Citation Nr: 21060925 Decision Date: 09/28/21 Archive Date: 09/28/21 DOCKET NO. 17-17 305 DATE: September 28, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for degenerative joint disease of the cervical spine with intervertebral disc syndrome (IVDS) is denied. Entitlement to a disability rating in excess of 30 percent for acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy is denied. Entitlement to a disability rating in excess of 30 percent for sarcoidosis with asthma and chronic obstructive pulmonary disease (COPD) is denied. Entitlement to a compensable disability rating for bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters) is denied. Entitlement to service connection for right elbow disability, to include as secondary to service-connected acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy is denied. Entitlement to service connection for left big toe disability is denied. Entitlement to service connection for right wrist disability is denied. Entitlement to service connection for left wrist disability is denied. Entitlement to service connection for knee scars is dismissed. Entitlement to service connection for a low back disability, to include as secondary to service-connected degenerative joint disease of the cervical spine is denied. Entitlement to service connection for fibromyalgia (also claimed as joint pain, polyarthritis) is denied. Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to service connection for a respiratory disability, to include chronic bronchitis and/or tuberculosis is denied. REMANDED Entitlement to service connection for sleep apnea (also claimed as insomnia) is remanded. Entitlement to service connection for right ankle disability is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for right hip disability is remanded. Entitlement to service connection for left hip disability is remanded. FINDINGS OF FACT 1. The Veteran's degenerative joint disease of the cervical spine with IVDS is manifest by symptoms no worse than forward flexion of the cervical spine of 30 degrees; and, the combined range of motion of the cervical spine of 195 degrees (170 degrees after repetitive motion); without muscle spasm nor guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. The Veteran's degenerative joint disease of the cervical spine with IVDS did not produce forward flexion of the cervical spine to 15 degrees or less; nor favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine, nor unfavorable ankylosis of the entire spine. 3. The Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy is manifested by limitation of motion of the arm midway between side and shoulder of the major extremity, no worse than 30 degrees. 4. The Veteran's sarcoidosis with asthma and COPD produced PFT results no worse than FEV-1 of 55-percent predicted (or worse), nor; FEV-1/FVC of 55 percent (or worse). 5. The Veteran's sarcoidosis with asthma and COPD produced PFT results with a DLCO (SB) of 43-percent predicted, however, the July 2015 VA examiner noted that the FEV-1/FVC test results most accurately reflects the Veteran's level of disability. 6. The Veteran's sarcoidosis with asthma and COPD did not result in a maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). 7. The Veteran's sarcoidosis with asthma and COPD did not result in pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control warrants; nor cor pulmonale, nor; cardiac involvement with congestive heart failure, nor; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 8. The Veteran's bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters) manifests as impaired visual acuity to no worse than 20/20 corrected distance in the right eye and no worse than 20/40 corrected distance in the left eye; and no incapacitating episodes in a twelve-month period. 9. The Veteran's right elbow disability is not secondary to service-connected acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post arthroscopy; and is not otherwise related to an in-service injury or disease. 10. The preponderance of the evidence is against finding that a left big toe disability began during active service, or is otherwise related to an in-service injury or disease. 11. The preponderance of the evidence is against finding that right wrist disability began during active service, or is otherwise related to an in-service injury or disease. 12. The preponderance of the evidence is against finding that left wrist disability began during active service, or is otherwise related to an in-service injury or disease. 13. Prior to the promulgation of a decision in the appeal, the RO granted the Veteran's claims for entitlement to service connection for scars of the bilateral knees. 14. The Veteran's low back disability is not secondary to his service-connected degenerative joint disease of the cervical spine, and is not otherwise related to an in-service injury or disease. 15. The preponderance of the evidence of record is against finding that the Veteran has had fibromyalgia (also claimed as joint pain, polyarthritis) at any time during or approximate to the pendency of the claim. 16. The preponderance of the evidence of record is against finding that the Veteran has had chronic fatigue syndrome at any time during or approximate to the pendency of the claim. 17. The preponderance of the evidence of record is against finding that the Veteran has had respiratory disability, to include chronic bronchitis and/or tuberculosis (that he is not already service-connected for) at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for degenerative joint disease of the cervical spine with IVDS; have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237, Diagnostic Code 5242. 