Citation Nr: 21042066 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 15-17 740 DATE: July 11, 2021 ORDER Entitlement to service connection for right ear hearing loss is granted. Entitlement to service connection for left ankle degenerative arthritis (left ankle disability) secondary to lumbar spine disability, or hypertension is denied. Entitlement to service connection for right hip strain, also diagnosed as trochanteric bursitis, is granted. Entitlement to service connection for left hip strain, also diagnosed as trochanteric bursitis, is granted. Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to an increased 60 percent rating, but not higher, for service-connected neurogenic bowel is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an increased, 40 percent rating, but not higher, for service-connected neurogenic bladder for the period prior to November 17, 2020, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 60 percent for service-connected neurogenic bladder from November 17, 2020, is denied. Entitlement to an initial compensable rating for erectile dysfunction is denied. Entitlement to an initial compensable rating for hypertension is denied. REMANDED Entitlement to service connection for right acromial and distal clavicle osteophytes, (right shoulder disability), secondary to lumbar spine disability is remanded. Entitlement to special monthly compensation (SMC) based on aid and attendance is remanded. Entitlement to special monthly compensation (SMC) based on housebound status prior to December 11, 2014, is remanded. Entitlement to special monthly compensation (SMC) based on housebound status from March 1, 2015, to March 3, 2017, is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's right ear hearing loss is related to service. 2. The Veteran's left ankle disability was not caused or aggravated by his service-connected lumbar spine disability. 3. The evidence is at least evenly balanced as to whether the Veteran's right hip strain, also diagnosed as trochanteric bursitis, had its onset in service. 4. The evidence is at least evenly balanced as to whether the Veteran's left hip strain, also diagnosed as trochanteric bursitis, had its onset in service. 5. The evidence is at least evenly balanced as to whether the Veteran's OSA had its onset in service. 6. The Veteran's neurogenic bowel symptomatology more nearly approximates extensive leakage and fairly frequent involuntary bowel movements. 7. For the period prior to November 17, 2020, the Veteran's neurogenic bladder symptomatology more nearly approximate a daytime voiding interval of less than one hour, or awakening to void five or more times per night. 8. From November 17, 2020, the Veteran's neurogenic bladder is rated at 60 percent, which is the maximum rating available under the applicable rating criteria and there is no evidence that the applicable rating criteria do not fully contemplate the symptoms associated with this service-connected disorder. 9. The Veteran's erectile dysfunction does not result in deformity of the penis with loss of erectile power. 10. The Veteran's hypertension symptomatology has not more nearly approximated predominant diastolic blood pressure of 100 or more, or a predominant systolic blood pressure of 160 or more. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for right ear hearing loss have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for entitlement to service connection for left ankle disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for right hip strain, also diagnosed as trochanteric bursitis, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for left hip strain, also diagnosed as trochanteric bursitis, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1131, 5107(b); 38 U.S.C. §§ 3.102, 3.303. 6. The criteria for an increased rating of 60 percent, but not higher, for neurogenic bowel have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.114, DC 7332. 7. The criteria for an increased rating of 40 percent, but not higher, for neurogenic bladder have been met for the period prior to November 17, 2020. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.115a, 4.115b, DC 7542. 8. The criteria for a rating in excess of 60 percent for neurogenic bladder for the period from November 17, 2020, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.115a, 4.115b, DC 7542. 9. 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. 10. 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. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1984 to June 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2013, September 2014, and May 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) which, respectively and among other things, continued a 20 percent rating for neurogenic bladder with urinary incontinence, a noncompensable rating for both hypertension and erectile dysfunction, continued a previous denial of service connection for bilateral hearing loss, denied reopening the Veteran's claims for service connection for right and left hip arthritis; denied service connection for sleep apnea, and continued its denial of service connection for left ankle disability; granted a 30 percent rating for bowel dysfunction, continued previous denials for service connection for right shoulder and left ankle disabilities, and denied SMC. The Veteran filed his notices of disagreement with, among other things: the denials of service connection for hearing loss, and right and left hip disability in June 2013; the denial of service connection for OSA, left ankle disability, and the rating assigned for bladder disability in December 2014; the rating assigned for hypertension in July 2015; the 30 percent rating assigned for bowel dysfunction, the noncompensable rating for erectile dysfunction, the denials of service connection for right shoulder and left ankle disabilities, and the denial of SMC in January 2017. The Veteran was issued his statements of the case in April 2015, and January 2017, and in May 2015 and February 2017, perfected his appeal to the Board. In June 2019, the Veteran appeared at a videoconference Board hearing before a Veterans Law Judge (VLJ) who is no longer employed by the Board. A copy of the transcript is of record. In May 2020, the Board, inter alia, remanded the Veteran's claims for service connection