Citation Nr: 21030101 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-28 181 DATE: May 17, 2021 ORDER Entitlement to service connection for bilateral eye disability, to include angle closure glaucoma suspect, is denied. Entitlement to service connection for colon cancer is denied. Entitlement to an initial rating higher than 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to an initial compensable rating for erectile dysfunction is denied. Entitlement to a temporary total disability rating due to surgery for colon cancer is denied. FINDINGS OF FACT 1. The Veteran's bilateral eye disability did not have its onset in service, was not caused or aggravated by the Veteran's service-connected hypertension, and is not otherwise related to service. 2. The Veteran's colon cancer did not have its onset in service or for many years thereafter, and is not otherwise related to service, to include as due to exposure to Agent Orange. 3. The Veteran's PTSD symptoms and overall impairment does not more nearly approximate total social impairment. 4. The symptoms of the Veteran's service-connected hypertension have not more nearly approximated predominant diastolic blood pressure of 100 or more, or a predominant systolic blood pressure of 160 or more. 5. The Veteran's erectile dysfunction does not result in deformity of the penis with loss of erectile power. 6. The Veteran's colon cancer surgery was not for a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral eye disability (to include angle closure glaucoma suspect), to include as secondary to service-connected hypertension, are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for colon cancer are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 3. The criteria for an initial rating higher than 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, diagnostic code (DC) 9411. 4. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, DC 7101. 5. The criteria for an initial compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.115b, DC 7522. 6. The criteria for entitlement to a temporary total disability rating have not been met. 38 C.F.R. §§ 3.102, 4.29, 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1966 to July 1968 with combat service in Vietnam. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision which, inter alia, granted service connection for PTSD, evaluating it as 70 percent disabling, granted service connection for hypertension, evaluating it as noncompensable, granted service connection for erectile dysfunction, evaluating it as noncompensable, denied service connection for both glaucoma and colon cancer to include pelvis condition, and denied a temporary total rating for surgery due to colon cancer. In August 2013, the Veteran filed his notice of disagreement with, among one other thing, the 70 percent rating assigned for PTSD, and in February 2014, filed his notice of disagreement with, among other things, the noncompensable ratings assigned for hypertension and erectile dysfunction, the denials of service connection for glaucoma and colon cancer, and the denial of a temporary total rating for surgery due to colon cancer. In June 2016, the Veteran was issued a statement of the case, and perfected his appeal to the Board. In December 2018, the Board, among other things, remanded the Veteran's claims for further development, including addendum medical opinions. For the reasons indicated in the discussion below, the opinions that the Board instructed the agency of original jurisdiction (AOJ) to obtain were in fact obtained and are adequate to decide the claims on appeal. Thus, the AOJ substantially complied with the Board's pertinent remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first 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). Certain chronic diseases may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is also warranted for any increase in severity of a nonservice connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). If a veteran was exposed to an herbicide agent, such as Agent Orange, during active service, service connection will be presumed for certain diseases which are listed at 38 U.S.C. § 1116(a)(2) and 38 C.F.R. § 3.309 (e), if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. 38 U.S.C. § 1116(f); 38 C.F.R. §§ 3.307(a) (6) (iii), 3.309(e). For purposes of establishing service connection for a disability resulting from exposure to an herbicide agent, a veteran who, during active military, navel, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, are presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C. § 1116 (f). In this case, the Veteran's DD-214 reflects that his military occupational specialty was as a heavy vehicle driver, and that he is a recipient of, among other decorations, the Vietnam Campaign Medal and Vietnam Service Medal. Additionally, the Veteran's military personnel record reflects service in Vietnam from July 1967 to July 1968. Therefore, service in Vietnam has been established and the Veteran is presumed to have been exposed to Agent Orange. As a final preliminary matter, the Board notes that there is evidence in the claims file that the Veteran may have engaged in combat while in Vietnam. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154 (b). The combat rules not only reduce the evidentiary burden for establishing in-service injury, but also allow a combat veteran to use "satisfactory lay or other evidence" to establish that he incurred the disability itself in service, even in cases where "there is no official record" that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). Section 1154 (b) does not, however, eliminate the need for evidence of a nexus; it merely reduces, for veterans who have engaged in combat with the enemy, the burden of presenting evidence of incurrence or aggravation of an injury or disease in service. Collette v. Brown, 82 F.3d 389, 392 (Fed.Cir.1996) ("Section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service-connected"). While the section 1154(b) rules can assist a claimant in showing both the in-service injury element and incurrence of the disability itself, Reeves, 682 F.3d at 999, in this case the lay evidence does not tend to show in-service incurrence of bilateral eye disability or colon cancer. As explained in more detail below, there is no evidence that the Veteran experienced his claimed disabilities in service. Also, assuming without deciding that the Veteran engaged in combat during service, the claims of service connection for bilateral eye disability and colon cancer must nevertheless be denied, as explained below. 1. Bilateral Eye Disability, to Include Angle Closure Glaucoma Suspect The Veteran's service treatment records do not indicate that the Veteran reported, or was treated for an eye disability, and his July 1968 medical examination report and medical history report upon discharge are normal with regard to the Veteran's eyes. An October 2012 VA examination report reflects that the Veteran was diagnosed with glaucoma suspect in 2011, and indicated that the Veteran did not have double vision. An October 2019 disability benefits questionnaire (DBQ) indicated that the Veteran had a diagnosis of anatomic narrow angles (angle closure glaucoma suspect), and that the Veteran claimed double vision due to hypertension as he stated that when his blood pressure is high, his vision will sometimes be "blurry, blackout, and goes double." The optometrist noted that the Veteran had no current diagnosis of double vision, nor documented episodes on clinical examination. In an October 2019 addendum opinion, the optometrist opined that the Veteran's eye disabilities were at least as likely as not (at least a 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The optometrist stated that the Veteran's condition of angle closure glaucoma suspect is an isolated anatomic finding and not the result of service. However, it is related to the development of ocular anatomy. Furthermore, the Veteran has farsightedness, a common developmental risk factor for angle closure. The optometrist noted that the Veteran does not demonstrate double vision on examination, and further opined that the Veteran's condition of angle closure glaucoma suspect is not the result of hypertension, noting that in very rare instances, hypertension can lead to a cascade of events that cause an angle to close, however this type of event has a constellation of signs, symptoms, and other ocular ramifications of which the Veteran has never been diagnosed. In an August 2020 DBQ, the optometrist opined that the Veteran's angle closure glaucoma suspect was at least as likely as not (at least a 50 percent probability) incurred in or caused by the claimed in service injury, event or illness, stating that the disability is an isolated anatomic finding and not the result of service, but is related to the development of ocular anatomy. He continued, the Veteran has farsightedness, a common developmental risk factor for angle closure. The optometrist also opined that the Veteran's angle closure glaucoma suspect was at least as likely as not (at least a 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. He stated the Veteran's condition is an isolated anatomic finding and not the result of hypertension, but is a developmental anomaly of ocular anatomy. The optometrist noted that the Veteran has never been diagnosed nor documented to have hypertension related ocular events. He also reported that the Veteran did not demonstrate double vision on examination, has no current diagnosis of double vision, nor documented episodes on clinical examination. In a January 2021 addendum opinion, the optometrist clarified his earlier opinion stating that the Veteran was diagnosed as having glaucoma suspect based on an anatomic finding and does not have a diagnosis of glaucoma. He also stated that the Veteran does not have a diagnosis of double vision, nor did he have symptoms of double vision on examination. Additionally, the optometrist reported, hypertension is not associated with the Veteran's glaucoma suspicion. He thus opined that it is less likely than not (less than a 50 percent probability) that the Veteran's glaucoma suspect is related to service and to hypertension, and less likely than not that his eye disorder was permanently aggravated beyond its natural progression by the service-connected hypertension. Considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for his claimed bilateral eye disability, diagnosed as angle closure glaucoma suspect. In