2. The criteria for entitlement to a disability rating in excess of 30 percent for acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy; have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003, Diagnostic Code 5201. 3. The criteria for entitlement to a disability rating in excess of 30 percent for sarcoidosis with asthma and COPD; have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.97, Diagnostic Code 6600, Diagnostic Code 6604, Diagnostic Code 6846. 4. The criteria for a compensable disability rating for the Veteran's bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters); have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79 Diagnostic Code 6099, Diagnostic Code 6034. 5. The criteria for entitlement to service connection for right elbow disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for entitlement to service connection for left big toe disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for right wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for left wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for dismissal of the appeal for entitlement to service connection for scars of the bilateral knees have been met. 38 U.S.C. § 7105. 10. The criteria for service connection for low back disability due to service or associated with the Veteran's service-connected degenerative joint disease of the cervical spine with IVDS; are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 11. The criteria for entitlement to service connection for fibromyalgia (also claimed as joint pain, polyarthritis) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for entitlement to service connection for chronic fatigue syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for service connection for a respiratory disability, to include chronic bronchitis and/or tuberculosis; are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from May 1979 until his honorable retirement in January 2001. The Veteran had service in the Southwest Asia theater of operations during the Persian Gulf War and is a recipient of the Combat Action Ribbon among other awards and decorations. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision by the Oakland, California Regional Office (RO) of the United States Department of Veterans Affairs (VA). In August 2019, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain VA treatment records from Mather, California VA Medical Center (VAMC) as well as Beale Air Force Base; obtain VA examinations for the above claims on appeal. In response, in November 2019, the RO obtained VA treatment records from Sacramento, California VAMC June 22, 2018 through November 14, 2019; in January 2020, the RO obtained VA treatment records from Chico, California VA Clinic from September 4, 2019 through January 7, 2020; in January 2020, the RO obtained a VA examiner opinion pertaining to the Veteran's sleep disability; in February 2020, the RO obtained a VA eye examination, a tuberculosis VA examination, a shoulder and arm VA examination, an ankle VA examination, a wrist VA examination, a respiratory VA examination (other than tuberculosis and sleep apnea), a hip VA examination, a Scar VA examination, a cervical spine examination, a thoracolumbar spine VA examination, a foot VA examination, an elbow VA examination, a fibromyalgia VA examination, a sleep apnea VA examination, a chronic fatigue syndrome VA examination; and in July 2020, the RO obtained the Veteran's medical treatment records from Beale Air Force Base. The Board finds that there has been substantial compliance with the Board's previous remand directives regarding the issue(s) on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 1. Entitlement to an initial disability rating in excess of 20 percent for degenerative joint disease of the cervical spine with IVDS The Veteran asserts that he is entitled to a higher rating because his disability rating does not adequately rate his disability. The Veteran's degenerative joint disease of the cervical spine with IVDS is rated under Diagnostic Code 5242-5237. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. In the present case, the Veteran is rated under Diagnostic Code 5242 for degenerative arthritis of the spine on the basis of Diagnostic Code 5237 for cervical strain for his degenerative joint disease of the cervical spine with IVDS. The Board notes that both Diagnostic Code 5237 and Diagnostic Code 5242 are rated under the exact same criteria. The Veteran's degenerative joint disease of the cervical spine with IVDS is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent disability rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent disability rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in 38 C.F.R. §§ 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA examination in March 2012. The March 2012 VA examiner found that the Veteran's degenerative joint disease of the cervical spine with IVDS produced forward flexion of the cervical spine of 30 degrees; and, the combined range of motion of the cervical spine of 195 degrees (170 degrees after repetitive motion); without muscle spasm nor guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Furthermore, the March 2012 VA examiner did not find forward flexion of the cervical spine to 15 degrees or less; nor favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine, nor unfavorable ankylosis of the entire spine. The Veteran was afforded a second VA examination in February 2020. The February 2020 VA examiner found that the Veteran's degenerative joint disease of the cervical spine with IVDS produced forward flexion of the cervical spine of 40 degrees; and, the combined range of motion of the cervical spine of 290 degrees; without muscle spasm nor guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Furthermore, the February 2020 VA examiner did not find forward flexion of the cervical spine to 30 degrees or less; nor favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine, nor unfavorable ankylosis of the entire spine. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for degenerative joint disease of the cervical spine with IVDS. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, fatigue, and weakness. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher disability rating. See 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for degenerative joint disease of the cervical spine with IVDS. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a disability rating in excess of 30 percent for acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy The Veteran asserts that he is entitled to a higher rating. The Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy is rated under Diagnostic Code 5003-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. In the present case, the Veteran is rated under Diagnostic Code 5003 for degenerative arthritis on the basis of Diagnostic Code 5201 for limitation of motion of his arm for his acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy. As a preliminary matter, the Board notes that the maximum disability rating under Diagnostic Code 5003 is 20 percent. See 38 C.F.R. § 4.71A, Diagnostic Code 5003. Since the Veteran's disability rating throughout the period on appeal is in excess of 20 percent, the Board will limit the analysis to the criteria under Diagnostic Code 5201. The Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Board notes that effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent disability rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent disability rating for the minor extremity and a 30 percent disability rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent disability rating for the minor joint and a maximum 40 percent disability rating for the major joint. Prior to February 7, 2021, Diagnostic Code 5201 provided that limitation of motion at the shoulder level warrants a 20 percent disability rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level warrants a 20 percent disability rating for the minor extremity and a 30 percent disability rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent disability rating for the minor joint and a maximum 40 percent disability rating for the major joint When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). As noted above, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." As noted above, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA examination in March 2012. The March 2012 VA examiner found that the Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy produced limitation of motion of the arm midway between side and shoulder level (45 degrees flexion and 50 degrees abduction). The Veteran was afforded a second VA examination in February 2020. The February 2020 VA examiner found that the Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy produced limitation of motion of the arm midway between side and shoulder level (0 to 100 degrees flexion and abduction) and 0 to 60 degrees rotation (internal and external). The Veteran was afforded a third VA examination in May 2021. The May 2021 VA examiner found that the Veteran's acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy produced limitation of motion of the arm midway between side and shoulder level (0 to 90 degrees flexion and abduction) and 0 to 70 degrees rotation (internal and external). The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy. The evidence of record shows that the Veteran is right-handed. See April 2012 VA examination, p. 24; February 2020 VA examination, p. 4; and May 2021 VA examination, p. 2. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the major extremity. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 30 percent for acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a disability rating in excess of 30 percent for sarcoidosis with asthma and COPD The Veteran asserts that he is entitled to a higher disability rating. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. In the present case, the Veteran is rated under Diagnostic Code 6604 for chronic obstructive pulmonary disease on the basis of Diagnostic Code 6846 for sarcoidosis for his sarcoidosis with asthma and COPD. The Veteran's sarcoidosis with asthma and COPD is rated by analogy pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6846-6604. Initially, the Board notes that sarcoidosis is rated under Diagnostic Code 6846 and that Diagnostic Code 6846 provides two methods to rate the Veteran's disability. First, Diagnostic Code 6846 provides that a chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment warrants a noncompensable disability rating; pulmonary involvement with persistent symptoms requiring low dose (maintenance) or intermittent corticosteroids warrants a 30 percent disability rating; pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control warrants a 60 percent disability rating; and cor pulmonale, or; cardiac involvement with congestive heart failure, or; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment warrants a 100 percent disability rating. Alternatively, active disease or residuals of sarcoidosis may be rated as chronic bronchitis under Diagnostic Code 6600 and extra-pulmonary involvement under specific system involved. A review of the rating criteria under Diagnostic Code 6600 shows that it mirrors the rating criteria under Diagnostic Code 6604. As such, rating the Veteran's sarcoidosis under either Diagnostic Code 6600 or 6604 provides the same outcome. The Board shall first address the criteria for active disease or residuals of sarcoidosis may be rated as chronic bronchitis under Diagnostic Code 6600 and extra-pulmonary involvement under specific system involved. The Board does note that there are special provisions for the application of the rating criteria for certain Diagnostic Codes, including Diagnostic Codes 6600, 6603, 6604, 6825-6833, and 6840-6845. 38 C.F.R. § 4.96(d). Pulmonary function tests (PFTs) are required to evaluate these conditions, except when the results of maximum exercise capacity test are of record and are 20 ml/kg or less; when pulmonary hypertension or pulmonale or right ventricular hypertrophy has been diagnosed; when there have been one or more episodes of acute respiratory failure; or when outpatient oxygen therapy is required. 38 C.F.R. § 4.96(d)(1). If Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) results are not of record, such conditions are evaluated based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96(d)(2). When PFTs are not consistent with clinical findings, conditions are evaluated based on the PFTs unless the examiner states why they are not a valid indication or respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96 (d)(4). When evaluating based on PFTs, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case, the pre-bronchodilator results are used for rating purposes. 38 C.F.R. § 4.96 (d)(5). However, when there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(6). Diagnostic Code 6604 provides ratings based on the results of pulmonary function tests. FEV-1 of 71- to 80-percent predicted value, or; the ratio of FEV-1/FVC of 56 to 71 to 80 percent or; DLCO (SB) of 66- to 80-percent predicted, is rated 10 percent disabling; FEV-1 of 56- to 70-percent predicted value, or; the ratio of FEV-1/FVC of 56 to 70 percent or; DLCO (SB) of 56- to 65-percent predicted, is rated 30 percent disabling; FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling; and FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97, Code 6604. The Veteran was afforded a VA examination in March 2012. The March 2012 VA examiner found that the Veteran was diagnosed with sarcoidosis with no physiologic impairment nor symptoms. The Veteran's September 2011 chest x-ray found that the Veteran's mediastinum and cardiac silhouette were within normal limits, there was no pulmonary vascular redistribution, no pleural fluid nor pneumothorax or pulmonary infiltrates. However, the Board notes that the Veteran was not afforded pulmonary function testing during the March 2012 VA examination. The Veteran submitted private treatment records from April 2012. The April 2012 private treatment records reflect FEV-1 of 97 percent predicted value; the ratio of FEV-1/FVC of 95 percent; and DLCO (SB) of 88-percent predicted. See April 2012 North State Pulmonary Associates private treatment records. The Veteran was afforded a second VA examination in July 2015. The July 2015 VA examiner found that the Veteran was diagnosed with sarcoidosis that had worsened and now required chronic low dose (maintenance) corticosteroids and the daily use of inhaled anti-inflammatory medications with persistent symptoms of dyspnea 2 or 3 times per month. The July 2015 PFT reflect FEV-1 of 64-percent predicted value; the ratio of FEV-1/FVC of 96 percent; and DLCO (SB) of 43-percent predicted. As noted above, when there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(6). The July 2015 VA examiner noted that the FEV-1/FVC test results most accurately reflects the Veteran's level of disability (based on the condition that is being evaluated for this report). Therefore, although there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, the FEV-1/FVC test results shall be the result that is used. The Veteran was afforded a Tuberculosis VA examination and a Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) in February 2020 that also included a PFT. The February 2020 VA examination found that the Veteran's PFT reflected FEV-1 of 78-percent predicted value; the ratio of FEV-1/FVC of 79 percent; and DLCO (SB) of 140-percent predicted. After thorough consideration of the evidence of record, the Board concludes that a disability rating in excess of 30 percent is not warranted for the Veteran's sarcoidosis with asthma and COPD under the criteria of active disease or residuals of sarcoidosis may be rated as chronic bronchitis under Diagnostic Code 6600 (and Diagnostic Code 6604) and extra-pulmonary involvement under specific system involved. The VA treatment records and other evidence of record reflect that the Veteran's sarcoidosis with asthma and COPD did not produce FEV-1 of 55-percent predicted (or worse), or; FEV-1/FVC of 55 percent (or worse), or; DLCO (SB) of 55-percent predicted (or worse), nor; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit) and therefore a disability rating in excess of 30 percent is not warranted. The Board will now review the evidence under the criteria for Diagnostic Code 6846. As noted above, the Veteran was afforded