of right and left hip disabilities, right shoulder disability, right ear hearing loss, OSA, and left ankle disability, and the claims for higher ratings for neurogenic bowel dysfunction, neurogenic bladder, erectile dysfunction, hypertension, and SMC, for new examinations and medical opinions regarding the etiology and severity of the Veteran's disabilities. In a July 2020 statement, the Veteran claimed CUE with the Board's May 2020 decision regarding his claims for service connection for PTSD, frostbite, dizziness, and headaches. However, this issue will be addressed in a separate decision. In a February 2021 rating decision, the RO granted a 60 percent rating for the Veteran's neurogenic bladder effective November 17, 2020, creating a staged rating. The 60 percent rating is the highest available schedular rating under DC 7542. In April 2021, the Veteran appeared at a virtual Board hearing before the undersigned VLJ. A copy of the transcript is of record. 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. § 1131; 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). 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 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). 1. Right Ear The Veteran reported in his May 2015 form 9 that he suffered from right ear hearing loss due to exposure to noise from the weapons he fired while in the infantry. He stated his other jobs since service included security, sanitation, and electric motor repair. The Veteran's DD-214 reflects that his military occupational specialty was as an indirect fire infantryman. A hearing loss disability is defined for VA compensation purposes with regard to audiological testing involving pure tone frequency thresholds and speech discrimination criteria. 38 C.F.R. § 3.385. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Id. On the authorized audiological evaluation in October 2011, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 40 85 Speech audiometry revealed speech recognition ability of 82 percent in the right ear. The Veteran reported difficulty understanding speech in noisy situations. On the authorized audiological evaluation in May 2013, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 45 85 Speech audiometry revealed speech recognition ability of 96 percent in the right ear. The examining audiologist opined that the Veteran's right ear hearing loss was not at least as likely as not (at least a 50 percent probability) caused by, or a result of an event in military service, noting that there was no audiometric data found from discharge in 1987, and that the Veteran had excellent hearing in both ears in March 1986. The Veteran reported having difficulty hearing when there is noise. An October 2020 DBQ reflected pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 20 50 85 Speech audiometry revealed speech recognition ability of 96 percent in the right ear. The audiologist reported right ear sensorineural hearing loss, but could not opine as to the etiology without resorting to speculation as the claims file was not available for review. The audiologist noted that the Veteran reported that his hearing loss had its onset in the late 1980s, and also noted the Veteran's occupational specialty as an indirect fire infantryman had a high probability of hazardous noise exposure. In a February 2021 addendum opinion, the audiologist reported that there is no significant permanent shift in hearing thresholds beyond test variability from entrance examination dated September 26, 1984 to the last documented audiogram March 24, 1986, bilateral, which is objective evidence of no permanent auditory damage on active duty from conceded noise at that time. The audiologist stated that there is no report of complaint or treatment for hearing loss in the service treatment records or at separation, and noted the Veteran's history of dizziness which began in 2000 or 2001 after an incident involving 2 speakers in choir which caused his hearing to decrease, and caused dizziness which may have contributed to hearing loss in his right ear versus his left since his left ear hearing is still within normal thresholds. The Veteran reported that he did not notice hearing loss until people started asking if he could hear okay. The audiologist concluded that although noise exposure is conceded and the relationship of noise, auditory damage, and hearing loss is well-established, auditory damage and hearing loss are not conceded based on noise alone. She stated that there must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology, thus the evidence is against a nexus in this case, and it is less likely than not that the Veteran's hearing loss is related to military noise exposure. The Board finds the Veteran has a current right ear hearing loss disability for VA purposes as both the May 2013 and October 2020 audiologists noted pure tone thresholds of 40 decibels or greater at both 3000 Hz, and 4000 Hz. Additionally, the Veteran has provided competent evidence of in-service noise exposure which is consistent with the Veteran's circumstances of service as an indirect fire infantryman. The dispositive issue is whether there is a nexus between the Veteran's in-service noise exposure and his current right ear hearing loss disability. For the following reasons, the evidence is at least evenly balanced as to whether the Veteran's current right ear hearing loss disability is related to service. While the May 2013 and February 2021 audiologists opined that the Veteran's right ear hearing loss was not at least as likely as not related to military service, they based their opinions primarily on the lack of treatment records noting hearing loss during service, and indicated that the Veteran's hearing was normal upon discharge. However, these opinions are flawed because normal hearing upon separation is not necessarily fatal to a claim for service connection for hearing loss. Ledford v. Derwinski, 3 Vet. App. 87 (1992). Additionally, the February 2021 audiologist provided a speculative alternative as to the nexus of the Veteran's right ear hearing loss, as he stated that the 2000 or 2001 incident which caused dizziness may have contributed to hearing loss in the right ear. See Hood v. Shinseki, 23 Vet. App. 295, 29899 (2009) (medical opinion is speculative when it uses equivocal language such as "could" or "might," without any other rationale or supporting data). Therefore, the negative nexus opinions are inadequate, and afforded no probative weight. However, the Veteran has provided competent and credible evidence of a hearing loss disability since service, stating that he noticed an onset of hearing loss in the late 1980s. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). Thus, there is credible and competent evidence of hearing loss since service, and inadequate negative nexus opinions. While the Board could remand the claim for a new medical opinion, doing so could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Gardner-Dickson v. Wilkie, 33 Vet. App. 50, 62 (2020) (Order) (denying petition for a writ of mandamus challenging a remand for additional development, but agreeing "with the petitioner that it 'would not be permissible for VA to undertake... additional development if a purpose was to obtain evidence against an appellant's case'" (citing Mariano v. Principi, 17 Vet. App. 305, 312 (2003) and Hart v. Mansfield, 21 Vet. App. 505, 508 (2007)). The above reflects that the evidence is at least evenly balanced as to whether the Veteran's right ear hearing loss is related to service. The Veteran has competently and credibly stated that he has been suffering from right ear hearing loss since in-service noise exposure which has worsened. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right ear hearing loss is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Left Ankle A May 2014 examination report reflected a diagnosis of left ankle pain (arthralgia) with the Veteran reporting intermittent flare-ups of pain, including with changes in the weather, and with being on his feet for too long. He reported use of a cane on a daily basis due to back, knee, and ankle pain, and use of a left ankle brace when the flare-ups occur. Left ankle flexion was to 45 degrees or greater with evidence of painful motion at 45 degrees or greater, extension was to 20 degrees or greater, with evidence of painful motion at 20 degrees or greater. The Veteran's range of motion was unchanged with repetitive use testing. The examiner noted tenderness or pain on palpation of the left ankle joints/soft tissue, but muscle strength testing was normal. There was no laxity compared with the right side with anterior drawer and talar tilt testing, and there was no ankylosis of the ankle, subtalar, and/or tarsal joint. The Veteran had not had "shin splints", stress fractures, achilles tendonitis or tendon rupture, malunion of calcaneus or talus, or a talectomy. The examination report indicated that the Veteran had not had a total ankle joint replacement, arthroscopic or other ankle surgery. The examiner noted that potential work-related limitations due to the Veteran's ankle disability may include restrictions regarding prolonged periods of weight-bearing. The examiner stated that he was unable to define a nexus between the Veteran's back disability and history of left ankle pain. He reported finding no evidence of arthritis of the ankle, finding only a small plantar calcaneal spur. He stated that there is no support in the literature that a plantar calcaneal spur is the direct and proximate result of any sort of back condition. In an April 2016 VA examination report, the examining physician's assistant (PA) reported that the Veteran had a diagnosis of left ankle degenerative arthritis which the Veteran claims is secondary to his back disability. The PA opined that the Veteran's left ankle disability was not at least as likely as not (at least a 50 percent probability) due to his service-connected back disability. The PA stated that there is no medical literature that supports a back condition causing or leading to arthritic changes in the ankle which is usually secondary to aging and weight, or past injuries. He stated that arthritis is not a condition which "spreads." In a November 2020 addendum opinion, the physician opined that lumbosacral pathology is not known to cause degenerative joint disease of the ankle joint, or aggravate such beyond its natural progression, and further, degenerative arthritis is most commonly associated with the wear and tear of normal aging, though such degenerative changes may be aggravated by obesity. The physician stated that as the Veteran received no care for an acute bony injury, or destabilizing internal derangement to his left ankle while on active duty, which might precipitate a post-traumatic arthritis, the Veteran's left ankle disability is less likely as not due to, the result of, or permanently aggravated by his service connected lumbosacral back disability. In a January 2021 addendum opinion, the physician stated that the Veteran's left ankle disability was not due to, the result of, or aggravated by his back disability, and is not pathophysiologically related to his benign, essential hypertension. The physician noted that the Veteran is prescribed multiple medications for his back disability, but he does not suffer from hypertensive heart disease or renal insufficiency, so none of these therapies would aggravate his hypertension. The physician noted that hypertension cannot cause or aggravate degenerative arthritis, concluding that it is less likely than not (less than a 50 percent probability) that the Veteran's hypertension was caused by, or permanently worsened by his claimed left ankle condition, or that his claimed ankle condition was caused by or permanently worsened by his benign, essential hypertension. The issue of establishing a nexus to a service-connected disease or injury such as lumbar spine disability or hypertension is a complex medical question since it is beyond any readily observable cause and effect relationship. Jandreau, 492 F.3d at 1377, n. 4. Thus, to the extent the Veteran asserts a nexus for left ankle disability, his statements in this regard are not competent. Woehlaert, 21 Vet. App. at 462. The record contains a negative nexus opinion provided by both the May 2014 examiner, and April 2016 PA, who stated that the Veteran's left ankle disability is less likely than not the result of, or aggravated by the Veteran's service connected lumbar spine disability, and there is no positive nexus opinion of record. Additionally, in November 2020 and January 2021 addendum opinions, the