this regard, the previously discussed medical opinions reflect that the Veteran does not have a diagnosis of, or symptoms of double vision, and his angle closure glaucoma suspect is less likely than not (less than a 50 percent probability) related to service, and less likely than not (less than a 50 percent probability) caused or aggravated by service-connected hypertension. While the October 2019 and August 2020 opinions are worded in a manner which would indicate that the Veteran's angle closure glaucoma suspect was at least as likely as not due to service, the Board affords more weight to the explanations provided by the optometrists which specify why the Veteran's eye disability is not related to service than to the erroneous notations on the DBQs. The optometrists provided thorough rationales to support their opinions based on an accurate characterization of the evidence of record. Therefore, their opinions are afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There are no contrary medical opinions in the evidence of record as to the etiology of the Veteran's angle closure glaucoma suspect, and the evidence does not otherwise indicate that the Veteran's angle closure glaucoma suspect is related to his service- connected hypertension or related to service. The Board acknowledges the Veteran's contention that his angle closure glaucoma suspect is due to service, or related to his service-connected hypertension. However, while the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue in this case is outside the realm of common knowledge of a lay person because it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Thus, the Veteran's statements in this regard are not competent and are afforded no probative weight. For the above stated reasons, the preponderance of the evidence weighs against a finding that the Veteran's claimed bilateral eye disability had its onset in service, is otherwise related to service, or is caused or aggravated by his service-connected hypertension. The benefit-of-the-doubt doctrine is therefore not for application, and service connection for bilateral eye disability, to include angle closure glaucoma suspect, is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Colon Cancer November 1967 service treatment records reflect that the Veteran was treated for diarrhea with red blood and mucous, but his July 1968 medical examination report and medical history report upon discharge are normal with the exception of a notation for venereal disease, but no indication that he suffered from a rectal issue, or colon cancer symptomatology. An October 2012 VA examination report reflected a diagnosis of rectum cancer which the Veteran claimed was incurred in or caused by the abdominal pain and diarrhea with red blood and mucous in his stool that he experienced while in service in 1967. The examining physician opined that the Veteran's colon cancer was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness, stating that the Veteran was not treated for, or diagnosed with colon cancer while in service, but was diagnosed with a viral illness when he presented with cramps and diarrhea which resolved. An August 2018 DBQ reflected a diagnosis of fecal incontinence due to rectal cancer diagnosed in 2012 and status post proctectomy, laparoscopically by total meso rectal excision with splenic flexor takedown and coloanal anastomosis. The examiner stated that as a result of this surgery, the Veteran has had problems with bowel control, and resulting bowel urgency and incontinence. In an October 2019 DBQ, the examining physician opined that the Veteran's claimed colon cancer was less likely than not (less than a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, reporting that there is no objective medical evidence establishing a direct cause and effect relationship between colon cancer that is at least as likely as not (at least a 50 percent probability) incurred in or caused by herbicide exposure during service. The physician also noted that the Veteran is not service-connected for colon cancer to include pelvis condition nor fecal incontinence due to rectal cancer diagnosed in 2012 and status-post proctectomy, laparoscopically by total meso rectal excision with splenic flexor takedown and coloanal anastomosis. The physician referenced the most common causes of colorectal cancer, and also addressed the Veteran's reports of abdominal pain, and diarrhea with blood and mucous in stool when formulating his opinion. Considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for colon cancer. Initially, the Board notes that colon cancer is not on the list of diseases presumed service connected in veterans exposed to herbicide agents, including Agent Orange. However, service connection may still be established on a direct basis. