Citation Nr: 21040555 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 19-21 176 DATE: July 6, 2021 ORDER Entitlement to an 80 percent rating for bilateral hearing loss is granted. Entitlement to a rating in excess of 30 percent prior to August 28, 2020 for major depressive disorder is denied. Entitlement to a 70 percent rating beginning on August 28, 2020 for major depressive disorder is granted. Entitlement to a rating in excess of 10 percent for bilateral pterygium with scars and dry eye is denied. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to residuals of a left knee injury, is denied. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to residuals of a left knee injury, is denied. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran's hearing acuity is manifested by Level IX, at worst, for the right ear and Level XI, at worst, for the left ear for the entire appeal period. 2. For the appeal period prior to August 28, 2020, Veteran's major depressive disorder was manifested by psychiatric symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks without more severe manifestations that more nearly approximates occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. For the appeal period beginning on August 28, 2020, Veteran's major depressive disorder was manifested by psychiatric symptomatology resulting in occupational and social impairment with deficiencies in most areas without total occupational and social impairment. 4. For the entire appeal period, the Veteran's bilateral pterygium with scars and dry eye resulted in corrected visual acuity for distance of 20/50 at worst in each eye without impairment of visual field or muscle function or incapacitating episode due to the service-connected eye disability. 5. The preponderance of the evidence is against finding that peripheral neuropathy of the right lower extremity began during active service, or is otherwise related to an in-service injury or disease, to include exposure to contaminated water supply at Camp Lejeune, and that peripheral neuropathy of the right lower extremity is secondary to service-connected residuals of a left knee injury. 6. The preponderance of the evidence is against finding that peripheral neuropathy of the left lower extremity began during active service, or is otherwise related to an in-service injury or disease, to include exposure to contaminated water supply at Camp Lejeune, and that peripheral neuropathy of the left lower extremity is secondary to service-connected residuals of a left knee injury. CONCLUSIONS OF LAW 1. The criteria for a rating of 80 percent, but no higher, for bilateral hearing loss have been met for the entire appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.85 Diagnostic Code 6100. 2. The criteria for a rating in excess of 30 percent prior to August 28, 2020 for major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9434. 3. The criteria for a 70 percent rating beginning on August 28, 2020 for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9434. 4. The criteria for a rating in excess of 10 percent for bilateral pterygium with scars and dry eye have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.79, Diagnostic Codes 6034, 6066. 5. The criteria for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected residuals of a left knee injury, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected residuals of a left knee injury, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1960 to November 1963. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2019 decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his daughter testified before the undersigned Veterans Law Judge during an August 2020 virtual hearing; a transcript is of record. The Board previously remanded the issues for further development in October 2020. Specifically, the matters were remanded to obtain updated VA treatment records, a VA examination to determine the nature and etiology of the claimed peripheral neuropathy and VA examinations to determine the severity of the Veteran's bilateral hearing loss, bilateral pterygium and major depressive disorder. Updated VA treatment records have been associated with the record and an October 2020 letter requested that the Veteran complete an appropriate authorization form so that VA could obtain records on his behalf. VA examinations were conducted in January 2021. The Board determines that there has been substantial compliance with its previous remand. The case has now been returned to the Board for appellate review. In a March 2021 rating decision, the agency of original jurisdiction (AOJ) granted a 80 percent rating for bilateral hearing loss, effective January 15, 2021 as well as a 50 percent rating for major depressive disorder, effective January 15, 2021. However, a higher rating is available for bilateral hearing loss and major depressive disorder. The Veteran is presumed to seek the maximum available benefit for a disability. As such, these claims are still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered 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 in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation 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. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's intent to file a claim was received on May 22, 2018, followed by formal claims for increased rating, received in November 2018. Therefore, the Board looks to the evidence of record since May 2017. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Veteran has reported that he is retired but has not asserted at any point in time that he is unable to secure and maintain employment due to his service-connected bilateral hearing loss. Should this occur in the future, the Veteran is free to file a TDIU claim at a later date. 1. Bilateral Hearing Loss The Veteran's bilateral hearing loss is evaluated under Diagnostic Code 6100. Under Diagnostic Code 6100, a disability rating for hearing loss is determined by a mechanical application of the Rating Schedule to the numeric designations assigned based upon audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in both ears. See 38 C.F.R. § 4.85. The Rating Schedule also recognizes exceptional patterns of hearing impairment. See 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1000; 2000; 3000; and 4000 Hertz) is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86 (a). Additionally, when the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86 (b). Thereafter, that numeral will be elevated to the next higher numeral. Id. In cases where the evaluation of hearing loss is at issue, an examination for VA purposes "must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations will be conducted without the use of hearing aids." 38 C.F.R. § 4.85(a). A November 2018 VA treatment record indicates that the Veteran reported increased hearing difficulty and requested to have cochlear implant. The Veteran underwent a VA examination in January 2019. However, the examiner reported that the test results were not valid for rating purposes, for they were not indicative of organic hearing loss. The examiner stated that the Veteran was able to respond to speech while wearing hearing aids and under insert phones at 100 decibels, noting that he was interviewed easily, inconsistent with profound bilateral hearing loss, but he offered no responses to stimuli during the pure tone test. In May 2019, the Veteran underwent a cochlear implant in his left ear. During the August 2020 Board hearing, the Veteran testified that he still had trouble hearing despite the cochlear implant, which was not working properly. The Veteran underwent a hearing examination in January 2021. The examiner found that the use of speech discrimination score was not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores that make the combined use of puretone average and speech discrimination scores inappropriate. The Board notes that the Veteran reported he could not hear and had to read lips. Audiometric test revealed that the Veterans pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average Right Ear 90 95 90 90 91.25 Left Ear 105 105 105 105 105 Since speech discrimination score is not available for the Veteran, the Board applies table VIa. Applying these pure tone findings to Table VIa shows a numeral of Level IX for the right ear and Level XI for the left ear. Applying those results to 38 C.F.R. § 4.85, Table VII, an evaluation of 80 percent, but no higher, is derived. Here, the evidence indicates that during the appeal period, the Veteran's hearing was severely impaired to the point of having to obtain a cochlear implant. Moreover, as the Veteran repeatedly complained, it appears that cochlear implant did not improve his hearing capacity in a significant manner. In fact, the evidence indicates that although the Veteran is aided with lip reading and hearing aids, his hearing impairment presents difficulties in communications in his daily life. Thus, with resolution of reasonable doubt in the Veteran's favor, the Board finds that the Veteran's hearing impairment is reflected by the level determined in the most recent January 2021 VA examination during the entire appeal period, not just after the January 2021 examination. Therefore, an evaluation of 80 percent, but no higher, is warranted for bilateral hearing loss since the claim date of May 22, 2018. The Board acknowledges that the Veteran asserts that his hearing is worse than currently rated. However, "[t]he criteria for hearing loss, unlike a majority of the conditions in VA's rating schedule, do not list any specific symptoms or functional effects." See 38 C.F.R. §§ 4.85, 4.86. Instead, VA evaluates service-connected hearing loss through the mechanical application of a veteran's audiometric testing results to a rating table. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992)." As such, the Board must rely on the mechanical application of the audiometric examinations' results to the schedular rating table and cannot take the Veteran's complaints of his inability to hear or understand the speech of others into consideration. To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated during any period on appeal, the Board observes that the Veteran, while competent to report symptoms, is not competent to report that his hearing acuity is of sufficient severity to warrant higher evaluations under VA's tables for rating hearing loss disabilities. Such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The January 2021 VA examiner has noted the Veteran had difficulty understanding conversations and that he read lips because he could not hear. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In Doucette v. Shulkin, 28 Vet. App. 366 (2017), the Court of Appeals for Veterans Claims (Court) held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday environment as these are the effects that VA's audiometric tests are designed to measure. The Veteran has not otherwise described functional effects that are considered exceptional or, that are not otherwise contemplated by the assigned rating. Id. Thus, his complete disability picture is compensated under the rating schedule. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. Id. (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). The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. In sum, resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 80 percent rating, but not higher, for bilateral hearing loss is warranted for the entire period on appeal. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Major Depressive Disorder The Veteran is currently in receipt of 30 percent prior to January 15, 2021 and 50 percent thereafter for his major depressive disorder under Diagnostic Code 9434, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. He contends that such disability is more severe than as reflected by the currently assigned rating, and as such, a higher rating is warranted. Psychiatric disabilities are rated based on the General Rating Formula for Mental Disorders (General Formula) codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. Diagnostic Code 9434. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is 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; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in January 2017. As such, the DSM-5 applies, and the GAF scores will not be considered. A July 2017 VA treatment record indicates that the Veteran's mood had been low due to his spouse's health status, but it has been improving overall now that she was getting better. His mental health was maintained by prescribed medications. He did not indicate problems with forgetting names or faces. He denied suicidal or homicidal ideation nor intent/plan. He reported having good support from his family. An October 2018 VA treatment record indicates that he stopped taking his medication for a while because the prescription lapsed unintentionally. It appears that he had some episodes of uncontrolled anger or aggression when he was not on medications. He denied any recent such episodes, however, after restarting his medications. He denied suicidal or homicidal ideation. He was taking sertraline, Aricept, and melatonin. A December 2018 VA examination reflects a DSM-5 diagnosis of major depressive disorder. The examiner noted symptoms of depressed mood, chronic sleep impairment, and mild memory loss such as forgetting names, directions, or recent events. According to the Veteran's daughter, the Veteran would have bouts of anger or frustration when he could not get something work, such as threading fishing line through the hook or difficulty walking down to get mail. He denied sleep disturbances. He reported having feeling of withdrawn, isolation, anhedonia, depressed mood, low energy, poor sleep, poor concentration and attention, forgetfulness, change in appetite, and guilt, for two thirds of the past month at a moderate severity. He denied having mania, anxiety, panic, psychosis, obsessions, or compulsions. He also denied having impaired impulse control. There was no indication of impact in activities of daily living from mental disorder. He was found capable of managing his financial affairs, though often he lacked motivation to do so. His medication was managed by his daughter. The examiner determined that the Veteran's psychiatric disorder was productive of 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. A June 2019 VA treatment record indicates that the Veteran reported having been doing well overall since the last visit with no acute complaints. His daughter reported that he had been having more thoughts about death and dying, which had worsened with a number of recent friends and family deaths. The Veteran denied having any suicidal or homicidal thoughts. He reported that his mood had been mostly stable and denied any recent periods of irritability or uncontrollable anger. The Veteran's daughter reported that she had been assisting him more with managing his finances and bookkeeping lately, though he did not require any assistance with activities of daily living. In July 2019, the Veteran underwent a neuropsychological evaluation. During the evaluation, the Veteran described memory concerns, in particular, recalling recent events and conversations. He also continued to manage his finances without errors, but he recently asked for assistance. He was assessed with mild neurocognitive disorder, and the pattern of deficits was most suggestive of a vascular etiology due to largely frontal cortical dysfunction. A November 2019 VA treatment record indicates that he reported similar symptomatology as he had done in the June 2019 VA treatment record. During the August 28, 2020 Board hearing, the Veteran's daughter testified that the Veteran talked to his psychiatrist about how his life was not worth living and that he would think of ways that he could do that. She reported that the Veteran had these types of thoughts about once a week. The Veteran underwent a VA examination in January 2021. The Veteran was diagnosed with major depressive disorder and mild major vascular neurocognitive disorder with likely vascular nature. The examiner determined that these disorders are separate and not related and that symptoms due to major depressive disorder were depressed mood, chronic sleep impairment, disturbance in motivation/mood, passive thoughts of death without suicidal ideation. The examiner attributed to his cognitive disorder symptoms of impairment of short and long term memory, speech intermittently illogical, obscure, or irrelevant, difficulty in understanding complex commands, impaired judgment, gross impairment in thought processes or communication, spatial disorientation, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, and disorientation to time or place. The examiner stated that it was not possible to differentiate to what extent impairment is caused by each mental disorder without resorting to mere speculation. Then, the examiner determined that the Veteran's mental disorders were productive of occupational and social impairment with reduced reliability and productivity. The examiner noted that while the Veteran endorsed some ambivalence about living and indicated passive thoughts of death since his wife's death, he denied any actual active suicidal or homicidal ideation, intent, or plan. Lastly, the examiner found that the Veteran was not capable of managing his financial affairs due to his cognitive disorder. For the appeal period prior to August 28, 2020, the Board finds that the Veteran's major depressive disorder did not result in occupational