physician opined that the Veteran's left ankle disability was less likely than not caused or aggravated by hypertension or lumbar spine disability, and, like the May 2014 examiner and April 2016 PA, provided a thorough rationale to support his conclusion based on an accurate characterization of the evidence of record. Therefore, the opinions are entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008). Weighing these opinions against the Veteran's contention, the examiners' opinions specifically indicating a lack of causation or aggravation in this case are of greater probative weight than the Veteran's contention that his service-connected lumbar spine disability or hypertension caused his left ankle disability. For the above stated reasons, the preponderance of the evidence weighs against a relationship between the Veteran's left ankle disability and service-connected lumbar spine disability or hypertension. Therefore, service connection for left ankle disability is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the above evidence reflects, the issue of entitlement to service connection for left ankle disability on a direct basis has not been raised by the Veteran or reasonably raised by the evidence of record, and the Board therefore need not address this theory of entitlement. Robinson, 557 F.3d at 1361. 3. Right and Left Hip Disability September 1985 service treatment records reflect that the Veteran reported a history of joint pains which began as pain and stiffness in his right hip followed by similar pain in his left hip. The Veteran's service treatment records from October 1985 reflect that the Veteran suffered from mild trochanteric bursitis of both hips. December 1985 medical treatment records reflect that the Veteran complained of bilateral hip pain since injuring his back after falling down a hill during service. The Veteran's March 1986 medical examination report indicated that the Veteran suffered from bilateral hip pain. January 1998 post-service treatment records reflect a diagnosis of trochanteric bursitis of the hips. In his February 2012 statement, the Veteran reported hip problems since service which have worsened. He stated that he cannot drive or sit without them burning and hurting badly. In a February 2017 statement, the Veteran reported that his hip disabilities would be directly service connected, or alternately, secondary to high blood pressure and a back condition. In a November 2020 DBQ, the nurse practitioner (NP) opined that the Veteran's left and right hip disabilities were less likely than not (less than a 50 percent probability) proximately due to or the result of his service connected hypertension, as there was no evidence that the disabilities resulted from, or were caused by his diagnosis of borderline hypertension. The NP also noted that the Veteran's left and right hip disabilities were not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by his hypertension, as there was no evidence that they were. In a separate November 2020 DBQ, the NP opined that the Veteran's left hip disability 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 there is no evidence of a current left hip disability that was caused by a fall, or of bilateral hip pain during service. The NP reported that there is no evidence of chronicity of care for a left hip disability that incurred in, resulted from, or was caused by service. The NP also opined that the Veteran's left hip disability is less likely than not (less than a 50 percent probability) proximately due to, the result of, or aggravated beyond its natural progression by a service connected condition, stating that there is no evidence that his left hip strain resulted from, or was caused by his lumbar spine disability, and that there is no evidence that the Veteran's left hip disability was aggravated beyond its natural progression by his service connected lumbar spine disability. Another November 2020 DBQ reflected that the Veteran reported being unable to lie down on either hip in 1985, and that he was diagnosed with bursitis. The Veteran stated in 2011 that he had pain in both hips which was revealed to be phleboliths in the pelvis. He reported not receiving any care or treatment, but took pain medications which did not help. The Veteran's current symptoms were noted as constant tenderness, swelling, and aching pain, and the DBQ indicated that the Veteran had a diagnosis of bilateral hip strain. The Veteran's NP opined in a November 2020 DBQ that his right hip disability is 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 has a diagnosis of right hip strain, and that acute strains can be caused by one event, and chronic muscle strains can result from repetitive injuries. The NP stated that the Veteran's disability is separate and unrelated to a fall and trochanteric bursitis during service, thus a nexus has not been established. The NP also opined that the Veteran's right hip disability was less likely than not (less than a 50 percent probability) due to or the result of his service connected back disability as the Veteran's strain is separate and unrelated to lumbar spine disability, noting how acute and chronic muscle strains occur. Finally, the NP opined that the Veteran's right hip disability was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by his service connected back disability, as there is no evidence his right hip disability was aggravated beyond its natural progression by his service connected back disability. The evidence is at least evenly balanced as to whether the Veteran's right and left hip disabilities are related to service. The November 2020 DBQ reflects a diagnosis of bilateral hip strain, and the previously discussed October 1985 service treatment records indicate the Veteran suffered from mild trochanteric bursitis. Therefore, the first 2 criteria for establishing service connection have been satisfied and the dispositive issue is whether there is a nexus between the two. While the November 2020 NP provided a negative nexus opinion as to the etiology of the Veteran's left and right hip disabilities, he did not fully consider the competent, credible lay statements of the Veteran about continuous hip pain in and since service. Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (noting that VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"). Additionally, the NP based his opinion as to left hip strain in part on the fact that there is no evidence of chronicity of care, indicating that the NP failed to consider the Veteran's statements that he used pain medications to treat his pain. Thus, the November 2020 NP's opinion is inadequate, and therefore afforded no probative value. The Veteran has provided competent evidence that he has suffered from bilateral hip pain since service which have worsened. There is no evidence which suggests that the Veteran lacks credibility, thus his statements as to the onset of his bilateral hip disability symptomatology are afforded significant probative value. Thus, there is competent and credible evidence of bilateral hip pain since service, and an inadequate negative medical nexus opinion regarding the etiology of the Veteran's right and left hip disabilities, diagnosed as hip strain and trochanteric bursitis. Although the Board could remand the claim for another medical opinion, there is sufficient evidence to decide the claim, and a remand could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c). The above reflects that the evidence is at least evenly balanced as to whether the Veteran's bilateral hip disabilities had their onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right and left hip strain, also diagnosed as trochanteric bursitis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Obstructive Sleep Apnea In a February 2012 statement, the Veteran reported being diagnosed with chronic sleep impairment, stating he was on medication for insomnia. A September 2012 letter from the Veteran's nurse practitioner, indicated that the Veteran's sleep study showed mild OSA. The Veteran submitted treatise material regarding risk factors and symptoms of OSA, and treatments thereof. The material indicated that those with congestive heart failure and atrial fibrillation have a higher risk for central sleep apnea, as do those who have had a stroke or brain tumor. In a November 2020 DBQ, the NP opined that the Veteran's OSA 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 she was unable to verify any chronic sleep condition or diagnosis during service with the available records. The NP also opined that the Veteran's OSA was less likely than not (less than a 50 percent probability) proximately due to or the result of the his service connected hypertension, stating that the most common causes of OSA are excess weight, enlarged tonsils and adenoids, excessive alcohol consumption, and smoking. She noted that the Veteran was obese which is most likely the cause of his OSA and not his borderline hypertension. Finally, the NP opined that the Veteran's OSA was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by hypertension as there is no evidence his OSA was aggravated beyond its natural progression by borderline hypertension. The Veteran reported onset of OSA in 1988 when he was unable to sleep and his parents told him he would experience respiratory disruption in his sleep, but he ignored his symptoms because he did not know what OSA was at that time. The Veteran stated that in 2011 he would awaken gasping and his spouse would tell him about her observations. He sought medical attention and was referred for a sleep study which revealed OSA. The evidence is at least evenly balanced as to whether the Veteran's OSA had its onset in service. While the November 2020 NP opined that the Veteran's OSA was less likely than not (less than a 50 percent probability) incurred in service, the NP based her opinion on a lack of diagnosis of OSA during service, and discounted the Veteran's described symptomatology despite the fact that the Veteran's in-service symptoms were a factor in his diagnosis of OSA. Therefore, her opinion is inadequate as the NP relied solely on a lack of evidence in the service treatment records, and did not fully consider the Veteran's report of symptomatology which had its onset shortly after service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide negative opinion). The Veteran has provided competent and credible evidence that he has suffered from OSA symptomatology since 1988. However, it is reasonable to conclude that while he was first informed of his symptoms by his parents shortly after service, that his symptoms had their onset during service approximately a year prior, yet no one notified the Veteran of his symptoms. To the extent that the grant of service connection in this case is based primarily on lay evidence, "nothing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself." Buchanan, 451 F.3d at 1335. See also Maples v. Wilkie, No. 18-2016 (mem dec. Feb. 11, 2019) (vacating the Board's denial of a claim for service connection for sleep apnea and finding that the Veteran's "lay statements could be evidence sufficient to support his claim, and the mere fact that there is no medical evidence about his snoring does not, by itself, render his lay statements insufficient"); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's OSA had its onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for OSA is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 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); Hart v. Mansfield, 21 Vet. App. 505 (2008). 5. Neurogenic Bowel The Veteran's neurogenic bowel is currently rated 30 percent disabling under 38 C.F.R. § 4.114, DC 7332 for impairment of sphincter control of the rectum and anus. Under DC 7332, a 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of pad; a 60 percent rating is warranted for extensive leakage and fairly frequent involuntary bowel movements; and a maximum 100 percent rating is warranted for complete loss of sphincter control. An October 2011 examination report indicated that the Veteran's treatment plan for his rectum disability required taking continuous medication, and the examiner noted mild or moderate internal or external hemorrhoids. The Veteran reported slight leakage if he takes MiraLax, but did not report wearing pads. The examination report indicated that the Veteran's rectal/anal area was normal, with no external hemorrhoids, anal fissure, or other abnormalities, and the report reflected that the Veteran's disability did not impact his ability to work. A July 2014 VA examination report reflects that