Citation Nr: 21053959 Decision Date: 08/31/21 Archive Date: 08/31/21 DOCKET NO. 15-19 863 DATE: August 31, 2021 ORDER The reduction of the disability evaluation rating from 100 percent to 40 percent for status post prostate cancer effective November 1, 2014 was proper. Entitlement to an increased disability rating in excess of 40 percent for status post prostate cancer is denied. Entitlement to an increased disability rating to 60 percent, but no higher, for radiation proctitis associated with status post prostate cancer is granted. Entitlement to service connection for peripheral neuropathy of the bilateral feet secondary to radiation treatment for service-connected prostate cancer is granted. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent prior to January 7, 2020, or in excess of 70 percent from that date is denied. Entitlement to service connection for hypertension to include as a result of active service or secondary to service-connected disabilities is denied. FINDINGS OF FACT 1. The reduction from 100 percent to 40 percent for status post treatment prostate cancer was proper. 2. The Veteran's status post prostate cancer was predominately manifested in voiding dysfunction with symptoms such as the wearing of absorbent materials which must be changed two to four times per day or urinary frequency of intervals at less than once per hour, but not the wearing of absorbent materials for urinary incontinence that required changing more than four times per day; the Veteran had no reported renal dysfunction. 3. The Veteran's service-connected radiation proctitis associated with status post prostate cancer is productive of symptoms consistent with extensive leakage and fairly frequent involuntary bowel movements but not complete loss of sphincter control. 4. The Veteran was treated with radiation for service-connected prostate cancer and as a result developed, or such treatment aggravated, peripheral neuropathy of the feet. 5. The Veteran's PTSD symptoms have not manifested in symptoms such 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 personal hygiene), disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. 6. Prior to January 7, 2020, the Veteran's PTSD was more closely represented by symptoms manifested as panic attacks more than once a week; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 7. From January 7, 2020, the Veteran's PTSD was more closely represented by symptoms such as impaired impulse control and difficulty in adapting to stressful circumstances. 8. The Veteran has a diagnosis of hypertension that is not a result of injury or disease during active service, did not develop within one year of separation, nor is it proximately due to or aggravated by service-connected disabilities. CONCLUSIONS OF LAW 1. The reduction from 100 percent to 40 percent for status post treatment prostate cancer was proper. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.7, 4.85, 4.115b, Diagnostic Code 7528. 2. The criteria for entitlement to an increased disability rating in excess of 40 percent for status post prostate cancer have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.115b, Diagnostic Code 7528. 3. The criteria for a disability rating of 60 percent, but no higher, for service-connected radiation proctitis associated with status post prostate cancer are met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7332. 4. The criteria for entitlement to service connection for peripheral neuropathy of the bilateral feet secondary to radiation treatment for service-connected prostate cancer have been met. 38 U.S.C. §§ 1110, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent prior to January 7, 2020, or in excess of 70 percent from that date have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.126, 4.3, 4.7, 4.130, Diagnostic Code 9411. 6. The criteria for entitlement to service connection for hypertension to include as a result of active service or secondary to service-connected disabilities have not been met. 38 U.S.C. §§ 105, 1101, 1110, 5103A, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.159, 3.301, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1966 to April 1967 and from May 1968 to July 1969. 1. The reduction of the disability evaluation rating from 100 percent to 40 percent for status post treatment prostate cancer effective November 1, 2014 The Veteran seeks a reinstatement of the previously assigned 100 percent disability evaluation for status post prostate cancer as opposed to the currently assigned 40 percent in effect since November 1, 2014. After a thorough review of the evidence, the Board finds that the reduction from 100 percent to 40 percent for status post prostate cancer was proper. For procedural background, the RO initially notified the Veteran that it proposed to reduce the disability rating for status post prostate cancer from 100 percent to 40 percent in an April 2014 rating decision. In a May 2014 notice letter, the RO informed the Veteran of the basis for the proposed reduction. In an August 2014 rating decision, the RO implemented the reduction from 100 percent to 40 percent for status post prostate cancer with an effective date of November 1, 2014. The Veteran submitted a notice of disagreement in October 2014 expressing a desire for reinstatement of the 100 percent disability rating for status post prostate cancer. The entitlement to service connection for the initial award was September 24, 2009 with a 100 percent rating. A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. See 38 U.S.C. § 1155; Greyzck v. West, 12 Vet. App. 288, 292 (1999). When a disability has not become stable and is likely to improve, and the disability rating has not continued at the same level for at least five years, a reexamination disclosing improvement in that disability will warrant a reduction in its rating. 