a VA examination in March 2012. The March 2012 VA examiner found that the Veteran's sarcoidosis with no physiologic impairment nor symptoms. The Veteran's September 2011 chest x-ray found that the Veteran's mediastinum and cardiac silhouette were within normal limits, there was no pulmonary vascular redistribution, no pleural fluid nor pneumothorax or pulmonary infiltrates. Furthermore, the March 2012 VA examiner noted that the Veteran did not require the use of oral parenteral corticosteroid medications nor inhaled medications. The Board notes that the April 2012 private treatment records do not note any use of oral parenteral corticosteroid medications nor inhaled medications. As noted above, the Veteran was afforded a second VA examination in July 2015. The July 2015 VA examiner found that the Veteran was diagnosed with sarcoidosis that had worsened and now required chronic low dose (maintenance) corticosteroids and the daily use of inhaled anti-inflammatory medications with persistent symptoms of dyspnea 2 or 3 times per month. The Veteran was afforded a Tuberculosis VA examination and a Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) in February 2020 that also included a PFT. The February 2020 VA examination found that the Veteran's respiratory condition no longer required the use of oral or parenteral corticosteroid medications but did require only intermittent bronchodilator therapy and inhalational anti-inflammatory medication due to his COPD. Therefore, the Board finds that throughout the period on appeal, the Veteran did not meet the criteria for a disability rating in excess of 30 percent for his sarcoidosis with asthma and COPD. Specifically, the Veteran's PFTs demonstrated that the Veteran's disability did not produce FEV-1 of 55-percent predicted (or worse), nor; FEV-1/FVC of 55 percent (or worse). Although the July 2015 VA examiner noted that the Veteran did have a DLCO (SB) of 43-percent predicted, however, the July 2015 VA examiner noted that the FEV-1/FVC test results most accurately reflects the Veteran's level of disability (based on the condition that is being evaluated for this report). Finally, the Board notes that the Veteran has not had a maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit); and his sarcoidosis with asthma and COPD did not result in pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a compensable disability rating for bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters) The Veteran asserts that he is entitled to a higher disability rating. Unlisted disabilities requiring rating by analogy are coded with the first two numbers of the schedule provisions most closely related body part and 99. Here, the hyphenated diagnostic code indicates that the Veteran's bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters) is currently rated as analogous to a diseases of the eye (Diagnostic Code XX99) under the diseases of the eye (Diagnostic Code 6034). 38 C.F.R. § 4.79, Diagnostic Code 6034. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. In the present case, the Veteran is rated under Diagnostic Code 6099 for an unlisted disability requiring rating by analogy on the basis of Diagnostic Code 6034 for pterygium for his bilateral eye disability to include pinguecula (claimed as eye inflammation and floaters). Evaluations of defective vision from noncompensable to 100 percent based on organic impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. §§ 4.76(a), 4.79. The examination for visual impairment must be conducted by a licensed optometrist or by a licensed ophthalmologist and the examiner must identify the disease, injury, or any other pathologic found. 38 C.F.R. § 4.76(b). Examination of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Id. Unless medically contraindicated, the fundus must be examined with the Veteran's pupils dilated. Id. Unless otherwise directed, evaluate diseases of the eye under the General Rating Formula for Diseases of the Eye. 38 C.F.R. § 4.79, Diagnostic Codes 6000 through 6009. Impairment of Visual Acuity is rated under Diagnostic Codes 6061 through 6066. Examinations of visual acuity must include the central uncorrected and corrected visual acuity for distance and near vision using Snellen's test type or its equivalent. 38 C.F.R. § 4.76(a). Evaluation of central visual acuity on the basis of corrected distance vision with central fixation, even if a central scotoma is present. 38 C.F.R. § 4.76(b). However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, evaluate the visual acuity of the poorer eye using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. Id. A February 2020 VA examination reveals that the Veteran had bilateral dry eye syndrome, bilateral (pre-operative) age-related cataracts (causing blur and glare), bilateral vitreous degeneration (causing occasional blur or floaters in vision), and bilateral pinguecula. The Board notes that the Veteran is only service connected for bilateral pinguecula (claimed as eye inflammation and floaters). Therefore, any visual impairments caused by the non-serviceconnected disabilities are not applicable in rating the Veteran's disability. 