Citation Nr: 21032142 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 15-03 432 DATE: May 26, 2021 ORDER Entitlement to an increased rating in excess of 10 percent for coronary artery disease (CAD), prior to March 26, 2019, is denied. Entitlement to an increased rating in excess of 60 percent for CAD, from March 26, 2019, is denied. Entitlement to an increased rating in excess of 10 percent for residuals of prostate cancer, prior to June 2, 2020, is denied. Entitlement to an increased rating in excess of 20 percent for residuals of prostate cancer, from June 2, 2020, is denied. Entitlement to a compensable rating for erectile dysfunction (ED) is denied. FINDINGS OF FACT 1. Prior to March 26, 2019, the Veteran's CAD manifested by METs of greater than seven and continuous medication but no cardiac hypertrophy or dilation. 2. From March 26, 2019, the Veteran's CAD has not been manifested by chronic congestive heart failure; or a workload of three METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. Prior to June 2, 2020, the Veteran's residual prostate cancer disability did not require the use of an absorbent pad, or urinary frequency of more than daytime voiding every three to four hours and nocturia twice a night. 4. From June 2, 2020, the Veteran's prostate cancer has been inactive with residual symptoms of voiding dysfunction, including urinary frequency requiring daytime voiding intervals between one and two hours and nocturia twice a night. 5. Throughout the appeal period, the Veteran's ED has not been manifested by a deformity of the penis. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for CAD, prior to March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for a disability rating in excess of 60 percent for CAD, from March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.104, DC 7005. 3. The criteria for an evaluation in excess of 10 percent for residuals of prostate cancer, prior to June 2, 2020, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1- 4.7, 4.10, 4.20, 4.31, 4.115a, 4.115b, DC 7528. 4. The criteria for an evaluation in excess of 20 percent for residuals of prostate cancer, from June 2, 2020, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1- 4.7, 4.10, 4.20, 4.31, 4.115a, 4.115b, DC 7528. 5. The criteria for a compensable disability rating for ED are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.115b DC 7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1966 to October 1968. INCREASED RATINGS Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. For claims for increased ratings which arise out of an initial grant of service connection, the Board must consider the application of "staged" ratings for different periods from the filing of the claim forward, if the evidence suggests that such a rating would be appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an increased rating in excess of 10 percent for CAD, prior to March 26, 2019 The Veteran's service-connected CAD is currently rated as 10 percent disabling under DC 7005 prior to March 26, 2019, and 60 percent, thereafter. The Veteran, generally, claims that his CAD condition is more severe than that contemplated by his current disability rating, during both periods. The Board, however, finds that the relevant medical evidence of record, to include several VA examinations, reveals that higher ratings are not warranted for either period and, as such, the Veteran's claim for increased ratings must be denied. Under DC 7005, a 10 percent disability rating is warranted for a cardiac workload tolerance of greater than seven metabolic equivalents (METs), but not greater than 10 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for evidence of a requirement for continuous medication. A 30 percent disability rating is warranted for a cardiac workload tolerance of greater than five METs, but not greater than seven METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent disability rating is warranted for more than one episode of acute congestive heart failure in the past year, or; for a cardiac workload tolerance of greater than three METs, but less than five METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction between 30 and 50 percent. A 100 percent disability rating is warranted for chronic congestive heart failure, or; for a cardiac workload tolerance of three METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. One MET is defined as the energy cost of standing quietly at rest, and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Again, the Veteran was initially rated at 10 percent disabling effective March 26, 2019, and 60 percent thereafter. With regards to the initial period, prior to March 26, 2019, the Board finds that the Veteran was afforded two separate VA examinations to assess the severity of the Veteran's CAD, in January 2014 and September 2015. During his initial examination in January 2014, the examiner noted a diagnosis of CAD, with continuous medication and no evidence of congestive heart failure. Upon testing, the Veteran's METs score was 10.1 during an exercise test. Diagnostic testing revealed no evidence of hypertrophy or dilatation, with left ventricular ejection fraction (LVEF) at 66 percent. The examiner noted that the condition did not affect the Veteran's functional abilities and did not impact his ability to work. In a September 2015 VA examination for the Veteran's CAD, the Veteran was again noted to require continuous medication, with no indication of myocardial infarction or congestive heart failure. Upon examination, the VA examiner noted the Veteran heart rhythm was regular, with METs score of 10.1. Diagnostic testing revealed no evidence of cardia hypertrophy or dilatation, with LVEF at 55-60 percent. Functional impact wise, the