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a Veteran from establishing service connection with proof of actual direct causation). In this regard, the October 2012 examination report and October 2019 DBQ reflect that the Veteran's colon cancer is less likely than not (less than a 50 percent probability) related to military service, including exposure to Agent Orange. While the October 2012 opinion is inadequate as the physician based his opinion on a lack of a diagnosis for colon cancer reflected in the service treatment records which is impermissible, see Dalton v. Nicholson, 21 Vet. App. 23 (2007), the October 2019 physician noted the common causes and risks associated with colon cancer and addressed the Veteran's reports of abdominal pain, diarrhea, and blood and mucous in his stool during service. The October 2012 physician provided a thorough rationale to support his opinion based on an accurate characterization of the evidence of record. Therefore, his opinion is afforded significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. There is no contrary medical opinion in the evidence of record, and the evidence does not otherwise indicate that the Veteran's colon cancer is related to Agent Orange exposure or anything else in service. The Board acknowledges the Veteran's contention that his colon cancer is due to Agent Orange exposure in service. However, while the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, 6 Vet. App. at 469-70. The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, the issue in this case is outside the realm of common knowledge of a lay person because it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau, 492 F.3d at 1377 n. 4. Thus, the Veteran's statements in this regard are not competent and are afforded no probative weight. In addition, although malignant tumors are chronic diseases for which service connection is warranted if they manifest in service or the one year presumptive period, the above reflects that there is no evidence or argument suggesting such manifestation. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a). For the above stated reasons, the preponderance of the evidence weighs against a nexus between the Veteran's colon cancer and service. The benefit-of-the-doubt doctrine is therefore not for application, and service connection for colon cancer is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Board is sympathetic to the Veteran and recognizes his distinguished service, but is bound by the applicable laws and regulations. 38 U.S.C. § 7104(c); 38 C.F.R. § 20.105. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). 1. PTSD The Veteran contends that his service-connected PTSD, which is currently rated 70 percent disabling, warrants a higher rating. The criteria for rating PTSD are found at 38 C.F.R. § 4.130, Diagnostic Code 9411. PTSD is rated under the General Rating Formula for Mental Disorders. Under this formula, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in the VA's general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held "that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration." Id. at 117. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V). See 38 C.F.R. § 4.130. Per applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, not solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126 (b). In this case, the Veteran's August 2006 VA examination report reflects that the Veteran was treated for PTSD with Paxil. The examining nurse practitioner (NP) noted that the Veteran had combat experience in Vietnam from 1967 to 1968. The Veteran reported a poor relationship with his family, and being estranged from his son due to the Veteran being "moody" with frequent verbal outbursts. The Veteran stated that he was employed part-time as a handyman, and as his friend owned the business, he was understanding as to why the Veteran was absent so often. The Veteran reported no history of suicide attempts, but was very isolative, and unable to deal with many stressors without becoming easily agitated. The Veteran was oriented to person, time, and place, reported sleep impairment, did not report inappropriate behavior or obsessive/ritualistic behavior, but did report panic attacks in the morning after having recurrent dreams of being attacked. There was no presence of homicidal or suicidal thoughts reported, the Veteran was able to maintain minimum personal hygiene, and his memory was normal. The NP reported that the Veteran's PTSD symptomatology resulted in deficiencies in family relations, work, and mood. The NP stated that the Veteran's PTSD caused him to be very unreliable, hypervigilant with poor motivation, have a sense of doom, isolative, and easily agitated. July 2011 VA treatment records reflect that the Veteran reported nightmares approximately 2 to 3 times per month with some avoidance of triggers, but panic attacks with triggers 2 to 3 times per month associated with lightheadedness, palpation, and a sense of impending doom. In a September 2011 statement, the Veteran reported that he suffers from panic attacks when he is in the shower due to an incident during service which causes a rise in his blood pressure, cold chills, dizzy spells, swelling in his abdomen and a numbing sensation in his arms. A December 2011 VA examination report reflects that the Veteran's PTSD causes occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. The Veteran reported having a few friends with whom he has weekly contact, but stated that he is mostly socially withdrawn and avoidant. He reported going for walks, exercising, going fishing, and occasionally playing dominoes with friends. He also stated that he attends church, but sits in the rear as crowds cause