to service connection for major depressive disorder or another acquired psychiatric disability, or otherwise indicating an intent to file for such benefit. The Veteran has not argued that he submitted a formal or informal claim for entitlement to service connection for major depressive disorder or another acquired psychiatric disability prior to October 28, 2014. The VA treatment records submitted along with the notice of disagreement suggest that the Veteran is arguing that an earlier effective date should be awarded based on treatment for depression and other mental health complaints prior to October 28, 2014. To the extent that the Veteran has made such an argument, the mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a disability. Lalonde v. West, 12 Vet. App. 377 (1999). Similarly, the mere presence of a disability does not establish intent on the part of the Veteran to seek service connection for that condition. Crawford v. Brown, 5 Vet. App. 33 (1995). Therefore, treatment records showing a diagnosis of or treatment for complaints similar to major depressive disorder or another acquired psychiatric disability prior to October 28, 2014, do not constitute a claim on which an earlier effective date for the award of service connection for major depressive disorder may be based. In summary, no communication was received from the Veteran prior to October 28, 2014, that reasonably can be interpreted as an informal or formal claim for entitlement to service connection for major depressive disorder or another acquired psychiatric disability. Therefore, the Board finds that the preponderance of the evidence is against the assignment of an effective date earlier than October 28, 2014, for the grant of entitlement to service connection for major depressive disorder. As the preponderance of the evidence is against the assignment of an earlier effective date, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Issues Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). 2. Entitlement to increased initial ratings for right lower extremity venous insufficiency The Veteran seeks a higher initial rating for right lower extremity venous insufficiency. The applicable rating period is from February 28, 2012, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The disability is currently rated at 40 percent prior to July 10, 2013, and at 10 percent from that date. The Veteran has contended that his symptoms have remained constant and most closely approximately the criteria for a 40 percent rating. He has also contended that he should be awarded a rating based on involvement of the bilateral lower extremities and not only the right lower extremity because his symptoms are present in both legs. The Veteran's right lower extremity venous insufficiency is rated under 38 C.F.R. § 4.104, Diagnostic Code 7199-7121. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. In this case, the use of Diagnostic Code 7199-7121 reflects that the Veteran's specific service-connected disability is not listed in the Schedule and that a diagnostic code was therefore "built-up" using 71, one of the two-digit codes used for disabilities of the cardiovascular system, and 99. Id. The Veteran's right lower extremity venous insufficiency has been rated using the criteria listed under Diagnostic Code 7121, which pertains to post-phlebitic syndrome. Under Diagnostic Code 7121, a 10 percent rating requires intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking with symptoms relieved by elevation of the extremity or compression hosiery. A 20 percent is warranted when there is persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating requires that the disability is manifested by persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating requires persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent rating requires massive board-like edema with constant pain at rest. Turning to the evidence of record, on a VA Form 21-0960A-2, Artery and Vein Conditions Disability Benefit Questionnaire (DBQ), completed in October 2012, the Veteran's VA doctor indicated that the Veteran's right lower extremity venous insufficiency manifests in persistent statis pigmentation or eczema, persistent edema that is relieved by elevation of the extremity, constant pain at rest, and aching and fatigue after prolonged standing or walking, which are relieved by elevation of the extremity and by compression hosiery. In July 2013, a VA examiner indicated that the Veteran's right lower extremity venous insufficiency manifests in persistent statis pigmentation or eczema, persistent edema, and aching and fatigue after prolonged standing or walking, which are relieved by elevation of the extremity and by compression hosiery. On July 2, 2019, a VA examiner indicated that the Veteran's right lower extremity venous insufficiency manifests in beginning statis pigmentation and aching and fatigue in the leg after prolonged standing and walking, which are relieved by elevation of the extremity. The Veteran's medical treatment records prior to July 2, 2019, show that he had intermittent edema in the lower extremities. Specifically, they show that on many visits he had no edema, but on many others he had edema ranging from trace to 3+ in severity. The medical treatment records from July 2, 2019, to the present do not document any findings of edema. In April 2021, the Veteran submitted photographs taken sometime in 2020 that reportedly show "statis pigmentation, and perhaps a little bit of ulceration, seen on both legs". The Board concludes that during the period prior to July 2, 2019, the Veteran's right