Veteran was noted to report some limitations, to include avoiding strenuous activities, and that he required a mid-day nap/rest. In addition to these VA examinations, the Veteran has also been receiving continuous treatment and care from the VA and private physicians. A close review of both the VA and private treatment records from this relevant period reveals no evidence that would fulfill the criteria for a higher rating. Private medical records from 2013 all note workload testing of 10.1 METs, and LVEF of over 50 percent, with no evidence of a diagnosis for hypertrophy or dilatation. Likewise, ongoing VA treatment, reveals no additional evidence of decreased METs or LVEF, or hypertrophy/dilatation. As noted above, the next higher 30 percent rating requires a finding of cardiac workload tolerance of greater than five METs, but not greater than seven METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. Therefore, the Board must find that the preponderance of the evidence is against a disability rating in excess of 10 percent for the time period prior to March 26, 2019. Here, for this entire period, the Veteran was placed on continuous medication and had a METs score of higher than 10. He did not demonstrate lower METs scores, cardiac hypertrophy, or dilation during this period, and the treatment records do not note any additional diagnoses. As such, as the Veteran's condition does not meet the criteria for the next higher rating under the appropriate diagnostic code for CAD, the claim for a higher rating must be denied. 2. Entitlement to an increased rating in excess of 60 percent for CAD, from March 26, 2019 For the later period, after March 26, 2019, the Veteran's CAD has been granted a rating of 60 percent, after a finding of a LVEF score of 50 percent, on that date. As noted above, a higher rating of the maximum schedular rating of 100 percent, for CAD, is only warranted for chronic congestive heart failure; or when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or for LVEF of less than 30 percent. Here, the Board notes that during this later relevant period, the Veteran was again afforded two VA examinations to assess the nature and severity of his CAD, in June 2020 and March 2021. The Board finds that none of the criteria for an even higher rating have been met. In June 2020, the Veteran underwent a VA heart examination. The Veteran's LVEF was indicated to have reduced to 50 percent. The Veteran's METs workload, based on an interview-based METs test estimate, was indicated to be seven to ten; no congestive heart failure was noted. The Veteran was also afforded a VA heart examination in March 2021. At that examination the Veteran's LVEF was 60-65 percent. Interview-based METs test revealed METs of five to seven, with reports of dyspnea and fatigue. Again, no chronic congestive heart failure was noted. The Board notes that in addition to these VA examinations, a close review of the VA treatment records have also been conducted. While, these treatment records do note treatment for the Veteran's heart condition, they do not provide evidence of any additional, or more severe, symptoms regarding the objective criteria required for a higher rating. In this regard, none of these records reveal any finding of chronic congestive heart failure, or a higher LVEF or lower METs based on testing. As such, the Board must find that the preponderance of evidence does not establish the criteria necessary for a 100 percent rating for the Veteran's CAD. The Board has considered whether a separate and/or higher rating may be assigned for the Veteran's CAD. There is no evidence, however, that the Veteran's heart disorder would be better classified under a different diagnostic code in 38 C.F.R. § 4.104. The remaining heart codes all have the same criteria as DC 7005, for which the Veteran has already been assigned a 60 percent evaluation. See e.g., Diagnostic Codes for valvular heart disease, pericarditis, hypertensive heart disease, and cardiomyopathy. In addition to the medical evidence, the Board has considered the Veteran's statement in support of his claim. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); see Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); 38 C.F.R. § 3.159(a)(2). However, as a layman, without the appropriate medical training and expertise, the Veteran is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his CAD in relation to the applicable rating criteria. The VA examiners have taken into account the Veteran's subjective complaints and performed objective testing to determine the overall severity of his heart disability. This determination is multi-factorial, not just predicated on lay statements and other testimony, but rather on all relevant medical and other evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In sum, the Board finds that there is no probative evidence of record to support an increased rating for the CAD at any time during the appeal period. As a preponderance of the evidence is against the award of an increased rating for the Veteran's CAD, the benefit of the doubt doctrine is not applicable, and the Veteran's claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an increased rating in excess of 10 percent for residuals of prostate cancer, prior to June 2, 2020 The Veteran's residuals of prostate cancer disability are currently rated as 10 percent disabling for the period prior to June 2, 2020, under DC 7528, for malignant neoplasms of the genitourinary system. 