anxiety. His PTSD symptomatology included difficulty establishing and maintaining effective work and social relationships, adapting to stressful situations, including work or a worklike setting, depressed mood, panic attacks, and anxiety. In a February 2012 letter, a VA psychiatrist (M.S.) reported that the Veteran experienced severe PTSD symptoms, including repeated intrusive thoughts of traumatic experiences, extreme irritability, marked depression and anxiety, chronic insomnia, frequent nightmares, poor concentration, marked isolation and avoidance, hypervigilance, and mistrust. Due to these symptoms (particularly avoidance and irritability), he had extreme difficulty being in the presence of other individuals. An April 2013 VA examination report indicated that the Veteran had diagnoses of PTSD, MDD, and panic disorder with agoraphobia, but reflected that it was not possible to differentiate what symptoms are attributable to each diagnosis. The Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran reported living with a lady he has known since his late teens, stating that his relationship with her is "ok" but difficult at times because of his irritable mood and short temper. He stated that he gets along better with his son than with his daughters, and stated that he has friends from his PTSD groups. The Veteran's PTSD symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances including work or a worklike setting. The VA examination report indicated that the Veteran's concentration and attention were good, he elicited no delusions, and he denied suicidal or homicidal ideation. In an April 2013 letter, the Veteran's wife stated that she has always noticed the Veteran's paranoid state of mind, and reported that he has frequent panic attacks and hallucinations, and was falling into severe depression. She stated that the Veteran frequently wakes up with cold sweats and being nervous, stating that he has had nightmares. She also noted that the Veteran has a big problem with concentration and memory loss. She stated that due to his health issues, there is no way he would be able to hold any type of job. A January 2015 assessment indicated that the Veteran denied suicidal plan or intent, but had passive suicidal ideation, and reported auditory and visual hallucinations. The Veteran reported chronic sleep impairment, nightmares, sleepwalking, mild memory loss, disturbances of motivation and mood, hypervigilance, exaggerated startle response, and sense of foreshortened future. The Veteran also reported lack of interest in participating in significant activities, an inability to establish and maintain relationships, difficulty concentrating, irritability, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner stated that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD. A January 2015 DBQ reflected that the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. His PTSD symptomatology included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, flattened affect, 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, an inability to establish and maintain effective relationships, suicidal ideation, peristent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran reported struggling remembering basic information and increased trouble with short and long-term memory. An April 2015 private psychiatrist letter indicated that the Veteran is being treated for chronic PTSD, and suffered from symptomatology which included sad and anxious mood, irritability, emotional detachment, low energy, low motivation, intrusive memories, avoidance behaviors, hypervigilance, impaired sleep, impaired concentration, and recurrent trauma-related nightmares. The psychiatrist noted that the Veteran's PTSD affects his ability to function in his social and occupational roles, and that he is unable to sustain employment due to his psychiatric conditions. In an August 2016 letter, the Veteran's wife explained that she takes care of her husband as the severity of his PTSD prevents him from leaving the house most of the time. She stated that she sometimes has to stay home due to his overwhelming anxiety and PTSD. She reported reminding the Veteran to take his medications, stay groomed and shaved, and to bathe regularly. The Veteran's wife stated that she has to shave him, or he will cut himself from nervousness, and that if she did not remind him to bathe and wear clean clothes, he would neglect his appearance and hygiene. An August 2020 DBQ reflected that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, and his PTSD symptomatology included exaggerated startle response, panic attacks almost every day, intrusive thoughts and nightmares, hypervigilance, middle night waking, irritability, frequent fatigue, low motivation, anhedonia, social isolation, depressed mood, and low appetite. The Veteran reported having a pretty good relationship with his wife as she understands him, and reported a good relationship with his three children. He also stated that he has a few friends in his therapy group, but rarely participates in other social activities outside of spending time with family. He reported difficulty maintaining employment due to his difficulty getting along with others and his back pain. In a January 2021 addendum, the