lower extremity venous insufficiency was manifested by persistent edema and statis pigmentation. The October 2012 DBQ completed by the Veteran's VA doctor and the July 2013 VA examination both indicate such symptoms. The medical treatment records show that the Veteran had edema at many medical treatment visits during that period. The Veteran has presented statements indicating he had persistent edema during that period. Based on the medical treatment records and the Veteran's statements, the Board will resolve doubt in the Veteran's favor and find he had persistent edema and statis pigmentation throughout the period prior to July 2, 2019. Accordingly, the Board concludes that the criteria for a 40 percent rating for right lower extremity were met throughout the relevant period prior to July 2, 2019. An initial rating in excess of 40 percent was not warranted during that period because the Veteran's right lower extremity venous insufficiency was not manifested by persistent ulceration or by massive board-like edema. The Board further concludes that during the period beginning July 2, 2019, the Veteran's right lower extremity venous insufficiency was manifested by no worse than intermittent edema or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity of compression hosiery. Specifically, at the July 2, 2019 VA examination, he had beginning statis pigmentation and aching and fatigue in the leg after prolonged standing and walking, which are relieved by elevation of the extremity. The medical records during that period do not document any findings of persistent edema, persistent ulceration, or massive board-like edema with constant pain at rest such that a rating in excess of 10 percent was warranted. In reaching this conclusion, the Board has considered the photographs the Veteran submitted in 2020, and concludes that they do not show that the Veteran had symptoms consistent with a rating in excess of 10 percent. The July 2019 VA examiner indicated that the Veteran had beginning statis pigmentation, but noted no edema. The Veteran did not assert that the photographs show persistent edema or massive board-like edema, which are required for a rating in excess of 10 percent under Diagnostic Code 7121. The Board has considered the Veteran's assertion that he should be rated based on bilateral involvement. However, he has only been service connected for venous insufficiency in the right lower extremity. Therefore, his symptoms in the left lower extremity are not for consideration in rating the service-connected right lower extremity venous insufficiency, and he is not entitled to a rating based on bilateral involvement. Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected right lower extremity venous insufficiency, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). In summary, the Board finds that, affording the Veteran the benefit of the doubt, during the entire rating period prior to July 2, 2019, his right lower extremity venous insufficiency was manifested by persistent edema and stasis pigmentation or eczema. In addition, from July 2, 2019, his right lower extremity was manifested by intermittent edema or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity. Therefore, an initial rating of 40 percent, and no higher, was warranted for the period prior to July 2, 2019, and an initial rating in excess of 10 percent was not warranted during the period beginning July 2, 2019. To the extent that the Veteran seeks initial ratings higher than those assigned previously or those assigned herein, the preponderance of the evidence is against appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 3. Entitlement to increased ratings for the right knee traumatic arthritis and instability The Veteran seeks an increased rating for right knee traumatic arthritis and instability. The applicable rating period is from February 28, 2011, one year prior to receipt of the claim, through the present. See 38 C.F.R. § 3.400(o)(2). The service-connected right knee disability is currently rated at 10 percent from February 28, 2012, to July 9, 2013, and as noncompensable from July 10, 2013, based on instability under 38 C.F.R. § 4.71a, Diagnostic Code 5257, and at 10 percent prior to February 28, 2012, 20 percent from that date to July 9, 2013, and 10 percent from July 10, 2013, based on limited motion under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. As noted above, hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The additional diagnostic code is shown after the hyphen. In this case, rating the Veteran's service-connected right knee disability under Diagnostic Code 5010, which pertains to traumatic arthritis, requires the use of Diagnostic Code 5260, which pertains to limited flexion of the leg. As discussed below, the Veteran's 20 percent rating from February 28, 2012, to July 9, 2013, was based on a finding of right knee extension limited to 15 degrees. In addition, the evidence does not show that the Veteran met the criteria for a compensable rating based on limited right knee flexion at any time during the relevant period. Therefore, the Board finds that the Veteran's service-connected right knee disability should be rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. This change in diagnostic code is appropriate given that Diagnostic Code 5261 more accurately describes the functional limitation of limited extension that is caused by the Veteran's right knee traumatic arthritis. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (The assignment of a particular diagnostic code to rate a disability is "completely dependent on the facts of a particular case."). During the pendency of the appeal, the criteria for rating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's appeal under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The regulatory changes reworded Diagnostic Code 5010 from "Arthritis, due to trauma, substantiated by X-ray findings" to "Post-traumatic arthritis". Prior to the regulatory change, Diagnostic Code 5010 directed that the disability be rated as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 directs that a rating shall be awarded on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. As of February 7, 2021, under the amended criteria, Diagnostic Code 5010 directs that the disability be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Further criteria for rating disabilities of the knees applicable in this case are found in 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5259, 5260, and 5261. Prior to the regulatory changes, under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 as in effect prior to February 7, 2021. Therefore, objective medical evidence cannot be categorically found more probative than lay evidence with respect to that diagnostic code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As of February 7, 2021, under Diagnostic Code 5257, a 10 percent rating is warranted when there is a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or where there is a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted when there is a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted when there is an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation; or there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. The regulatory changes did not affect Diagnostic Codes 5259, 5260, and 5261. Under Diagnostic Code 5259, a 10 percent rating is warranted when there is symptomatic removal of the semilunar cartilage. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees or greater. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that increased ratings on the basis of limited motion are not warranted, but that the Veteran was entitled to a separate 10 percent rating based on symptomatic meniscectomy from February 28, 2012, and to a 10 percent rating based on instability from July 10, 2013. The Veteran stated in November 2013 that he experiences pain and instability in his right knee. At the December 2019 Board hearing, he testified "I know I don't feel secure on it sometimes if I'm like taking big steps like from stepping down like a large step or something like that. I ... I don't always feel stable doing that". The Veteran's medical records show that he underwent a right knee meniscectomy in August 2007. In January 2012, he had full range of motion of all joints. In June 2012, he had full range of motion of the right knee with some slight swelling and knee joint effusion without heat or stiffness to passive range of motion. In July 2013, he had mildly decreased range of motion in the right knee with some discomfort, but no swelling, discoloration, or deformity. In March 2015, his right knee had normal flexion and muscle strength, but lacked 5 degrees of extension. At an April 2015 consultation examination provided by the Social Security Administration in conjunction with his claim for disability benefits, he had right knee flexion to 150 degrees and extension to 0 degrees. In September and October 2015, he had mild tenderness and decreased range of motion in the right knee. A VA Form 21-0960M-9, Knee and Lower Leg Conditions DBQ, completed by the Veteran's VA doctor in July 2012 indicates that the Veteran had right knee flexion to 120 degrees with pain at 110 degrees, and extension to 15 degrees. The Veteran could not perform repetitive-use testing. He had 4 out of 5 strength on right knee flexion and extension. He had 1+ anterior instability on testing, but did not have a history of recurrent patellar subluxation or dislocation. The VA doctor indicated that the Veteran has a history of meniscectomy with current symptoms of frequent episodes of joint locking, pain, and effusion. At a July 2013 VA examination, the Veteran had had right knee flexion to 140 degrees or greater with objective evidence of painful motion beginning at 45 degrees. He did not have limitation of extension or objective evidence of painful motion on extension in the right knee. He had the same range-of-motion measurements on repetitive-use testing. He had full 5 out of 5 strength on right knee flexion and extension, and normal stability testing. The examiner indicated that there was no evidence or history of recurrent patellar subluxation or dislocation, but that the Veteran has a history of meniscectomy with current symptoms of frequent episodes of joint locking, pain, and effusion. The examiner indicated that there are no contributing factors of weakness, fatiguability, incoordination, or pain during flare-ups or repeated use over time that could additionally limit the Veteran's right knee functional ability. A VA Form 21-0960M-9 completed by the Veteran's VA doctor in February 2015 indicates that the Veteran reported that his right knee symptoms flare-up at times. During those flare-ups, the knee is sore when he walks, is always swollen, causes pain of 2 to 3 out of 10, prevents him from squatting and climbing, and locks up. On examination, the Veteran had right knee flexion to 120 degrees and extension to 10 degrees. He did not have additional loss of motion following repetitive-use testing. He had 3 out of 5 strength in the right knee on flexion and extension. The VA doctor indicated that the Veteran would have right knee flexion