38 C.F.R. § 4.115. A July 2020 rating decision increased the assigned rating to 20 percent disabling, from June 2, 2020, which will be discussed below. With regards to both periods, the Veteran is also currently separately service-connected for erectile dysfunction, which will also be discussed herein. Prostate cancer is evaluated under 38 C.F.R. § 4.115b, DC 7528, which covers malignant neoplasms of the genitourinary system and provides for an initial 100 percent disability rating. The 100 percent disability rating is provided until at least six months following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, at which time the Veteran is to be provided a VA examination. 38 C.F.R. § 4.115b, DC 7528, Note. Based upon that or any subsequent VA examination, the disability rating is open to revision in accordance with the criteria set forth in 38 C.F.R. § 3.105(e). If there is no local reoccurrence or metastasis, the service-connected genitourinary disease is to be rated on residuals as a voiding dysfunction or a renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, DC 7528. The Veteran underwent a prostatectomy for treatment of prostate cancer in 2006. VA and private medical records demonstrate no local reoccurrence or metastasis of the Veteran's prostate cancer, and the Veteran has not contended otherwise. Accordingly, the Veteran is not entitled to a 100 percent disability rating at any time during the appeal period. Instead, for the entire rating period, the Veteran's disability is properly rated based on residual symptoms, either as a voiding dysfunction or a renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b, DC 7528. Voiding dysfunction is evaluated under 38 C.F.R. § 4.115a, which provides that any voiding dysfunction shall be rated by the particular condition as urine leakage, urinary frequency, or obstructive voiding. Under urine leakage conditions (continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence), a 60 percent disability rating is warranted for the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. A 40 percent disability rating is warranted for the wearing of absorbent materials which must be changed two to four times per day. A 20 percent disability rating is warranted for the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. Under urinary frequency conditions, a 40 percent disability rating is warranted for a daytime voiding interval of less than one hour, or; awakening to void five or more times per night. A 20 percent disability rating is warranted for a daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 10 percent disability rating is warranted for a daytime voiding interval between two and three hours, or; awakening to void two times per night. Id. Under obstructed voiding conditions, a 30 percent disability rating is warranted for urinary retention requiring intermittent or continuous catheterization. A 10 percent disability rating is warranted for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post void residuals greater than 150 cc; (2) uroflowmetry demonstrating markedly diminished peak flow rate (less than 10 cc/sec); (3) recurrent urinary tract infections secondary to obstruction; or (4) stricture disease requiring periodic dilation every two to three months. A non-compensable disability rating is warranted for obstructive symptomatology with or without stricture disease requiring dilation one to two times per year. Id. Renal dysfunction is also evaluated under 38 C.F.R. § 4.115a. A 100 percent disability rating is warranted for regular dialysis or such dysfunction that precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, a BUN [blood urea nitrogen] level more than 80 mg% [milligrams of urea nitrogen per 100 milliliters of blood]; or a creatine level more than 8mg% [milligrams of serum creatine per 100 milliliters of blood]; or, markedly decreased function of the kidney or other organ systems, especially cardiovascular. An 80 percent disability rating requires persistent edema and albuminuria with a BUN level of 40mg to 80mg; or a creatine level of 4mg to 8mg; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 60 percent disability rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101. A 30 percent disability rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under DC 7101. A non-compensable disability rating is warranted for albumin and casts with history of acute nephritis; or, hypertension non-compensable under DC 7101. Id. With regards to the earlier period, prior to June 2, 2020, the Board notes that the Veteran was afforded two VA examination to assess the nature and severity of his prostate cancer residuals, in January 2014 and September 2015. The Board will discuss these in turn. A January 2014 VA examination report shows that the Veteran's prostate cancer was in remission and had not had a reoccurrence since the 2006 prostatectomy. The Veteran was noted to report voiding dysfunction, to include urine leakage, but he did not require absorbent materials or appliance. However, he reported increased urinary frequency to include daytime voiding at intervals between 2 and 3 hours, and nighttime awakening to void 2 times. The Veteran reported having a markedly slow/weak stream with severe urgency. No urinary tract or kidney (renal) condition was noted in the report. The report of the September 2015 VA examination shows that the Veteran's prostate cancer was in remission and he had not had a reoccurrence since the 2006 prostatectomy. The Veteran reported symptoms of voiding dysfunction, including symptoms of leakage, and increased urinary frequency. The VA examiner noted that although the Veteran complained of urinary leakage, he denied use of an absorbent material pad. The Veteran reported urinary frequency with daytime voiding every two to three hours and nocturia two times a night. He noted no issues with voiding dysfunction, to include obstructive symptoms, and there was no sign or symptom of a urinary tract or kidney infection. There was no evidence of renal