the Veteran's rectal sphincter control impairment symptoms include alternating diarrhea and constipation. The Veteran reported taking fiber 2 to 3 times a day to prevent constipation, and having been prescribed medication for his spinal condition. He reported leakage on occasion due to his use of fiber, and stated that he does notice blood on tissue occasionally, but denied frank bleeding. The examiner noted mild or moderate internal or external hemorrhoids with the Veteran reporting intermittent flare-ups when constipated. There were no visible hemorrhoids upon examination. The examination report indicated that the Veteran's rectal disability required continuous medication. An April 2016 VA examination report indicated that the Veteran has difficulty with fecal incontinence and uses pads in his undergarments, averaging 4 to 5 a day. The Veteran reported hemorrhoids and slight rectal bleeding when he wipes 2 to 3 times per week which he treated with Preparation H. He stated that his constipation issues were under relatively good control with medication. The examination report indicated that the Veteran's treatment plan included taking continuous medication, and the examiner noted small or moderate external hemorrhoids, and impairment of rectal sphincter control. The examining physician stated that the Veteran's anal sphincter incompetence is moderate in severity. A May 2017 DBQ reflects that the Veteran reported that his neurogenic bowel has worsened with more leakage, and stated that VA told him it was from his back. His disability required continuous medication, but he had not had surgical treatment. A November 2020 DBQ indicated that the Veteran's neurogenic bowel dysfunction currently caused bowel incontinence, but was not treated with continuous medication. The DBQ reflected that the results of the rectal/anal area examination were normal. The evidence reflects that the Veteran's neurogenic bowel symptomatology more nearly approximates extensive leakage and fairly frequent involuntary bowel movements as is contemplated by a 60 percent rating under DC 7332. The May 2017 DBQ indicated that the Veteran's neurogenic bowel disability worsened with more leakage, the November 2020 DBQ reflected bowel incontinence, and while the Veteran described leakage on occasion during his July 2014 VA examination, he reported difficulty with fecal incontinence requiring pads averaging 4 to 5 a day during his April 2016 examination. The overall neurogenic bowel dysfunction symptomatology thus more nearly approximates extensive leakage and fairly frequent involuntary bowel movements, therefore a higher 60 percent rating under DC 7332 is warranted. However, the evidence of record does not indicate that a higher, 100 percent rating is warranted under DC 7332. The Veteran's DBQs and examination reports provide evidence of bowel incontinence and leakage, but indicate that the Veteran maintains at least some sphincter control. Thus, the Veteran has provided evidence of impairment of rectal sphincter control, but not complete loss of sphincter control. Therefore, a higher 100 percent rating under DC 7332 is not warranted. The above examination reports reflect that the Veteran suffers from hemorrhoids, therefore the Board has considered whether other DCs may be applicable. DC 7336 governs external or internal hemorrhoids. A 10 percent rating is warranted for internal or external hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue and evidencing frequent recurrences. Id. The maximum 20 percent schedular rating is warranted for internal or external hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Id. The evidence of record does not indicate that the Veteran's hemorrhoids are large, thrombotic, irreducible, with excessive redundant tissue and evidencing frequent recurrences. In fact, the July 2014 and April 2016 VA examination reports indicate that the Veteran's external hemorrhoids are small or moderate. Therefore, the evidence reflects that the Veteran's hemorrhoids do not more nearly approximate those contemplated by a 10 percent rating, thus a separate, compensable rating under DC 7336 is not warranted. 6. Neurogenic Bladder As previously discussed, the Veteran's neurogenic bladder currently has a staged rating, as it is rated 20 percent disabling prior to November 17, 2020, and 60 percent disabling from November 17, 2020, under 38 C.F.R § 4.115a, Ratings of the Genitourinary System-Dysfunctions for voiding dysfunction, DC 7542. As applicable to this case, voiding dysfunction is rated as urine leakage, frequency, or obstructed voiding. Urine leakage contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. A 20 percent rating is warranted for urine leakage that requires the wearing of absorbent materials which must be changed less than two times per day. A 40 percent rating is warranted for the wearing of absorbent materials which must be changed two to four times per day. A 60 percent rating is warranted for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a. For a rating based on urinary frequency, a 10 percent rating is warranted where there is daytime voiding interval between 2 and 3 hours, or awakening to void 2 times per night. A 20 percent rating is warranted where there is a daytime voiding interval between one and two hours, or if the disability results in awakening to void three to four times per night. A 40 percent rating is warranted for a daytime voiding interval of less than one hour, or if the disability results in awakening to void five or more times per night. For a rating based on obstructed voiding, a 10 percent 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; markedly diminished peak flow rate (less than 10 cc/sec); 3. Recurrent urinary tract infections secondary to obstruction; 4. Stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating is warranted for urinary retention requiring intermittent or continuous catheterization. In an October 2011 VA examination report, the Veteran reported a voiding dysfunction which caused urine leakage, but did not require the wearing of absorbent material or the use of an appliance. The examination report indicated that the Veteran had a daytime voiding interval between 1 and 2 hours, and nighttime awakening to void 3 to 4 times. The Veteran's voiding dysfunction did not cause signs or