examining psychiatrist reported that she had diagnosed the Veteran with PTSD, MDD, and panic disorder which were not new conditions as they were diagnosed in a previous VA examination in April 2013. However, she stated that his MDD and panic disorder are most likely related to the Veteran's PTSD, but given the chronicity, progressiveness, and known overlap of the symptoms, it is not possible to separate the individual effects of each disorder. The evidence of record indicates that the Veteran's PTSD symptoms have included almost daily panic attacks, hypervigilance, short and long-term memory loss, irritability, depressed mood, social isolation, nightmares, anhedonia, chronic sleep impairment, suicidal ideation, persistent delusions or hallucinations, and difficulty establishing and maintaining effective work and social relationships. Additionally, the Veteran's wife reported that she has to remind the Veteran to tend to his personal hygiene and take his medications. However, the August 2020 DBQ reflects that the Veteran has been able to maintain a good relationship with his wife and three children, and reported forming and maintaining friendships with people in his therapy group. While the Veteran has provided evidence of substantial social impairment, neither his statements nor the other evidence of record reflects total social impairment or its approximation due to PTSD. Moreover, the Veteran has experienced some impaired memory and occasional hallucinations/delusions, and he requires some reminders to perform activities of daily living (e.g., maintaining personal hygiene). Nevertheless, he has not experienced memory loss for names of close relatives, own occupation, or name, there have only been occasional reports of hallucinations/delusions, and he has generally been able to perform activities of daily living (even if ne needs reminders). Also, he has not generally demonstrated gross impairment in thought processes or communication, he has generally been cooperative with examiners, he has remained fully oriented to time and place, and he has not been a persistent danger to himself or others. Therefore, although the Veteran's symptoms and overall impairment are significant, he has not exhibited most of the symptoms listed in the criteria for the maximum, 100 percent rating under the General Rating Formula as examples of the type and extent, frequency or severity, as appropriate, to indicate both total social and occupational impairment at any point since the effective date of service connection. Rather, the Veteran's psychiatric symptoms have most closely approximated the criteria for a 70 percent rating under the General Rating Formula during the entire claim period. See 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9434. As the preponderance of the evidence is against a 100 percent rating, the benefit of the doubt doctrine is not for application in this regard. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board notes that as indicated above, the Veteran has been diagnosed with MDD and panic disorder in addition to PTSD. Notably, the examiners did not differentiate between symptomatology associated with the Veteran's PTSD and his other psychiatric disorders. As the Veteran will therefore be compensated for all of his psychiatric symptoms, the Board will not separately adjudicate a claim of service connection for any other psychiatric disorder, and the Board has attributed all of the Veteran's psychiatric symptoms to PTSD for the purposes of assessing the severity of that disability. Mittleider v. West, 11 Vet. App. 181 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). 2. Hypertension The Veteran's hypertension is currently rated noncompensable under 38 C.F.R. § 4.104, DC 7101. Under DC 7101, a 10 percent evaluation is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent evaluation is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent evaluation is warranted where diastolic blood pressure is predominantly 130 or more. 38 C.F.R. § 4.104. July 2011 VA treatment records reflect that the Veteran reported taking medication for his hypertension, and stated that he checks his blood pressure at home with readings usually indicating systolic blood pressure in the 120s, and diastolic blood pressure in the 70s. In an October 2012 VA examination report, the examining physician noted blood pressure readings of 121/79, 117/76, and 113/71, and reported that the Veteran's treatment plan included taking continuous medication for hypertension. The Veteran denied dizziness, chest pain, headaches, and shortness of breath. In an April 2013 letter, the Veteran's wife stated that the Veteran's blood pressure frequently rises to over 200/105, and that at times they have to put him in a bathtub with a lot of ice to control it. A November 2020 DBQ reflected that the Veteran's hypertension has worsened since its onset, with the Veteran stating that his ears get red, hands get sweaty, and he gets a headache when he gets elevated blood pressure. He also reported blurred vision with elevated blood pressure. The Veteran reported that these episodes come daily, and when they occur at home, his blood pressure gets up to 200/105. The examining physician noted that the Veteran's treatment plan