to 90 to 100 degrees and extension to 10 degrees or less during flare-ups and on repetitive use over time. No instability was shown on joint stability testing. The VA doctor indicated that the Veteran has a history of meniscectomy with current symptoms of frequent episodes of joint locking, pain, and effusion. At a July 2019 VA examination, the Veteran reported that his current right knee symptoms include pain, swelling, tightness, and a cracking sound when he walks. His right knee symptoms flare up once or twice per week. On examination, the Veteran had right knee flexion to 140 degrees and extension to 0 degrees both on initial testing and on repetitive use testing. He had 5 out of 5 strength on right knee flexion and extension. Joint stability testing was normal. The examiner opined that the Veteran would have additional pain on repetitive use over time due to pain or during flare-ups, but that his flexion and extension would not decrease in such instances. The examiner further indicated that there was no evidence of pain on passive range of motion or on non-weightbearing of the right knee. Thus, the record shows that the Veteran had right knee extension limited to 15 degrees at the time the July 2012 VA Form 21-0960M-9 was completed such that a 20 percent rating was warranted under Diagnostic Code 5261 from the date of the claim through the day prior to the July 2013 VA examination, which showed that the Veteran no longer met the criteria for a 20 percent rating under Diagnostic Code 5261. For the remainder of the relevant period, to include during the one-year period prior to the February 28, 2012 claim, the record shows that he had painful motion of the right knee, but that he did not have right knee extension limited to 15 degrees or more or flexion limited to 45 degrees or less, to include during flare-ups and on repetitive use over time, such that a compensable rating was warranted under Diagnostic Code 5260 or 5261. As such, he was not entitled to a rating in excess of 20 percent during the period from February 28, 2012, to July 9, 2013, or in excess of 10 percent at any time during the relevant period prior to February 28, 2012, or from July 10, 2013, to the present under Diagnostic Codes 5010, 5260, and 5261. The Board further finds that a separate rating of 10 percent for the service-connected right knee disability was warranted throughout the relevant rating period based on slight instability of the right knee. Specifically, the Veteran had 1+ anterior instability in the right knee at the time the July 2012 VA Form 21-0960M-9 was completed. Although instability testing was negative at the VA examinations completed after July 2012 and at the time the February 2015 VA Form 21-0960M-9 was completed, the Veteran has reported at other times that he has instability in the right knee. As noted above, he testified at the December 2019 Board hearing that he has instability in the knee when he takes large steps and when he steps downward. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 as in effect prior to February 7, 2021. See English, 30 Vet. App. at 352-53. The Veteran's right knee instability is considered slight in severity because objective testing has been negative and, more importantly, there is no indication in the record that the instability caused falls, caused other injuries, or was otherwise moderate or severe in terms of the pain or harm it caused. As such, the right knee instability warranted a rating of 10 percent, and no higher, under Diagnostic Code 5257 as in effect prior to February 7, 2021, throughout the relevant rating period. The record does not show that the Veteran was entitled to a rating in excess of 10 percent for the service-connected right knee disability under Diagnostic Code 5257 as in effect beginning February 7, 2021. Specifically, the record does not show that during the period beginning February 7, 2021, the Veteran's service-connected right knee disability involved the patellofemoral complex or an unrepaired or failed repair of a ligament tear. The Veteran has not contended, and the record does not show, that the August 2007 surgery on his right knee, which included reconstruction and allograft of the anterior cruciate ligament, failed to repair the ligament tear. Finally, the Board finds that a separate 10 percent rating is warranted under Diagnostic Code 5259 since February 28, 2012, the date of the claim for an increased rating. The evidence shows that the August 2007 involved a removal of the right meniscus. The July 2013 VA examination and the July 2012 and February 2015 VA Forms 21-0960M-9 each indicate that the Veteran's meniscal condition results in frequent episodes of locking, pain, and joint effusion. Although the Veteran's right knee pain is already contemplated through his compensable rating under Diagnostic Code 5010, 5260, and 5261, his locking and effusion are not. As such, his right knee traumatic arthritis is manifested by a history of meniscectomy, which has caused symptoms not otherwise compensated through the other ratings for the disability. Therefore, a separate rating under Diagnostic Code 5259 is warranted. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, in this case, the record does not show that the Veteran's service-connected right knee disability has resulted in ankylosis of the knee or dislocation (but not removal) of the semilunar cartilage. Therefore, higher or additional ratings under Diagnostic Codes 5256 and 5258 are not warranted. Neither the Veteran nor his representative has raised any other issues with regard to the ratings for the service-connected right knee traumatic arthritis, nor have any other such issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. In summary, the Board finds that the criteria for higher ratings under Diagnostic Codes 5010, 5260, and 5261 were not met during the relevant period. However, the criteria for an initial rating of 10 percent, and no higher, under Diagnostic Code 5257 were met from February 28, 2012, and throughout the relevant period, and that the criteria for a separate rating of 10 percent, and no higher, under Diagnostic Code 5259 were also met from February 28, 2012, and throughout the relevant period. To the extend the Veteran seeks ratings higher than or in addition to those previously assigned and those assigned herein, the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to increased initial ratings for right knee surgical scars The Veteran seeks higher initial ratings for right knee surgical scars. The applicable rating period is from February 28, 2012, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The disability is currently rated at 10 percent prior to July 10, 2013, and as noncompensable from that date. The Veteran has contended that a 10 percent rating is warranted throughout the relevant period because the scars are deep and involve damage/alteration to the underlying soft tissue. The Veteran's right knee surgical scars are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805, which pertain to scars not of the head, face, or neck. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Codes 7801 through 7805 were not changed by those amendments. Under Diagnostic Code 7801, a 10 percent rating is warranted for scars due to causes other than burns not of the head, face, or neck that are deep and nonlinear and cover an area or areas of at least 39 square centimeters but less than 77 square centimeters. Higher ratings, up to a maximum 40 percent, are warranted under Diagnostic Code 7801 for a scar or scars with a larger area or areas. Under Diagnostic Code 7802, a 10 percent rating is warranted for scars that are not associated with underlying soft tissue damage and have an area or areas of 929 square centimeters or greater. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Diagnostic Code 7805 directs that other effects of scars not considered under Diagnostic Codes 7801, 7802, and 7804 should be rated under another appropriate diagnostic code. The Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent prior July 10, 2013, or a compensable initial from that date. On the VA Form 21-0960M-9 completed in July 2012, the Veteran's VA doctor marked "Yes" to the question of whether the Veteran's scar associated with his service-connected right knee disability is painful and/or unstable, or has a total area greater than 39 square centimeters. The Form directed that if the answer to that question was in the affirmative, a scars/disfigurement DBQ should also be completed. However, there is no indication that the Veteran's VA doctor completed that DBQ, and he did not clarify the extent to which the service-connected scars are painful and/or unstable or provide measurements for the scars. The medical treatment records do not provide any further information as to the severity of the Veteran's service-connected scars prior to July 10, 2013. Given the general nature of the responses on the July 2012 VA Form 21-0960M-9 and the lack of description of the service-connected scars in the medical records during the period prior to July 10, 2013, the Board concludes that the evidence does not show that an initial rating in excess of 10 percent was warranted during that period. Specifically, the evidence does not show that, during that period, the Veteran's service-connected right knee scars manifested in more than one painful or unstable scar, in a scar that was both painful and unstable, in a deep scar with an area of at least 39 square centimeters, in a scar with an area of 929 square centimeters or greater, or in a scar with other disabling effects. The Veteran underwent a VA knee and lower leg conditions examination on July 10, 2013. The examiner noted that the Veteran had a scar associated with the service-connected right knee disability, but that the scar was not painful and/or unstable and did not have a total area of greater than 39 square centimeters. He indicated that the scar measures 1 centimeter by 0.2 centimeters. On the VA Form 21-0960M-9 completed in February 2015, the Veteran's VA doctor indicated that the Veteran's scars associated with the service-connected right knee disability were not painful or unstable and did not have a total area greater than 39 square centimeters. He indicated that the Veteran had four scars with lengths from 1 to 3 centimeters and widths of one-half to 1 centimeter. The total of the areas provided was less than 39 square centimeters. The Veteran underwent a VA scars/disfigurement examination in July 2019. The examiner indicated that the Veteran's service-connected scars were not painful or unstable. There were five scars, one of which measured 2 centimeters by 0.2 centimeters and four of which measured 1 centimeter by 0.2 centimeter. The examiner indicated that the scars involved underlying tissue damage in an area of 6 square centimeters. The Veteran did not have any other findings, complications, signs, or symptoms associated with his service-connected right knee scars. The medical treatment records dating during the period from July 10, 2013, do not provide any further information as to the severity of the Veteran's service-connected scars during that period. Thus, the evidence does not show that, during