symptoms of obstructed voiding, and the Veteran did not have a history of recurrent symptomatic urinary tract or kidney infections according to the examination report. A July 2014 VA examination report reflected that the Veteran had a voiding dysfunction which caused urine leakage that did not require the wearing of absorbent material or use of an appliance. The Veteran reported increased urinary frequency with daytime voiding interval between 2 and 3 hours, and nighttime awakening to void 3 to 4 times. The Veteran's voiding dysfunction did not cause signs or symptoms of obstructed voiding. A March 2016 VA examination report indicated that the Veteran's voiding dysfunction required absorbent material which must be changed 2 to 4 times a day, did not require use of an appliance, but caused increased urinary frequency with daytime voiding interval between 1 and 2 hours, and nighttime awakening to void 5 or more times. The examiner noted that the Veteran's voiding dysfunction caused hesitancy, but hesitancy was not marked. In a May 2017 DBQ, the Veteran reported that he has to wear undergarments as his neurogenic bladder disability has worsened. He reported urine leakage which required absorbent material which must be changed 2 to 4 times per day, but did not require the use of an appliance. His urine leakage also caused increased urinary frequency with daytime voiding interval between 1 and 2 hours, and nighttime awakening to void 5 or more times. The Veteran did not have a history of urethral or bladder calculi, or recurrent symptomatic bladder or urethral infections. The examining physician opined that the Veteran's neurogenic bladder did not impact his ability to work. A November 2020 DBQ indicated that the Veteran had a voiding dysfunction which caused urine leakage which required absorbent material which must be changed more than 4 times a day, but did not require use of an appliance. The DBQ also reflected that the voiding dysfunction caused increased urinary frequency with daytime voiding interval between 1 and 2 hours, and nighttime awakening to void 3 to 4 times. The Veteran did not have a history of recurrent symptomatic bladder or urethral infections. The examining NP stated that the Veteran's neurogenic bladder impacted his ability to work as he requires easy access to the restroom, and may require frequent breaks to empty his bladder or change absorbent under pads. In a November 2020 DBQ, the Veteran reported voiding dysfunction which caused urine leakage which required absorbent material which must be changed more than 4 times per day, but did not require use of an appliance. The DBQ also reflected that the Veteran's voiding dysfunction caused increased urinary frequency with daytime voiding interval between 1 and 2 hours, and nighttime awakening to void 3 to 4 times. The NP noted that the Veteran's voiding dysfunction did not cause signs or symptoms of obstructed voiding. For the period prior to November 17, 2020, a higher, 40 percent rating is warranted. While the July 2014 examiner reported that the Veteran's urine leakage due to his voiding dysfunction did not require wearing absorbent materials which needed to be changed two to four times per day, the March 2016 and May 2017 examiners each noted nighttime awakening to void 5 or more times, with the March 2016 examination report reflecting that the Veteran's voiding dysfunction required absorbent material which must be changed 2 to 4 times a day. The evidence of record thus reflects that the Veteran's neurogenic bladder symptomatology more nearly approximates daytime voiding interval of less than one hour, or awakening to void 5 or more times per night, as contemplated by a 40 percent rating under DC 7542 for urinary frequency for the period prior to November 17, 2020. However, for the period prior to November 17, 2020 the evidence of record does not reflect that the Veteran's neurogenic bladder symptomatology requires use of an appliance, or wearing of absorbent materials that require changing more than 4 times a day. The July 2014, March 2016, and May 2017 examiners each reported that the Veteran did not require the use of an appliance, or the wearing of absorbent materials which must be changed more than four times per day. Therefore, a higher 60 percent rating prior to November 17, 2020 is not warranted. For the period from November 17, 2020, the Veteran is in receipt of a 60 percent disability rating for his neurogenic bladder, the highest available schedular rating available under DC 7542. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b) (1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board" (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). Therefore, for the period from November 17, 2020, a rating higher than 60 percent for neurogenic bladder is not warranted. 7. Erectile Dysfunction The Veteran's erectile dysfunction is currently rated noncompensable under DC 7599-7522. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. 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 SMC based on loss of use of a creative organ since February 26, 1998. The August 1999 rating decision granted this benefit based on the Veteran's erectile dysfunction which was rated noncompensable from February 26, 1998. 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 October 2011 VA examination report reflected that the Veteran's erectile dysfunction required continuous medication. The Veteran reported taking Levitra which produced a partial erection sufficient for penetration, but not ejaculation every time. The Veteran had not had an orchiectomy, and did not have retrograde ejaculation. The examiner noted that the Veteran's penis, testes, and epididymis were normal, but his prostate was abnormal with a slight increase in size. A July 2014 VA examination report note reflected that the Veteran's treatment plan for erectile dysfunction requires taking continuous medication. The Veteran had no renal dysfunction due to his condition. The examination report indicated that the Veteran was unable to achieve an erection sufficient for penetration and ejaculation without medication, but he was able to do so with medication. The Veteran did not have retrograde ejaculation, and declined an examination of his penis, testes, epididymis, and prostate. A March 2016 VA examination