38 C.F.R. § 3.344(c). The duration of the disability rating at issue is measured by the effective date assigned for that rating until the effective date of the actual reduction. Brown v. Brown, 5 Vet. App. 413, 418 (1993). If a reduction in the evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, the RO must issue a rating proposing the reduction and setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). A period of 60 days is allowed for response. Id. Furthermore, the effective date of the reduction will be the last day of the month in which a 60 day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e), (i). As a preliminary matter, the Board notes that the Veteran does not contend, and the evidence does not reflect, noncompliance with the procedural requirements for rating reductions. See 38 C.F.R. § 3.105 (requiring, inter alia, notification of the proposed reduction in evaluation, a statement of the facts and reasons for such reduction, and an opportunity to submit evidence against proposed reduction). Moreover, the Board finds the notice provisions have been satisfied. The criteria governing certain rating reductions for certain service-connected disabilities is found in 38 C.F.R. § 3.344. The provisions of 3.344(a) and (b) apply to ratings that have been continued for five years or more. In the present case, the 100 percent evaluation had been in effect for slightly more than five years at the time the reduction took place. Specifically, the 100 percent rating was in place from September 24, 2009 to November 1, 2014. Therefore, the provisions of 38 C.F.R. § 3.344(a) and (b) apply. Nevertheless, in Brown v. Brown, 5 Vet. App. 413 (1993), the Court stated that there are general VA regulations that apply to all rating reductions regardless of whether the rating has been in effect for five years or more. Id. at 420-421, citing 38 C.F.R. § 4.1, 4.2, 4.10, 4.13. Specifically, 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history. 38 C.F.R. § 4.2 establishes that it is the reasonability of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21. A claim as to whether a rating reduction was proper must be resolved in the veteran's favor unless the Board concludes that a preponderance of evidence weighs against the claim. Brown, 5 Vet. App. at 421. Prostate cancer is evaluated under 38 C.F.R. § 4.115b, Diagnostic Code 7528, which covers malignant neoplasms of the genitourinary system and provides for an initial 100 percent disability rating. The 100 percent disability rating is provided until at least 6 months following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, at which time the Veteran is to be provided a VA examination. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Based upon that or any subsequent VA examination, the disability rating is open to revision in accordance with the criteria set forth in 38 C.F.R. § 3.105(e). If there is no local reoccurrence or metastasis, the service-connected genitourinary disease is to be rated on residuals either voiding dysfunction or a renal dysfunction, whichever is predominant. An October 2009 rating decision granted entitlement to service connection for prostate cancer with a 100 percent evaluation effective September 24, 2009. The evidence was medical treatment records showing diagnosis of prostate cancer and related treatment. The rating decision explained that the rating is in place at 100 percent until six months after completion of treatment, at which point a VA examination determines residual disability. The March 2014 VA examination noted that the prostate cancer was in remission. The examiner noted that radiation treatment was completed in 2010 and hormonal therapy was completed in 2013. The Board finds that this examination was adequate, as the examiner took into account the Veteran's medical history and the reported responses indicate consideration of the Veteran's medical condition at examination. Tucker v. Derwinski, 2 Vet. App. 201 (1992) (indicating that examination reports on which the reduction are based must be adequate). As the examiner noted that the Veteran's prostate cancer was in remission, the Board finds that indicates "that there has been an actual change in the condition." 38 C.F.R. § 4.13. As the initial award of entitlement was based on medical records, there is not a VA examination with which to compare if the 2014 examination was more thorough. The Board finds that since the Veteran's prostate cancer was previously in active status and being treated and in March 2014 was in remission, an improvement in a disability actually occurred and such improvement reflects improvement in ability to function under ordinary conditions of life and work Brown, 5 Vet. App. at 420-21. Whether the Veteran is entitled to an increased in excess of 40 percent disability rating for status post prostate cancer is discussed below. The Board concludes that a preponderance of evidence weighs against the claim and therefore the reduction from 100 percent to 40 percent for status post prostate cancer was proper. Brown, 5 Vet. App. at 421. 2. Entitlement to an increased disability rating in excess of 40 percent for status post prostate cancer The Veteran contends that his residuals of prostate cancer are worse than contemplated by the 40 percent disability rating assigned for status post prostate cancer. After a thorough review of the evidence, the Board finds that a rating in excess of 40 percent is not warranted for evaluation of status post prostate cancer. The Veteran is currently assigned a 40 percent disability rating for status post prostate cancer from November 1, 2014. In October 2014, the Veteran submitted a notice of disagreement to the September 2014 rating decision that assigned a 40 percent evaluation, requesting a higher evaluation up to 100 percent for "prostate cancer issues." As the initial April 2014 rating decision proposing the reduction in status post prostate cancer also awarded the Veteran a separate rating for radiation proctitis secondary to service-connected status post prostate cancer, and the Veteran filed a notice of disagreement for "prostate issues" that was within one year of both the final reduction rating decision in September 2014 and the March 2014 assignment of evaluation for proctitis, the Board finds that the increased rating claim applies to the scope of disabilities associated with prostate cancer as a reasonable expectation of a non-expert. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509- 10 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations 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). In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Prostate cancer is evaluated under 38 C.F.R. § 4.115b, Diagnostic Code 7528, which covers malignant neoplasms of the genitourinary system and provides for an initial 100 percent disability rating. The 100 percent disability rating is provided until at least 6 months following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, at which time the Veteran is to be provided a VA examination. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Based upon that or any subsequent VA examination, the disability rating is open to revision in accordance with the criteria set forth in 38 C.F.R. § 3.105(e). If there is no local reoccurrence or metastasis, the service-connected genitourinary disease is to be rated on residuals either voiding dysfunction or a renal dysfunction, whichever is predominant. Voiding dysfunction related to residuals of prostate cancer is evaluated under 38 C.F.R. § 4.115a, which provides that any voiding dysfunction shall be rated by the particular condition as urine leakage, urinary frequency, or obstructive voiding. For urinary leakage, a 40 percent evaluation is assigned for the wearing of absorbent materials which must be changed two to four times per day. A 60 percent evaluation is assigned for the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. Under urinary frequency, a 40 percent rating is assigned for daytime voiding at interval of less than one hour or awakening to void five or more times per night. The maximum rating permitted for urine leakage is 60 percent, frequent urination is 40 percent, and obstructed voiding is 30 percent. Accordingly, with regard to voiding dysfunction, the next highest evaluation potential for this Veteran is found in the urinary leakage criteria. The March 2014 VA examination for prostate conditions indicate that the Veteran changed absorbent material less than two times daily, which corresponds to a 20 percent disability rating under urinary leakage/voiding dysfunction. In the same examination, the report indicates that the Veteran had daytime voiding at intervals of less than one hour, which equates to a 40 percent disability evaluation under urinary frequency/voiding dysfunction. In the January 2015 DRO hearing, the Veteran stated that he voided one time per hour in the daytime and that the absorbent material he had was for his rectum. At the July 2018 Board hearing, the Veteran stated that he had to use the restroom to urinate "every couple of hours," and was more concerned about his bowel issues, which he referenced changing "undergarments" three to five times daily for diarrhea issues. When asked if he had trouble controlling his urination, the Veteran replied, "not as much now as I did." At the August 2020 VA examination, the examiner indicated that the Veteran had to change absorbent material less than two times per day with regard to urine leakage, which is equivalent to a 20 percent disability rating. There was no need for an appliance. Urinary frequency was listed at daytime voiding interval between one hour and two hours and nighttime voiding at five times per night, which equates to the 40 percent criteria under urinary frequency. Initially, the Board notes that there has been no local reoccurrence or metastasis, of the Veteran's prostate cancer. Thus, a rating in excess of 6"0 percent could be awarded only for renal dysfunction associated with the residuals of prostate cancer. A 60 percent rating is warranted for renal dysfunction with constant albuminuria with some edema; or, a definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101; renal dysfunction with persistent edema and albuminuria with BUN 40 to 80 mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion, warrants the assignment of an 80 percent evaluation. 38 C.F.R. § 4.115a. Under Diagnostic Code 7101, hypertension with diastolic pressure predominantly 120 or more warrants a 40 percent disability rating. 38 C.F.R. § 4.104. The evidence of record does not support a finding that the Veteran's residuals of prostate cancer include renal dysfunction. In a March 2014 VA medical examination report, a VA examiner specifically indicated that the Veteran's residuals of prostate cancer did not result in renal dysfunction. The August 2020 examiner did not indicate renal dysfunction. The Veteran's hypertension does not manifest in diastolic pressure predominantly 120. E.g., readings at the January 2016 VA examination were 157/90, 152/89, and 155/88. As such, an increased evaluation under 38 C.F.R. § 4.115a for renal dysfunction is not warranted. During the entire increased rating period, the evidence does not support that an increased disability evaluation in excess of the currently-assigned 40 percent for status post prostate cancer is warranted for voiding dysfunction associated with his prostate cancer residuals and there is no associated renal dysfunction. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. Therefore, the Veteran's claim for an increased disability rating in excess of 40 percent for status post prostate cancer must be denied. 