the period beginning July 10, 2013, the Veteran's service-connected right knee scars were associated with underlying soft tissue damage having an area of at least 39 square centimeters, had an area or areas of 929 square centimeters or greater, were unstable or painful, or caused any other disabling effects such that a compensable initial rating was warranted during that period. The Board acknowledges that the Veteran believes that his service-connected right knee scars have been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. His assertion that the scars are deep and involve damage/alteration to the underlying soft tissue are consistent with the July 2019 VA examiner's findings. However, for a compensable rating to be awarded based on underlying soft tissue damage, the total area or areas of the scar must be at least 39 square centimeters, which is not shown in this case. Neither the Veteran nor his representative has raised any other issues with regard to the initial ratings for the service-connected right knee surgical scars, nor have any other such issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for an initial rating in excess of 10 percent prior to July 10, 2013, and a compensable initial rating from that date for right knee surgical scars. As the preponderance of the evidence is against the assignment of higher initial ratings, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 5. Entitlement to a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012 The Veteran seeks a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012. He contends that the treatment required several days of hospitalization followed by a period of several months of convalescence, during which he established a weekly regime for determining his blood coagulability, began a course of Coumadin, and coordinated and attended numerous referrals, including knee MRIs, brace fittings, and hematology consultations. The need for followup treatment after the initial treatment had a negative impact on his school performance. In support of the claim, the Veteran has submitted a letter from his VA doctor that is dated in April 2013 and states, "It is my understanding that he spent almost a week in the hospital for this episode. Following his acute PE, he did convalesce for over six months, during which time he attended regular blood draws for INR and adjusted his Coumadin dosing appropriately. This has continued until the present day." The VA doctor further stated that the Veteran "will need to remain on Coumadin for life at this point" and that the condition will "continue throughout his life and will require ongoing maintenance." The Veteran has argued that VA "cannot override the doctor's opinion" that he required over six months of convalescence following treatment for a pulmonary embolism in early 2012. A total disability rating will be assigned effective from the date of a hospital admission or outpatient treatment and continuing for a period of one, two, or three months from the first day of the month following such hospital discharge or outpatient release, if the hospital treatment of a service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe post-operative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. See 38 C.F.R. § 4.30(a). Extensions of one, two, or three months beyond the initial three months may be made under paragraph 38 C.F.R. § 4.30(a)(1), (2), or (3). Extensions of one or more months up to six months beyond the initial six months period may be made under 38 C.F.R. § 4.30(a)(2) or (3) upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.30(b). "Convalescence" is defined as the stage of recovery following an attack of disease, a surgical operation, or an injury. Felden v. West, 11 Vet. App. 427, 430 (1998) (citing Dorland's Illustrated Medical Dictionary, 374 (28th ed. 1994)). "Recovery" is defined as the act of regaining or returning toward a normal or healthy state. Id. (citing Webster's Medical Desk Dictionary, p. 606 (1986)). The purpose of a temporary total convalescence evaluation is to aid a claimant during the immediate post-surgical period when he or she may have incompletely healed wounds or may be wheelchair-bound, or when there may be similar circumstances indicative of transient incapacitation associated with recuperation from the immediate effects of an operation. See Seals v. Brown, 8 Vet. App. 291, 296-97 (1995); Felden, 11 Vet. App. at 430. Turning to the evidence of record, a discharge summary shows that the Veteran was admitted in early January 2012 for complaints of chest and thoracic pain. A chest CT scan showed an acute pulmonary embolism. The Veteran was started on anticoagulation medications and followed until his INR was therapeutic. Prior to discharge, the patient had no dyspnea and his oxygen saturation was 94 percent. He was discharged home less than one week after his admission with diagnoses of acute pulmonary embolism; deep vein thrombosis in the right femoral, popliteal, and peroneal veins; and grade 1 diastolic dysfunction. He was instructed to continue anticoagulation, follow up with a hematologist in two weeks for the results of a hypercoagulable panel, and follow up with his primary care provider in one week. Subsequent medical treatment records show that the Veteran followed up for Coumadin treatment and for consultation of his hypercoagulable workup, which was negative according to a hematologist. The medical treatment records indicate that it is expected the Veteran will continue with anticoagulation therapy for the remainder of his life. The Board concludes that the record does not show