report reflects that the Veteran is unable to have an erection, and cannot penetrate or ejaculate. He reported that his last erection occurred in 2014, and that he has tried the pump and oral medication without success. The examiner noted that the Veteran's penis, testes, and epididymis were normal. The Veteran did not have a history of chronic epididymitis, epididymo-orchitis, or prostatitis, and he did not report retrograde ejaculation. The examining physician noted that the Veteran's erectile dysfunction is severe. A November 2020 DBQ indicated that the Veteran's erectile dysfunction treatment plan did not include taking continuous medication, and the Veteran had not had an orchiectomy. The Veteran reported that he is unable to achieve an erection sufficient for penetration and ejaculation with and without medication. The Veteran did not have retrograde ejaculation, or a history of chronic epididymitis, epididymo-orchitis, or prostatitis. The Veteran's penis, testes, prostate, and epididymis were not examined per his request. 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, while the July 2014 and November 2020 examination reports indicate that the Veteran refused a penile examination, the March 2016 VA examiner reported that the Veteran's penis, testes, and epididymis were normal. Additionally, 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. Therefore, the Veteran's erectile dysfunction symptoms do not more nearly approximate those that are 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. 8. 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. The Veteran's October 2011 VA examination report indicates that the Veteran reported that his hypertension runs between 140 to 150 systolic over 92 to 93 diastolic at his home. The Veteran required continuous medication to treat his hypertension, his blood pressure readings were 124/88, 122/86, and 122/84, and the VA examination report indicated that the Veteran's hypertension did not impact his ability to work. A July 2014 VA examination report indicated that the Veteran takes medication daily for his hypertension, but did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. His blood pressure readings were as follows: 133/87, 127/77, and 140/89, for an average of 133/84. The examining NP stated that the Veteran's hypertension did not impact his ability to work. A May 2015 VA examination report reflected that the Veteran stated that his home blood pressures were running in the 140/90 range, and that his treatment plan including taking continuous medication. The Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more, and his blood pressure readings were noted as 143/97, 144/99, and 132/89, for an average of 139/95. A May 2017 disability benefits questionnaire (DBQ) reflects that the Veteran's hypertension requires continuous medication, but that the Veteran does not have a history of a diastolic blood pressure elevation to predominantly 100 or more. The Veteran's blood pressure readings were noted as 150/110, 150/100, and 150/100, for an average of 150/103. The examining physician noted that the Veteran's hypertension did not impact his ability to work. A May 2018 DBQ indicates that the Veteran's hypertension required continuous medication, but the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. His blood pressure readings were 131/90, 135/90, and 140/90 for an average of 135/90. In a November 2020 DBQ, the NP noted that the Veteran's hypertension treatment plan included taking continuous medication for hypertension, and his blood pressure readings were 147/97, 150/98, 145/99, 130/90, 130/89, and 140/90. The Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. At the time of the DBQ, the Veteran's blood pressure readings were 132/82, 138/88, and 136/82. The NP reported that the Veteran's hypertension did not impact his ability to work. 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 77 and 110, and his systolic blood pressure has ranged between 122 and 150. These blood pressure readings are sufficient for making an increased rating determination even considering the Veteran's use of medication in order 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). 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 the May 2017 DBQ reflects instances where the Veteran's diastolic pressure was 100 or above, the evidence suggests that these episodes 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. REASONS FOR REMAND Entitlement to service connection for right acromial and distal clavicle osteophytes, (right shoulder disability), secondary to lumbar spine disability is remanded. The Veteran seeks service connection for a right shoulder disability. However, following the Board's remand of this matter and the completion of the development requested in the Board's remand, this issue was not addressed in a supplemental statement of the case before its return to the Board. The Board therefore finds that it has no alternative but to return this issue to the RO for the issuance of a supplemental statement of the case. 38 C.F.R. §§ 19.31, 19.37. Entitlement to special monthly compensation (SMC) based on aid and attendance is remanded. Entitlement to special monthly compensation (SMC) based on housebound status prior to December 11, 2014, is remanded. Entitlement to special monthly compensation (SMC) based on housebound status from March 1, 2015, to March 3, 2017, is remanded. As the further adjudication of the claim for service connection for a right shoulder disability could impact the remaining issues on appeal, adjudication of these issues will be deferred pending the completion of the development requested with respect to that claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). This matter is REMANDED for the following actions: Issue a supplemental statement of the case with respect to the issues of entitlement to service connection for the Veteran's right shoulder disability, entitlement to SMC based on aid and attendance, and entitlement to SMC based on housebound status for the period prior to December 11, 2014, and the period from March 1, 2015, to March 3, 2017, provide an appropriate time for response, and thereafter return the matter to the Board for further appellate review. Michael J. Skaltsounis 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.