3. Entitlement to an increased disability rating to 60 percent, but no higher, for radiation proctitis associated with status post prostate cancer As explained above, the Veteran contends that his "prostate issues" are worse than the 40 percent assigned for status post prostate cancer and the Board interprets this under Clemons to include the separate rating currently at 30 percent for radiation proctitis associated with status post prostate cancer. After a thorough evaluation of the evidence, the Board finds that a 60 percent initial increased disability evaluation, but no higher, is warranted for radiation proctitis. In the September 2020 supplemental statement of the case, the RO included a denial of increased rating in excess of 30 percent for radiation proctitis under DC 7332 in its discussion of status post prostate cancer. Diagnostic Code 7332 is used to rate disability of the rectum and anus based on impairment of sphincter control. When an unlisted condition is encountered, it is permissible to rate the condition under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. 38 C.F.R. § 4.27. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. As impairment of sphincter control reflects the predominant symptoms related to the Veteran's radiation proctitis, the Board finds DC 7332 an appropriate Diagnostic Code for evaluation rating. The Veteran's radiation proctitis associated with status post prostate cancer is rated at 30 percent from its initial assigned effective date in March 2014 under DC 7332. Under Diagnostic Code 7332, a 10 percent rating is warranted for constant slight impairment of sphincter control, or occasional moderate leakage. A 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of a pad. A 60 percent rating is warranted for extensive leakage and fairly frequent involuntary bowel movements. Finally, a 100 percent rating is warranted for complete loss of sphincter control. 38 C.F.R. § 4.114. In the March 2014 VA examination, the Veteran reported that he had recently been hospitalized due to dehydration from diarrhea. The Veteran reported that he had obtained his own "protective clothing" for managing his fecal incontinence and also wore adult diapers. The examiner described the Veteran's stool incontinence as "feels sudden sense of urgency and has loose stools." The examiner noted that leakage necessitated a pad and there was constant slight leakage. In the January 2015 DRO hearing, the Veteran stated that he defecated three to five times daily at times, or not at all. At the July 2018 Board hearing, the Veteran stated that he had to use the restroom to urinate "every couple of hours," and was more concerned about his bowel issues, which he referenced changing "undergarments" three to five times daily for diarrhea issues. He described diarrhea as a regular morning occurrence. At the August 2020 VA examinations reports for rectal and prostate conditions, the Veteran mentioned 15 incidents of loss of sphincter control per month. The examiner selected the pre-populated option for "leakage necessitates pad." The examiner noted that the Veteran said he changes absorbent material, which is for the purpose of diarrhea leakage, at least four times per day. The Board finds credible and competent the lay statements from the Veteran regarding his experiences with managing symptoms of radiation proctitis. Lay persons are competent to report information to which they have knowledge of facts or circumstances and matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. The terms such as "occasional," "fairly frequent," and "extensive" are not defined in the regulations. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Although the use of such terms by VA examiners and others is evidence to be considered by the Board, it is not dispositive of the issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Relying on the common meanings, the Board interprets the term "occasional" as meaning "encountered, occurring, appearing, or taken at irregular or infrequent intervals;" the term "fairly frequent" as meaning "acting or returning regularly or often;" and the term "extensive" as meaning "very large in amount or degree." See Merriam-Webster dictionary; see also MacMillan dictionary; see Cantrell v. Shulkin, 28 Vet. App. 382, 392 (2017) ("VA's failure to define [a relevant term] or to otherwise specify the factors that adjudicators should consider in making that determination frustrates judicial review of that issue."). With regard to the Veteran's complaints and description regarding his diarrhea and rectal leakage, the Board finds that the Veteran's reported frequency of every other day at a minimum with multiple occurrences per day constitutes "fairly frequent," and having to change pads at least four times per day and owning protective clothing specifically for this issue constitutes responses indicative of extensive leakage. As the two criteria for a 60 percent disability rating under Diagnostic Code 7332 - extensive leakage and fairly frequent involuntary bowel movements - have been met, the Board finds that such disability rating is warranted for the Veteran's service-connected radiation proctitis. However, a higher disability rating is not warranted under Diagnostic Code 7332 because the evidence fails to demonstrate the Veteran has complete loss of sphincter control. 4. Entitlement to service connection for peripheral neuropathy of the bilateral feet secondary to radiation treatment for service-connected prostate cancer The Veteran contends that he developed peripheral neuropathy in his feet or at least a previously existing peripheral neuropathy worsened as a result of his treatment for service-connected prostate cancer. After a thorough review, the Board finds that the evidence is in equipoise as to whether the Veteran's diagnosed bilateral feet peripheral neuropathy was proximately due to or aggravated by the treatment for service-connected prostate cancer; accordingly the Board finds that entitlement to service connection on a secondary basis is warranted. Service connection may also be granted for a disability, which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. In a May 2015 medical opinion, a VA medical provider opined that "peripheral neuropathy