the Veteran required at least one month of convalescence following his admission for pulmonary embolism in early January 2012. Rather, it shows that his admission lasted less than one week and that following his discharge he was seen only for regular followups, to include being counseled on his hypercoagulable panel and receiving regular anticoagulation treatment. The Board acknowledges that the Veteran's need for medical followup after his discharge shows that he did not return to his pre-admission state of health. However, the medical evidence indicates that he will likely require that same level of medical followup for the remainder of his life. Thus, when he was discharged home with no stated restrictions and with instructions to continue with anticoagulation and to follow up with his primary care provider, he entered a new normal state of health. That new state of health, namely, regular follow up for anticoagulation treatment, has continued through the present. As such, upon being discharge the Veteran had achieved a normal state of health and cannot be said to have undergone convalescence after his discharge. The Board acknowledges the April 2013 statement from the Veteran's VA doctor. The doctor did not explain how followup for blood draws and adjustments in Coumadin dosing constitutes convalescence, as defined above. Moreover, the doctor's statement that such followup "has continued until the present day" and that the Veteran "will need to remain on Coumadin for life" indicates that the post-discharge followup was not part of the stage of recovery following the attack of the pulmonary embolism, but rather was the Veteran's normal state of health following his initial stage of recovery, which occurred during his hospital admission. Accordingly, the Board does not afford probative weight to the doctor's conclusion that the Veteran required over six months of convalescence following treatment for the pulmonary embolism. The Board therefore finds that the criteria for entitlement to a temporary total rating based on convalescence following treatment for a pulmonary embolism in 2012 have not been met because the Veteran did not require at least one month of convalescence following his admission for that condition. As the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. Service Connection Issues Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of 38 U.S.C. § 1110 as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 6. Entitlement to service connection for a left knee disability The Veteran seeks entitlement to a left knee disability, which he contends is manifested by pain and is caused by favoring his left knee due to his service-connected right knee disability. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, or proximately due to or aggravated by a service-connected disability. The Board concludes that the Veteran does not have a current left knee disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). July 2013 and July 2019 VA knee and lower leg conditions examiners evaluated the Veteran and determined that, although he reported subjective symptoms of bilateral knee pain, he did not have a diagnoseable left knee disability. The VA Forms 21-0960M-9 completed in July 2012 and February 2015 do not reflect a diagnosis of a left knee disability. The Veteran has not submitted or identified any medical treatment records showing that he has been diagnosed with a left knee disability at any time during the pendency of the claim or recent to the filing of the claim, nor have any such records been received. The Board acknowledges that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018). However, the record does not show that the Veteran's reported left knee pain reached the level of a functional impairment of earning capacity. The July 2013 VA examination indicates that the Veteran had full flexion and extension of the left knee without objective evidence of painful motion both prior to and after repetitive-use testing. He also had full five out of five strength on left knee flexion and extension, and had normal joint stability testing of the left knee. He had the same examination results at the July 2019 VA examination. The record does not show that the Veteran's left knee pain causes functional impairment, such as loss of motion, loss of muscle strength, or instability, so as to constitute a service connectable disability. Although the Veteran believes he has current service-connectable left knee disability, he is not considered competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Furthermore, he is considered competent and credible in his reports that he has left knee pain. However, the objective medical testing conducted at the July 2013 and July 2019 VA examinations does not show that his pain alone has risen to the level of a service-connectable disability. In summary, the record does not show that the Veteran had a service-connectable left knee disability at any time during or recent to the filing of the claim. As noted above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a current disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for a left knee disability. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 7. Entitlement to service connection for sexual dysfunction The Veteran contends that he currently has delayed ejaculation and that the condition began during his active service after he was prescribed Effexor. The Veteran's service treatment records do not show complaints of or treatment for delayed ejaculation. However, they also do not include affirmative evidence showing that the Veteran did not have delayed ejaculation during his active service. The Board finds that, aside from the lack of contemporaneous medical treatment records documenting complaints of or treatment for delayed ejaculation during active service, there is no reason to doubt the Veteran's assertions that he had such a condition during his active service. Therefore, his assertions in that regard are considered credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board also finds the Veteran credible in his assertions that his difficulties with delayed ejaculation have continued through the present. As such, the Veteran has presented competent and credible evidence that he first experienced delayed ejaculation during his active service and that he has continued to have that condition through the present. The Board acknowledges that in September 2020 a VA examination opined that it is less likely than not that the Veteran's delayed ejaculation is proximately due to, the result of, or aggravated by his service-connected major depressive disorder because there is an absence of a pathophysiological connection between the Veteran's major depressive disorder and his delayed ejaculation and because he no longer takes Effexor. That opinion does not discuss the issue of service connection on a direct basis and therefore does not weigh against the probative statements provided by the Veteran that his delayed ejaculation began during his active service and has continued through the present. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current delayed ejaculation began during his active service. Accordingly, after resolving any remaining doubt in the Veteran's favor, the Board finds that service connection for delayed ejaculation is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal disability is remanded. The February 2020 Board decision directed the AOJ to obtain an opinion as to whether the Veteran's gastrointestinal condition may be related to an in-service injury, event, or disease, including acid reflux the Veteran reports he had during his active service, or whether the condition may satisfy the criteria for compensation under 38 C.F.R. § 3.317. In September 2020, a VA examiner diagnosed the Veteran with gastroesophageal reflux disease (GERD) and lactose intolerance, and opined that the conditions are less likely than not related to an in-service injury, event, or disease. As a rationale for that opinion, the examiner explained that the Veteran's service treatment records show diagnoses for diarrhea and loose stools, but indicate that those were temporary and limited illnesses diagnosed as acute gastroenteritis or viral illness. They do not show a condition consistent with the currently diagnosed lactose intolerance. In February 2021, the examiner provided an addendum opinion stating that it is less likely than not that the Veteran's GERD was incurred during military service because there is an absence of supporting evidence in the service treatment records of a condition consistent with GERD. The Board finds that the September 2020 and February 2021 VA opinions are inadequate for decision-making purposes because they do not reflect consideration of the Veteran's contentions, to include at the December 2019 Board hearing, that he had acid reflux during and shortly after his active service. The examiner also did not provide an opinion sufficient to determine whether compensation under 38 C.F.R. § 3.317 is warranted. Therefore, the issue must be remanded for an addendum opinion. 2. Entitlement to a TDIU prior to July 27, 2018, is remanded. Finally, because a decision on the renanded issue of entitlement to a gastrointestinal disability could significantly impact a decision on the issue of entitlement to a TDIU prior to July 27, 2018, the issues are inextricably intertwined. A remand of the issue of entitlement to a TDIU prior to July 27, 2018, is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's diagnosed gastrointestinal disabilities, to include gastroesophageal reflux disease and lactose intolerance, at least as likely as not (50 percent probability or greater) had their onset during his active service or are otherwise related to an in-service event, injury, or disease, to include the gastrointestinal symptoms documented in the service treatment records. The opinion must reflect consideration of the Veteran's lay statements, to include his testimony at the December 2019 Board of Veterans' Appeals hearing, that he had acid reflux during and shortly after his active service. In considering those assertions, the clinician must note that a lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible, but may be considered in conjunction with other factors in determining the credibility of lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). If the above opinion is in the negative, then the clinician is asked to provide responses to the following: A) Can the Veteran's diagnosed gastrointestinal conditions be characterized as a functional gastrointestinal disorder as defined in the note to 38 C.F.R. § 3.317(a)(2)(i)(B)(3)? B) If not, is the etiology of the Veteran's diagnosed gastrointestinal conditions (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. C) Is the pathophysiology of the Veteran's diagnosed gastrointestinal conditions (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. A complete rationale must be provided for all opinions expressed. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU prior to July 27, 2018. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. J. Anthony, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.