included taking continuous medication, and that the Veteran had a history of a diastolic blood pressure elevation to predominantly 100 or more. The Veteran's readings at the time of the DBQ were 129/83, 127/83, and 121/80. The physician noted that the Veteran's hypertension impacted his ability to work as when his blood pressure is elevated, he gets emotional, has trouble with vision, and develops headaches. The preponderance of the evidence is against the Veteran's claim for an initial compensable rating for service-connected hypertension under DC 7101. While the Veteran reports taking prescribed medication for his hypertension, his noted diastolic pressure has ranged between 71 and 83, and his systolic blood pressure has ranged between 113 and 129. These blood pressure readings are sufficient for making an increased rating determination even considering the Veteran's use of medication to control his blood pressure. See McCarroll v. McDonald, 28 Vet. App. 267. 276-77 (2016) (the Board may properly consider ameliorative effects of blood pressure medication in adjudicating claims for increased ratings for hypertension, because medication is specifically mentioned in DC 7101). While the Veteran and his wife have reported daily episodes of elevated blood pressure wherein the Veteran's blood pressure frequently rises up to 200/105, the evidence of record does not demonstrate findings of diastolic pressure predominantly of 100 or more, or systolic blood pressure predominantly of 160 or more. Predominantly means "being most frequent or common." See Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/predominant (last visited April 28, 2021). In the context of DC 7101, this means "above a certain level more often than it was below it." See Thompkins v. McDonald, No. 15-4128, 2016 U.S. App. Vet. Claims LEXIS 2013 (Dec. 29, 2016) (Greenberg, J.) (accepting this definition of predominant in the Board's decision and affirming based on the Board's application of the definition to the facts of that case); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). While these episodes of elevated blood pressure are reported to occur daily, the evidence suggests that these episodes, where the Veteran may need to soak in an ice bath to alleviate the symptoms, are temporary and do not represent the predominant nature of the Veteran's blood pressure. Thus, the Veteran's hypertension symptomatology does not more nearly approximate that contemplated by a higher disability rating, and an initial compensable rating for service-connected hypertension is not warranted at any time during the claim period. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The Board notes the Veteran's contention that he suffers from sweaty hands, ears becoming red, and headaches as a result of elevated blood pressure. The Board has thus considered whether referral for an extraschedular rating is warranted in this case under 38 C.F.R. § 3.321 (b)(1). However, the Board notes that the Veteran was awarded a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, during the entire period from the July 22, 2011 effective date of service connection for hypertension through October 15, 2015, and that he has been in receipt of a combined 100 percent rating for his service-connected disabilities since October 16, 2015. Although the Court had previously indicated that the award of a TDIU did not render an extraschedular issue moot, see Colayong v. West, 12 Vet. App. 524, 527 (1999) (VA "conceded... that the veteran's TDIU rating claim was a matter separate from the adjudication of his schedular or extraschedular rating claims and also that even if a TDIU rating is awarded, the veteran is still entitled to fair adjudication of those other claims"), it reached the opposite result in Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014). In Johnson, the Federal Circuit held that the TDIU provision only accounts for instances in which a veteran's combined disabilities establish total unemployability, i.e., a disability rating of 100 percent. Id. at 1366. On the other hand, 38 C.F.R. § 3.321 (b)(1) performs a "gap-filling" function and accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented. Id. The Federal Circuit thus indicated that an award of a TDIU would result in a veteran being deemed to have total unemployability, with no "gap" to fill by 38 C.F.R. § 3.321 (b). Thus, based on the more recent Federal Circuit case, the Board finds that the award of a TDIU and a combined 100 percent rating for the entire claim period has also rendered any issue of entitlement to an extraschedular rating for hypertension moot. 3. Erectile dysfunction The Veteran's erectile dysfunction is currently rated noncompensable under DC 7522. Pursuant to DC 7522, a 20 percent rating is warranted for deformity of the penis with the loss of erectile power. This is the only schedular rating provided under this diagnostic code. Where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. There are no other schedular criteria applicable to erectile dysfunction. In Williams v. Wilkie, 30 Vet. App. 134 (2018) the Court noted that, although DC 7522 requires a "deformity" for a compensable rating, VA has not expressly defined this term. The Court therefore assigned the ordinary meaning