dysfunction. Base on a review of the foregoing evidence, the Board finds that an evaluation in excess of 10 percent for residuals of prostate cancer, status-post prostatectomy, is not warranted at any time during the appeal period. As discussed above, the 2006 prostatectomy was the last therapeutic treatment for the Veteran's prostate cancer. As the cessation of therapeutic treatment occurred more than six months prior to the Veteran's claim of service connection, the Veteran is not entitled to the 100 percent disability rating as provided in the Rating Schedule. Instead, the Veteran's prostate cancer disability is to be rated on the basis of residual symptoms, either as a voiding dysfunction or a renal dysfunction, whichever is predominant. The competent medical evidence does not demonstrate that the Veteran experiences residual symptoms of renal dysfunction, and that Veteran's symptoms of a voiding dysfunction are the predominant residual symptom of his prostate cancer. However, the evidence of record does not show that the Veteran's symptoms of voiding dysfunction support an evaluation in excess of the currently assigned 10 percent rating. See 38 C.F.R. § 4.115a. Collectively, the evidence during the relevant period, includes the Veteran's statements and medical history in which he describes symptoms of urinary incontinence (leakage), increased urinary frequency, and obstructed voiding (weak urinary stream). VA treatment records and VA examiners have characterized his urinary incontinence, ostensibly, as mild in nature, as the Veteran has consistently denied the use of an absorbent material pad, to include explicitly during examinations. He has reported urinary frequency, at worst, of daytime intervals between two and three hours, and nocturia no more than twice a night. The Veteran's reported daytime intervals and nocturia are consistent with the criteria associated with the 10 percent rating for urinary frequency. See 38 C.F.R. § 4.115a. A higher evaluation of 20 percent is not warranted under this evaluation unless there is evidence of daytime voiding interval of one to two hours and awakening to void three to four times per night. As the evidence does not indicate that the Veteran voids this frequently, and he has never asserted that he does, an evaluation of 20 percent for urinary frequency is not warranted. See 38 C.F.R. § 4.115a. In addition, a higher rating cannot be assigned under the rating criteria for urine leakage or voiding obstruction. For the assignment of a 20 percent rating for urine leakage or voiding obstruction, a veteran must require the wearing of absorbent materials which must be changed less than twice daily, or have urinary retention that requires intermittent or continuous catheterization. Although the Veteran has reported some incontinence, he has denied the use of absorbent material pads throughout the relevant period. The Veteran has also reported symptoms of slow or weak stream, but his symptoms did not require requiring intermittent or continuous catheterization. Accordingly, a higher rating is not warranted based on urinary leakage or voiding obstruction. 38 C.F.R. § 4.115a. The Veteran is competent to report observable symptoms, such as his urinary frequency. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that here, the Board finds no lay assertion that specifically speak to these observable symptoms of his residuals that rise to the level of the next higher rating. Here, neither the Veteran, nor his representative, have consistently and/or continuously asserted urinary and/or voiding issues to a frequency and/or severity, as to meet the criteria for the next higher rating, to include the need for absorbent pads. As such, when considered with the competent medical evidence, the Board does not find that the lay evidence establishes the criteria requisite for the next higher rating. For these reasons, the Board finds the preponderance of the evidence weighs against entitlement to an evaluation in excess of 10 percent for a residual prostate cancer disability at any point during the relevant period prior to June 6, 2020. Consequently, as the preponderance of the evidence is against the claim for a rating in excess of 10 percent for residuals of prostate cancer, prior to June 2, 2020; the benefit of the doubt doctrine is not for application, and the Veteran's claim for this earlier period must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to an increased rating in excess of 20 percent for residuals of prostate cancer, from June 2, 2020 With regards to this later period after June 2, 2020, the Board finds that, again, the preponderance of evidence is against the finding that a higher rating in excess of 20 percent is warranted. Like the earlier period, the Veteran was afforded two VA examinations to assess the nature and severity of his residuals of a prostate cancer, in June 2020 and February 2021. During his June 2020 VA examination, the examination in which his increased rating and effective date to 20 percent was based, the Veteran was noted to be in remission, with no evidence of recurrence of the cancer. The Veteran reported that he did not require the wearing of absorbent material for voiding dysfunction but had increased urinary frequency with daytime voiding between one to two hours, and nighttime awakening to void two times a night. In addition, the Veteran reported no voiding dysfunction such as obstruction. Urinary and kidney infections were not noted, and there was no evidence of a renal condition. The reported results from the February 2021 examination were essentially identical with regards to all facets reported in the earlier examination. The reported urinary and voiding dysfunction, and obstruction, were all the same with regards to