may be a side effect of some types of radiation," after noting that the Veteran had radiation treatment for prostate cancer. The provider then noted that the Veteran also has peripheral vascular disease and back problems, concluding that "it would be mere speculation to state with any degree of certainty the cause of this veteran's peripheral neuropathy due to the multiple comorbidities that exist." In a September 4, 2015 CAPRI note, the provider noted, "peripheral neuropathy: etiology not clear. Could be due to chemotherapy in the past." In an October 2015 CAPRI record, the medical provider referenced a May 2011 EMG study showing peripheral neuropathy, and complaints by the Veteran of painful peripheral neuropathy in the lower extremities "likely [due to] prior heavy alcohol use." In the January 2016 VA examination for peripheral neuropathy, the examiner confirmed a diagnosis of peripheral neuropathy, bilateral lower extremities and listed a diagnosed date of 2000, as reported by the Veteran. The Veteran reported that he has had the issue since around 2000 and that he thinks it worsened after his treatment for prostate cancer in 2009. The examiner opined that the PN was not related to service because it was not diagnosed within one year of separation and it was not aggravated by prostate cancer/treatment because "there is no validated clinical evidence to show" such. In the July 2018 Board hearing, the Veteran stated that he had a difficult time walking after treatment for prostate cancer and that he developed peripheral neuropathy at that time, and he did not have it earlier. This case was remanded in March 2019 and the Board requested an opinion on the claim of service connection due to aggravation of peripheral neuropathy in the feet from radiation treatment for prostate cancer and it specifically asked that the new opinion incorporate reference to the May 2015 medical opinion that states that peripheral neuropathy can be a side effect of some types of radiation treatment. The December 2019 VA opinion states that the Veteran's diagnosed peripheral neuropathy is not due to treatment for prostate cancer, but a result of years of tobacco use. The examiner simply stated, "review of the medical record shows no evidence prostate cancer or treatment for prostate cancer (XRT, ADT) caused or aggravated the veteran's lower extremity peripheral neuropathy" and references that "medical literature does not support a relationship." The Board finds that the December 2019 opinion does not reply to the directives of the previous remand and therefore there has not been substantial compliance with its March 2019 remand. Stegall v. West, 11 Vet. App. 268 (1998). However, the Board is granting the Veteran's claim herein, and accordingly, a new remand for additional development is not indicated and not remanding is not prejudicial to the Veteran. In the August 2020 VA examination for prostate, the examiner noted that the Veteran had nerve damage from radiation treatment for prostate cancer resulting in erectile dysfunction. In an August 21, 2020 CAPRI record, the medical provider noted that peripheral neuropathy can be associated with early glucose intolerance or can be idiopathic. To the extent that the Veteran attempts to relate his feet peripheral neuropathy to either developing from or being aggravated by radiation treatment for prostate cancer, based on his own personal knowledge of medicine and his familiarity with his individual medical history, the Board notes that he is not a trained medical clinician. The records show that he has never received any formal medical training. Although lay persons may be competent to provide opinions as to some medical issues (Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), as the specific question in this case regarding the etiology of the Veteran's bilateral feet peripheral neuropathy falls outside the realm of common knowledge of a lay person, he lacks the competence to provide a probative medical opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Consequently, we turn to the medical evidence and opinions of record. In this case, there have been numerous etiologies proposed for the Veteran's development or aggravation of peripheral neuropathy in the feet, including radiation from prostate cancer treatment, chemotherapy, alcohol use, tobacco smoking, back problems, peripheral vascular disease, early glucose intolerance, or idiopathic reasons. Because some of these etiologies include treatment for cancer and it does not appear that the medical doctors can agree with certainty that there is a sole etiology that does not include treatment for cancer, the Board finds that treatment for cancer must be considered a potential etiology for the Veteran's bilateral feet peripheral neuropathy. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current bilateral feet peripheral neuropathy is proximately due to or aggravated beyond its natural progression by his service-connected prostate cancer treatment. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1Vet. App.49, 53-54 (1990). Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bilateral feet peripheral neuropathy as secondary to service-connected prostate cancer treatment is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent prior to January 7, 2020, or in excess of 70 percent from that date The Veteran contends that his PTSD symptoms caused total occupational and social impairment during the period on appeal and requests a 100 percent rating. After a thorough review of the evidence, the Board finds that an increased disability rating in excess of 50 percent prior to January 7, 2020, or in excess of 70 percent from that date is not warranted. This issue was previously remanded for additional records and a VA examination in March 2019. The Board finds that the RO has substantially complied with the remand directives for PTSD as it uploaded more recent medical treatment records and obtained another VA examination for the Veteran in 2020. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings are sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 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 his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. However, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Diagnostic and Statistical Manual (Fifth Edition) (the DSM-5). See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted as final, without change, this interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). In the present case, the RO certified the Veteran's appeal to the Board in February 2016, which is after August 4, 2014. Thus, the version of 38 C.F.R. § 4.125 conforming to the DSM-5 is applicable in the present case. In any event, the Board will still consider any private or VA examiner's discussion of both the DSM-IV and DSM-5 in adjudicating the current Veteran's PTSD claim, in order to provide the Veteran with every benefit of the doubt. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). As provided by the General Rating Formula, a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is warranted if the disability is productive of 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 in 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. A 70 percent rating is in order when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is in order 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; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. The Federal Circuit has clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration, but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. The Veteran's service-connected PTSD is currently assigned a 50 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, prior to January 7, 2020 and 70 percent from that date. The Veteran filed the initial claim for service connection for PTSD on May 12, 2014, and that is the currently assigned initial effective date. The Veteran contends that the PTSD symptoms he experiences support a higher 100 percent evaluation. The Board finds that a rating in excess of 50 percent prior to January 7, 2020, or in excess of 70 percent from that date is not warranted. The Veteran's record reflects that he is a Vietnam veteran. In 2009 he sought VA treatment and benefits when he developed prostate cancer. The Veteran had worked for many years in the bar and restaurant industry. The record reflects that the Veteran also has used alcohol for many years and had multiple DUIs that resulted in suspension of his driving license around 2016. In a June 2014 PTSD evaluation, the medical provider noted that the Veteran was not psychotic, nor did he present suicidal or homicidal ideations. There was no major thought disorder. The Veteran reported nightmares and sleep issues as well as feeling depressed and hypervigilant with an exaggerated startle response. In a June 2014 letter, a friend who knew the Veteran prior to service describes the Veteran as "very withdrawn and solitary," and someone who "has never married and not been able to sustain long-term relationships." He goes on to write that, "merely inquiring about [Vietnam] seems at times to considerably upset his usual mild manner." He also describes how the Veteran chose to work in the restaurant and bartending industry, where he interacts with lots of people, but on a superficial and short-term basis. At the August 2014 VA examination, the examiner diagnosed PTSD without any other psychiatric diagnoses. In the narrative summary, the examiner reported that the Veteran has a good relationship with his family and has several friends. The Veteran reported, "he experienced PTSD symptoms such as anxiety, hypervigilance, nightmares, anger outbursts, intrusive memories, and startle response. Veteran states that he has flashbacks, particularly when waking from dreams." The Veteran reported "keeping to himself over the years," and using alcohol to alleviate PTSD symptoms. As for symptoms specific to PTSD, the examiner identified depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting. The examiner chose the box corresponding with 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. At the January 2015 DRO hearing, the Veteran expressed that he felt he had anger issues which he was unsure of how they may have developed, and that, although he worked as bartender and therefore in crowds, he said he did not like crowds in unfamiliar places. The Veteran stated that although he never formally married, he had been in several multi-year relationships and expressed that he had been afraid to be a father. He also explained how he has flashbacks in response to things that remind him of events in Vietnam. The Veteran described how he "didn't sleep" for the "better part of 40 years" and in the early years drank himself to sleep. The Veteran also stated that he's had issues with anxiety and depression over the years. As for his experience at home, he described knowing all the sounds of his neighborhood and being very aware of unusual sounds around the home. In a May 2015 PTSD evaluation note, the provider commented that the Veteran did not exhibit psychosis or suicidal or homicidal ideations. The Veteran was attending regular therapy for PTSD and exhibited issues with long term intimate relationships, anxiety, depression, sleep disturbance and reported panic type attacks a few times per month. The November 2015 DRO conference report summarized the Veteran's concerns about his PTSD, "Veteran stated that he receives psychiatric treatment at the VAMC; he is in a relaxation group and a PTSD group. His symptoms include anger, anxiety, depression, aggressive behavior, flashbacks and sleep disorder, etc. He does not hang out with his friends. He is a bartender and works 3-4 nights a week. He last worked full time in 2009. He stated that his symptoms affect his occupational functioning. He described his job involves in dealing people