to this word. In doing so, the Court noted that a "deformity" is a "distortion of any part or general disfigurement of the body" (citing Dorland's Illustrated Medical Dictionary 478 (32d ed. 2012)). The Court also noted that Dorland's further defines various types of internal and external deformities. The Court therefore held that "deformity" under DC 7522 means a distortion of the penis, either internal or external. Williams, 30 Vet. App. at 138. The Board notes that the Veteran has been awarded special monthly compensation (SMC) based on loss of use of a creative organ since July 22, 2011. The March 2013 rating decision granted this benefit based on the Veteran's erectile dysfunction which was rated noncompensable from July 22, 2011. However, granting a compensable rating under DC 7522 in addition to SMC for loss of use of a creative organ does not constitute impermissible pyramiding. Id. at 137. An April 2013 VA examination report reflected that the Veteran had a diagnosis of erectile dysfunction for which he was receiving treatment. The examination report indicated that the Veteran is unable to achieve an erection sufficient for penetration and ejaculation without medication, but the Veteran did not have retrograde ejaculation. The Veteran reported being treated with Viagra, with mild symptom relief, and the examination report indicated that the Veteran refused an examination of the penis, testes, epididymis, and prostate. August 2018 VA treatment records reflect the Veteran was advised to utilize medication to treat his erectile dysfunction every week prior to sexual activity. Based upon the evidence of record and the relevant laws and regulations, a compensable rating for the Veteran's erectile dysfunction is not warranted. In this regard, the Veteran's disability is manifested by erectile dysfunction which was treated with medication. While the Veteran's erectile dysfunction is controlled by medication, that fact may not be used as a basis upon which to consider whether the Veteran is entitled to a higher rating as the DC 7522 does not specifically contemplate relief provided by medication. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, while the April 2013 VA examination report indicates that the Veteran refused a penile examination, the Veteran does not contend, and the evidence of record does not otherwise suggest, that the Veteran suffers from a deformity of the penis, either external or internal. The Veteran specifically reported during the April 2013 VA examination that he had a "normal anatomy." Therefore, the Veteran's erectile dysfunction symptoms do not more nearly approximate those contemplated by a 20 percent rating under DC 7522. As a preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and an initial compensable rating for erectile dysfunction is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 4. Temporary total rating The Veteran contends that he is entitled to a temporary total disability rating for his colon cancer due to his 2012 colon surgery. A total disability rating (100 percent) will be assigned without regard to other provisions of the Rating Schedule when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days, or that hospital observation at VA expense is required for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. A total disability rating (100 percent) also will be assigned without regard to other provisions of the Rating Schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement to a temporary total convalescence rating is warranted, effective from the date of 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. 38 C.F.R. § 4.30. Entitlement to a temporary total convalescence rating is warranted if treatment of a service-connected disability results in: (1) surgery necessitating at least one month of post-operative convalescence; (2) surgery with severe post-operative residuals, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of a one major joint or more, application of a body cast, 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. 38 C.F.R. § 4.30 (a). This regulation only authorizes the assignment of a disability rating and payment of compensation for service-connected disabilities. June 2012 VA treatment records reflect that the Veteran received inpatient care from June 18, 2012 to June 23, 2012 and received discharge instructions to recuperate from colon surgery. As per the current decision, service connection for the Veteran's colon cancer is not warranted. Therefore, the Veteran's colon cancer surgery and any subsequent hospitalization due to the procedure may not be considered eligible for a temporary total disability rating under 38 C.F.R. §§ 4.29 and 4.30. Thus, a temporary total disability rating is not warranted. See Sabonis v. Brown, 6 Vet. App. 426, at 430 (1994) (where the law and not the evidence is dispositive, the claim should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law). (CONTINUED ON NEXT PAGE) 5. Additional Considerations As a final point, in conjunction with the higher rating matters decided herein, no other related issues have been raised by the Veteran or his representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Brian J. Elwood Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.