severity and frequency. Again, no evidence of renal or kidney condition were noted. The Board also notes that a thorough review of the VA treatment records also reveals no additional supporting evidence of a more severe disability with regards to his residuals. No additional conditions such as any renal disability were noted, or any evidence of increase in the frequency and/or severity of the Veteran's urinary/voiding dysfunction were presented or noted in such records. As such, the Board finds that two identical VA examination reports to be of high probative value in identifying the nature and severity of the Veteran's claimed disabilities, as they relate to this relevant period. Consequently, the Board must find that such evidence does not meet the criteria for a higher rating. As an initial matter, the Board again notes that, like the earlier period, the competent medical evidence does not demonstrate that the Veteran experiences residual symptoms of renal dysfunction, and that Veteran's symptoms of a voiding dysfunction are the predominant residual symptom of his prostate cancer. However, the evidence of record does not show that the Veteran's symptoms of voiding dysfunction support an evaluation in excess of the currently assigned 20 percent rating. See 38 C.F.R. § 4.115a. As noted above, a higher rating can be reached several ways to include under voiding dysfunction, where a higher 30 percent rating under urinary obstruction for urinary retention requiring intermittent or continuous catheterization; 40 percent rating under voiding dysfunction for requiring the wearing of absorbent pads, that needs to be changed two to three times a day; or a 40 percent rating under urinary frequency that manifests by a daytime voiding interval less than one hour or awakening to void five or more times per night. Here, the Board finds that as there is no evidence of urinary obstruction, and/or the need for absorbent pads, higher ratings under these criteria are not warranted. Regarding urinary frequency, the Board finds that the preponderance of the evidence is against the objective measure of frequency required by the higher criteria. Here, the record clearly shows that, at worse, the Veteran's urinary frequency only requires daytime voiding at intervals between one and two hours and awakening to void two times a night. The medical evidence, which includes contemporaneous reporting of symptoms from the Veteran, does not show a condition worse than that reported by the VA examinations described herein, which are consistent with a 20 percent rating. As such, the Board must find that the preponderance of evidence is against the finding that the Veteran's residuals of his prostate cancer warrants a higher rating for voiding frequency. Consequently, as the preponderance of evidence is against the finding for a higher rating, the Board must find that the Veteran's claim for a higher rating, in excess of 20 percent, for the period from June 2, 2020, must be denied. 5. Entitlement to a compensable rating for erectile dysfunction (ED) The Veteran claims that his ED is more severe than contemplated by his current noncompensable rating. The Board notes that the Veteran's ED is currently rated under DC 7522. Under this diagnostic code, a compensable rating requires a physical deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, DC 7522. The requirement under DC 7522 of deformity of the penis "with" loss of erectile power clearly means that both factors are required. 38 C.F.R. § 4.115b; see Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). In this case, the Veteran has been afforded several VA examinations to assess the nature and etiology of his ED, in January 2014, September 2015, June 2020, July 2020, and March 2021. During the Veteran' s initial examinations in January 2014, September 2015, and June 2020, the Veteran was examined as part of his claims for residuals of his prostate cancer. To this end, during all three examination, the Veteran was diagnosed with erectile dysfunction, to include with loss of erectile power without medication. However, none of these VA examinations noted any finding of a penis deformity, as it relates to the Veteran's ED. In July 2020, the Veteran was afforded his first examination explicitly to address the nature and severity of his ED. During this examination, the Veteran was again diagnosed with ED, and it was noted that such condition included the loss of erectile power without the use of medication. Upon actual examination of the Veteran, the VA examiner explicitly noted that the Veteran's penis was normal, with no deformities. Finally, during the most recent VA examination in March 2021, the VA examiner noted that Veteran's the complain of loss of erectile power, but it was noted that the Veteran refused physical examination of his penis. As such, no report of the existence of any deformities were noted by the examiner. As noted above, a compensable rating is only warranted when there is evidence of both loss of erectile power, as well as penial deformity. While there is ample evidence of the former, there is no evidence, to include lay assertions, that the Veteran also suffers from a penis deformity at any point during the claims period. A close review of even the contemporaneous VA and private treatment records also do not document a deformity of the penis during the appeal period. Thus, a compensable disability rating for ED is not warranted at any period on appeal. (Continued on the next page) In sum, the preponderance of the evidence is against the assignment of a compensable disability rating for service-connected ED at any time during the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ziheng Zhu, 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.