and social impairment with reduced reliability and productivity or occupational and social impairment with deficiencies in most areas. A July 2017 VA treatment note indicates that the Veteran's mood was low due to the poor health of his spouse and he denied problems with forgetting names or faces. The Veteran reported poor concentration and attention as well as forgetfulness in the December 2018 examination. The record was negative for, the Veteran has not alleged, a flattened effect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood or difficulty in establishing and maintaining effective work and social relationships. Therefore, a rating in excess of 30 percent is not warranted for the appeal period prior to August 20, 2020. In addition, occupational and social impairment with deficiencies in most areas was not demonstrated prior to August 20, 2020. Impairment to mood was demonstrated as the Veteran reported depression. Impairment to family relations was not demonstrated as the Veteran reported a good long-term marriage of 58 years, that his daughter lived next door to him and provided care and that he had a good relationship with his three children in a December 2018 VA examination. Impairment to thinking was not demonstrated as the December 2018 VA examination found thought content and progression to be unimpaired without hallucination and delusions. Impairment to judgment was not demonstrated as the December 2018 VA examiner found the Veteran's judgment and insight to be fair. Work and school were not attempted during the appeal period. Suicidal ideations were consistently denied part of this appeal period. The Veteran did not allege, and the record did not demonstrate, 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, spatial disorientation, the neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. For the appeal period beginning on August 28, 2020, the Veteran's major depressive disorder manifested as social and occupational impairment with deficiencies in most areas. Impairment to mood was demonstrated as the Veteran reported depression. Impairment to thinking was demonstrated as the January 2021 VA examiner found gross impairment to thought processes and communication. Impairment to judgment was demonstrated as the January 2021 VA examiner found that it was impaired. In addition, the Veteran and his daughter reported that the Veteran expressed suicidal ideations. Impairment to family relations was not demonstrated as the Veteran maintained a relationship with his daughter and son-in-law and reported the recent death of his wife in the January 2021 VA examination. School and work were not attempted during the appeal period. Therefore, a 70 percent rating is warranted as of August 28, 2020. However, the record reflects that the Veteran's symptoms have not been consistent with total occupational and social impairment such that a 100 percent rating is warranted at any time during the appeal period. In that regard, despite the severity of his psychiatric symptoms, the Veteran maintained some social functioning. Specifically, the Veteran was able to maintain social relationships with his wife, daughter and son in law. Moreover, the Veteran has not displayed persistent gross impairment in thought processes or communication, nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. Specifically, VA treatment records indicate the Veteran shown not to be an imminent threat to himself or to others. Although the Veteran has voiced some suicidal ideation, he has never had plants, intent, nor attempted suicide. Moreover, there is no evidence that the Veteran has experienced persistent hallucinations or delusions, or obsessive rituals. While the Veteran displayed impairment of short and long term memory, he has not displayed disorientation to place, or memory loss for names of close relatives, his prior occupations, or his own name. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. As such, this is not a disability picture indicating total occupational and social impairment at any point during the appeal period. In assessing the severity of the major depressive disorder, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has also considered whether further staged ratings under Hart, supra, are appropriate for the Veteran's service-connected major depressive disorder; however, the Board finds that his symptomatology referable to such disability has been stable throughout the period on appeal. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, supra. Accordingly, the Board finds that the preponderance of the evidence is for the assignment of a 70 percent rating, but not higher, for a major disorder for the appeal period beginning on August 28, 2020. However, the preponderance of the evidence is against a rating in excess of 30 percent prior to August 28, 2020; to that extent, the appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Bilateral Pterygium with Scars and Dry Eye The Veteran's bilateral pterygium is currently rated as 10 percent disabling under Diagnostic Code 6034. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim considering both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. The former criteria for Diagnostic Code 6034 instructed to evaluate based on visual impairment, disfigurement (Diagnostic Code 7800), conjunctivitis (Diagnostic Code 6018), etc. depending on the particular findings. The revised criteria for Diagnostic Code 6034 instruct to evaluate based on the General Rating Formula for Diseases of the Eye, disfigurement (Diagnostic Code 7800), conjunctivitis (Diagnostic Code 6018), etc. depending on the particular findings, with all ratings to be combined pursuant to 38 C.F.R. § 4.25. Disfigurement of the head, face, or neck is rated under Diagnostic Code 7800. A compensable rating requires at least one of the following characteristics of disfigurement: a scar more than 13 cm in length, a scar at least 0.6 cm wide, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, or any of the following in an area exceeding 39 square cm: skin hypo- or hyper-pigmented, skin texture abnormal, underlying soft tissue missing, or skin indurated and inflexible. 