and he tries to stay calm on occasions. He indicated that his PTSD has worsened since last VA exam." At the January 2016 VA PTSD examination, the examiner confirmed a diagnosis of PTSD and adjustment disorder with mixed anxiety and depressed mood. As for symptoms specific to PTSD, the examiner identified intrusive thoughts, physiological and emotional reactions to trauma cues, nightmares, avoidance symptoms, emotional distance from others, and hypervigilance. The examiner wrote that, "Both PTSD and adjustment disorder contribute to veteran's current social impairment." In the narrative summary, the examiner described that the Veteran's job as bartender serves as his social life, actively socializing with clientele and that he also had friends he sees from time to time. The Veteran had reluctance regarding intimate relationships, with concern especially around his medical issues. The Veteran reported that he was good at his job, believing himself to be the best bartender at the bar. "He denied performance impairments at his job. He indicated that he gets along with most coworkers, but some he does not, although has not had major incidents. He denied missing any time out of work. He reported that he has to work to keep his anger in check so customers do not pick up on it." The Veteran participated in three weekly veteran groups as well as individual treatment for PTSD. The Veteran's symptoms for PTSD included depressed mood, anxiety, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), and difficulty in establishing and maintaining effective work and social relationships. The examiner chose the box corresponding with 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. At the July 2018 Board hearing, the Veteran stated that he talked regularly with people on a superficial level but did not engage in deeper relationships and described himself as having "trust issues." He described having an exaggerated response to unexpected sounds like backfiring cars or random screaming. He specifically expressed fear of gasoline trucks and intentionally avoiding them. The Veteran discussed how he has had more than one DUI and it resulted in suspension of his driving license. The Veteran stated the he thought he was "more calm" five years ago than at the present and indicated he thought his condition was overall worse although the symptoms vary in severity over time. At the January 7, 2020 VA PTSD examination, the examiner confirmed a diagnosis of PTSD and major depressive disorder. The examiner commented that the symptoms for the diagnoses overlap and she could not differentiate specific symptoms for each diagnosis. The examiner described that, "Veteran was friendly and cooperative. He arrived on time for the scheduled visit and willingly participated. His speech was normal, mood and affect were somewhat depressed. He denied [suicidal ideation, homicidal ideation, auditory hallucination, visual hallucination]. Veteran had some difficulty ambulating which he attributed to neuropathy in his feet and knee pain." The Veteran reported depression related to his life not being how he imagined but denied suicidal ideations. The Veteran reported that he had a lot of "nice relationships" but he doesn't go to the point of intimacy as he has concerns over his medical issues. The Veteran reported working about 30 hours weekly as a bartender for the previous five years. The Veteran's symptoms for PTSD included depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner chose the box corresponding with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In a July 2020 CAPRI note, the medical provider reported on a telephone consultation with the Veteran in which the provider describes the Veteran as "otherwise emotionally and physically stable" apart from the ongoing gastrointestinal issues and boredom. The Veteran did describe himself as "very depressed" relating to work or physical ailments. The Veteran described how the bar he worked at was closed due to the pandemic, but the Veteran later chose to not return to work due to his painful feet and retire from work at the suggestion of a medical provider. The medical provider reported diagnosis of adjustment disorder with anxiety and depression. The Board finds that based on the record including, but not limited to, VA examinations, lay statements, other medical provider letters and records, and mental health treatment records, that the Veteran's PTSD, when viewed in light most favorable to the Veteran, was not productive of total occupational and social impairment. In adjudicating this claim, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his PSTD symptoms warrant a higher rating. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds that the Veteran's statements about his PTSD symptoms are credible where they are consistent with the overall record. The Veteran's overall record does not demonstrate that his PTSD symptoms manifest in 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 personal hygiene), disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. As for the increased disability rating appeal for rating in excess of 50 percent prior to January 7, 2020, the Board finds that the Veteran's PTSD during that period more closely approximates the 50 percent rating criteria with symptoms such as panic attacks more than once a week; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, but acknowledges that there was a report of symptoms from the 70 percent criteria during that period with, e.g., difficulty in adapting to stressful circumstances. See August 2014 VA examination. He also had symptoms associated with a 30 percent disability rating for PTSD such as panic attacks weekly or less often, depressed mood, anxiety, chronic sleep impairment, and mild memory loss. With regard to the appeal for a rating increase in excess of 70 percent from January 7, 2020, the Board finds that the Veteran's overall PTSD from that date more closely approximates the 70 percent rating criteria with symptoms such as impaired impulse control and difficulty in adapting to stressful circumstances. Accordingly, the Veteran's PTSD more nearly approximates the 50 percent disability level prior to January 7, 2020 and the 70 percent disability level from that date, and the appeal for an increased disability rating for PTSD in excess of those evaluation levels is denied. 