38 C.F.R. § 4.118. Here, the evidence does not show that scars from pterygium removal procedures resulted in a compensable rating under Diagnostic Code 7800 for the entire appeal period. Both the former and revised criteria under Diagnostic Code 6018 for chronic conjunctivitis (nontrachomatous) distinguished active and inactive disease processes. Under the former criteria, an active disease process (with objective findings, such as red, thick conjunctivitae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (Diagnostic Code 7800). Here, the Veteran is already in receipt of 10 percent rating. As such, for an evaluation in excess of 10 percent, visual impairment due to service-connected disability or incapacitating episodes in the General Rating Formula must be considered. The General Rating Formula for Diseases of the Eye instructs to rate based on incapacitating episodes or visual impairment, whichever would afford a higher rating. Thus, the change to the rating criteria effectively just added consideration of incapacitating episodes because visual impairment was to be considered in the former criteria. Regarding combining ratings under 38 C.F.R. § 4.25, this language appears to clarify how the rating criteria should be applied and does not represent a substantive change; separate disabling effects should have been combined pursuant to 38 C.F.R. § 4.25 under the former criteria. The rating criteria based on incapacitating episodes under the General Rating Formula are provided as follows: Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, Diagnostic Code 6061-6091. Here, the Veteran has never had any incapacitating episodes that meet the requirement under the General Rating Formula. Therefore, a rating in excess of 10 percent is not warranted based on the incapacitating episode criteria. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). The amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Evaluations of visual impairment of muscle function is based on the degree of diplopia. 38 C.F.R. § 4.78(a). Here, the Veteran has not complained of diplopia and treatment records or VA examinations do not note any diplopia. Therefore, a compensable rating is not warranted for impairment of muscle function. Evaluation of visual field is based on the remaining field of vision in each eye. 38 C.F.R. § 4.77. Here, treatment records and VA examinations do not indicate defect in visual field due to his service-connected eye disability. The February 2021 VA examiner noted that kinetic (Goldmann) visual field results were unreliable due to the Veteran's hearing difficulty and his inability to cooperate with testing procedure due to reduced cognition. The examiner alternatively conducted confrontation fields testing, which were reliably repeated and revealed no field defects. Therefore, a compensable rating is not warranted for impairment of visual field. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity, provided under Diagnostic Codes 6061 to 6066. 38 C.F.R. § 4.76(c). A 10 percent rating is warranted for impairment of central visual acuity in the following situations: (1) if corrected visual acuity is 20/100 in one eye and 20/40 in the other eye; (2) if corrected visual acuity is 20/70 in one eye and 20/40 in the other eye; (3) if corrected visual acuity is 20/50 in one eye and 20/40 in the other eye; (4) or when corrected visual acuity is 20/50 in both eyes. 38 C.F.R. § 4.79, Diagnostic Code 6066. A 20 percent rating is warranted for impairment of central visual acuity in the following situations: (1) if corrected visual acuity is 15/200 in one eye and 20/40 in the other eye; (2) if corrected visual acuity is 20/200 in one eye and 20/40 in the other eye; (3) if corrected visual acuity is 20/100 in one eye and 20/50 in the other eye; or (4) corrected visual acuity of 20/70 in one eye and 20/50 in the other eye. 38 C.F.R. § 4.79, Diagnostic Code 6066. Here, the Veteran's corrected visual acuity for distance has been 20/50 at worst in each eye for the entire appeal period. The impairment of visual acuity has been attributed to the Veteran's service-connected bilateral pterygium. Thus, a rating of 10 percent, but no higher, for impairment of visual acuity is warranted under Diagnostic Code 6066. The Veteran complains that his eyes are light sensitive, which requires him to wear sunglasses, and symptoms of dry eyes has increased in severity. See August 2020 Board hearing transcript. The Veteran has been diagnosed with dry eye syndrome and the disability has been attributed to bilateral pterygium. See December 2018 VA examination. His dry eye syndrome has been treated with artificial tears and was found to not cause visual impairment. Moreover, the evidence does not indicate that the Veteran's light sensitivity results in impairment not mitigated by wearing sunglasses. The Veteran has been diagnosed with glaucoma suspect, pseudophakia, and status post lid surgery in both eyes. However, they are determined not related to service-connected pterygium or service. See December 2018 VA examination report; February 2021 VA examination report. Therefore, a rating in excess of 10 percent for bilateral pterygium with scars and dry eye is not warranted for the entire appeal period. In assessing the severity of the bilateral pterygium, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, supra and Grottveit v. Brown, supra. However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, supra. As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has also considered whether a staged rating under Hart, supra, is appropriate for the Veteran's service-connected bilateral pterygium; however, the Board finds that his symptomatology referable to such disability has been stable throughout the period on appeal. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, supra. Accordingly, the Board finds that the preponderance of the evidence against a rating in excess of 10 percent for the bilateral pterygium with scars and dry eye and the appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id; see also 38 C.F.R. § 3.310(b). In addition, for veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Effective March 14, 2017, VA amended its adjudication regulations regarding presumptive service connection, adding certain diseases associated with contaminants present in the base water supply at United States Marine Corps Base Camp Lejeune, North Carolina from August 1, 1953, to December 31, 1987. The final rule establishes that Veterans who served at Camp Lejeune for no less than 30 days during this period, and who have been diagnosed with any of eight associated diseases (adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, liver cancer, multiple myeloma, Non-Hodgkin's lymphoma, and Parkinson's disease) are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits. See 38 C.F.R. § 3.309(f). The Veteran's claimed disabilities (peripheral neuropathy) are not currently on the presumptive disability list. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, supra. 4. Peripheral neuropathy of the right lower extremity 5. Peripheral neuropathy of the left lower extremity The Veteran contends that he has neuropathy of bilateral lower extremities as a result of a 60- to 70-foot fall during a training exercise or due to drinking contaminated water while he stationed in Camp Lejeune. Alternatively, he indicates that the disability is proximately due to his service-connected left knee, which gave way while he was lifting a bag of mail. See August 2020 Board hearing transcript, July 2002 Veteran's statement. As reflected in a January 2021 VA examination, the Veteran has a current diagnosis of peripheral neuropathy of the lower extremities bilaterally. As for in-service element, the Veteran is capable of reporting an even he experienced such as a fall during a training exercise and an October 1963 medical board report indicates that he injured his left knee during a training in Camp Lejeune. The length of his stay at Camp Lejeune is not ascertainable based on the records currently in the claims file. However, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran is presumed to have been exposed to contaminants in the water supply at Camp Lejeune under 38 C.F.R. § 3.307(a)(7). Thus, the issue before the Board is whether the Veteran's current peripheral neuropathy of bilateral lower extremities is etiologically related to the in-service fall during a training exercise, to presumed exposure to contaminated water at Camp Lejeune or is proximately due to or aggravated beyond its natural progression by a service-connected disability. Based on the evidence of record, the Board finds that the weight of the evidence is against his claim. A review of the service treatment records indicate that the Veteran injured his left knee during a fall while in training in 1960. It is also indicated that he re-injured his left knee in 1962. However, his service treatment records, to include the October 1963 medical board report, do not reflect that he had suffered an injury to his right lower extremity or sought treatment for a right lower extremity disability while in service at any time during his active duty. During a January 2021 VA examination, the Veteran reported that his peripheral nerve condition had begun with shooting pain in the bilateral extremities with tingling sensation and numbness during physical activities in 1979. The January 2021 examiner opined that it is less likely than not that the Veteran's peripheral neuropathy was incurred in or caused by the claimed in-service event. The rationale provided was that there are no medical records showing diagnosis or treatment for peripheral neuropathy or any related in-service nerve condition or injury that would progress to peripheral neuropathy. Moreover, the examiner opined that peripheral neuropathy is less likely than not proximately due to or aggravated by his service-connected left knee disability. In fact, the examiner stated that the Veteran's neuropathy is most likely from the lumbar condition, not the knees and the lumbar disability most likely became worse over the years since having a laminectomy and fusion in the lower back in 2002. The Board finds this opinion to be highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no contrary opinion of record. (Continued on the next page) The Board acknowledges the competent and credible statements from the Veteran regarding symptomatology. Nevertheless, to the extent that the Veteran attributes his disability to service, he is not competent to opine on the etiology of a complex medical condition such as neuropathy. Additionally, the Veteran's statement concerning onset of the neuropathy symptoms has not been consistent over the years, and consequently, it is less persuasive. Moreover, as for the relationship with the onset of neuropathy and exposure to contaminate water at Camp Lejeune, there is no other evidence, other than the Veteran's contention, that supports such connection. In this case, medical professionals have determined that the cause of peripheral neuropathy is degenerative arthritis of the lumbar spine, for which the Veteran had laminectomy. Thus, his statements are therefore afforded no weight. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the claims must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claims, the doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor, 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.