38 C.F.R. § 4.7. 6. Entitlement to service connection for hypertension to include as a result of active service or secondary to service-connected disabilities The Veteran contends that he developed hypertension during active service or as a result of service-connected disabilities. After a thorough review of the evidence of record, the Board finds that entitlement to service connection for hypertension is not warranted. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110, 1131. To establish a right to compensation, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability, which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Certain chronic diseases, such as hypertension, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The provisions for establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, DC 7101 Note (1). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. In this sense, the Board finds that the Veteran is competent to report that episodes of feeling like he would faint, did faint, or being light headed, or other similar experiences, but not that such episodes are indicative of a certain underlying disease or what its etiology may be. The Veteran's service treatment records (STRs) do not contain indications of diagnosis of hypertension. The Veteran's May 1966 medical examination and related history show blood pressure of 120/78 and no mention of fainting history. On the April 1967 medical examination and related history, the Veteran's blood pressure was 130/76 and the Veteran responded "no" to whether he had a history of dizziness or fainting spells. On the April 1968 medical examination, the Veteran's blood pressure is recorded as 138/72 and overall health as "no significant abnormalities" and the Veteran responded "no" to whether he had a history of dizziness or fainting spells. July 1968 record shows the Veteran had a syncopal episode after drinking cold liquid. April 1968 records note "vaguely described" fainting episode without suspected loss of consciousness. In May 1969, the Veteran complained of chest pain. At the July 1969 separation examination and medical history, the Veteran's blood pressure was 118/80 and he responded affirmatively to history of dizziness or fainting spells, and in the notation, the examiner wrote, "fainting x 2." The January 2016 VA examiner noted that the Veteran's hypertension was diagnosed in 2007. The examiner opined that the Veteran's hypertension was not as least as likely as not related to service because it did not develop within one year of separation. The examiner opined that the Veteran's hypertension was not at least as likely as not proximately due to or aggravated prostate cancer treatment or PTSD based on "no validated clinical evidence" to support that theory. At the July 2018 Board hearing, the Veteran said he was diagnosed with hypertension in the 1970s or 1980s but did not know when he started medication for it. The Veteran stated the doctors attributed hypertension to anxiety of dealing with prostate cancer. This issue was previously remanded for additional records and a VA opinion in March 2019. The Board finds that the RO has substantially complied with the remand directives for PTSD as it uploaded more recent medical treatment records and obtained another VA opinion for the Veteran. In the addendum December 2019 medical opinion, the examiner opined that the Veteran's hypertension was not at least as likely as not developed in active service, or proximately due to or aggravated by service-connected disabilities of prostate cancer or PTSD. The examiner noted that "anxiety states can cause a temporary elevation in blood pressure, they do not cause or permanently aggravate primary essential hypertension." The examiner then listed several risk factors for hypertension that pertain to the Veteran including family history, sodium intake, excess alcohol intake, obesity and weight gain, inactivity, and dyslipidemia. The RO obtained another opinion in September 2020 in which the examiner opined that the Veteran's hypertension was not at least as likely as not developed during or within one year of active service based on STRs that do not show that he was diagnosed or treated for hypertension or symptoms suggestive of hypertension during or within one year of service. The separation examinations showed the Veteran was normotensive. The examiner referenced the syncopal episodes and complaints of chest pain from the STRs and provided the rationale to support the opinions with, "Both of these incidents were associated with a vaso vagal response which involves a temporary low blood pressure condition brought on by external sources and has no relation to hypertension. The veteran's substernal discomfort or "chest pain" was a result of cold liquid affecting the vagal nerve. While lay statements indicate the veteran "felt" he had blood pressure issues while in service, the medical record does not support this. Review of the medical record shows the veteran was diagnosed with hypertension in 2007." The preponderance of the evidence is against the claim that the Veteran's hypertension occurred during or resulted from active service, manifested to a compensable degree within one year of separation from service, or is otherwise related to in-service injury or disease during active duty or proximately due to or aggravated by service-connected disabilities. Accordingly, the benefit-of-the-doubt rule is not for application and entitlement to service connection is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.