02.20.2020 Uncorrected Distance Corrected Distance Uncorrected Near Corrected Near RIGHT 20/70 20/20 20/40 20/40 LEFT 20/40 20/40 20/50 20/40 The February 2020 VA examination also revealed that the Veteran did not have a documented visual field defect. Furthermore, the February 2020 VA examiner noted that the Veteran's pinguecula is not in the Veteran's line of sight. However, the Veteran reports constant decrease in vision that does not improve with blinking or artificial tears. The Board notes that even without accounting for the impairment of visual acuity of only the service-connected eye disabilities (of which there appears to be none), based on the evidence above, a compensable disability rating for the Veteran's loss of visual acuity is not warranted and therefore the Board finds that a remand for clarification is not required. The Veteran's visual acuity of 20/20 corrected distance of the right eye and 20/40 corrected distance of the left eye warrants a noncompensable disability rating. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable disability rating for a loss of visual acuity. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of the disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). Additionally, disabilities, including those arising from a single disease entity, are generally rated separately before ratings are then combined in accordance with 38 C.F.R. § 4.25. However, VA is prohibited from pyramiding (rating the same disability, or the same manifestation of a disability, under different diagnostic codes). 38 C.F.R. § 4.14. When disabilities have duplicative or overlapping symptoms, the rule against pyramiding prohibits VA from compensating the Veteran more than once for the same symptom or impairment. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017). 5. Entitlement to service connection for right elbow disability, to include as secondary to service-connected acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy The Veteran asserts that his right elbow disability is related to his service-connected acromioclavicular arthritis of the right shoulder with rotator cuff tear, status post shoulder arthroscopy. Affording the Veteran the benefit of the doubt, the Board finds that there is evidence of a current disability (reports of pain) at some point during the period on appeal. See Wallin, 11 Vet. App. 509, 512 (1998); see Holton, 557 F.3d at 1366; see also Allen, supra; 38 C.F.R. § 3.303(d). The Veteran was afforded a VA examination in February 2020. During the February 2020 VA examination, in response to the inquiry about the Veteran's right elbow symptoms by the February 2020 VA examiner, the Veteran did not report any symptoms. In contrast, the Veteran reported only his right shoulder symptoms and advised the examiner that due to his right shoulder disability, he can claim for his right elbow as well. The Veteran is quoted as saying "VA denied me, but I did my research on it and I know I can claim elbow due to shoulder problem." See February 2020 VA examination, p. 3. Furthermore, the February 2020 VA examiner found that the Veteran's right elbow was normal without flare-ups, pain, nor limitation on range of motion. However, the Board notes that included within the Veteran's March 2012 Veteran's Supplemental Claim for Compensation (VA Form 21-526b), the Veteran asserted right elbow (joint pain). Furthermore, the record indicates that the Veteran reported right elbow pain in August 2014. See August 2014 private treatment records. Although there appears to be no disability at the time of the February 2020 VA examination, the evidence indicates that there may have been a disability at some point during the lengthy period on appeal. Therefore, affording the Veteran the benefit of the doubt, the Board finds that there is a current disability (a disability present at any point during the period on appeal). As to the second element of secondary service connection, the Board finds that there is evidence of a service-connected disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran is service connected for a right shoulder disability, specifically acromioclavicular arthritis of the right shoulder, with rotator cuff tear, status post shoulder arthroscopy. As to the final element of secondary service connection, the Board finds that there is not medical nexus evidence establishing a connection between the Veteran's service-connected disability and the current disability. The February 2020 VA examiner opined that the Veteran's right elbow disability is less likely than not (less than 50 percent probability) caused by nor aggravated beyond natural progression by the Veteran's service-connected right shoulder because there is no correlation either anatomical, pathophysiological, neuronal, nor hormonal as they are both independently functioning joints. Accordingly, entitlement to service connection on a secondary basis for right elbow disability is denied. As to direct service connection under 38 C.F.R. § 3.303, the Veteran does not claim, and the record does not show that his right elbow disability are directly due to his military service. In this regard, a review of the record on appeal does not show the Veteran being diagnosed with right elbow disability while on active duty. See 38 C.F.R. § 3.303(a). Likewise, the record does not show the Veteran had a problem with his right elbow in and since service because the record does not reflect him being diagnosed with a right elbow disability since his separation from service in 2001. See 38 C.F.R. § 3.303(b). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for left big toe disability The Veteran asserts that his left big toe disability began during service and has existed since that time and/or it is related to an in-service injury to his left big toe. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran is diagnosed with hallux rigidus of his left great toe. See November 2011 private treatment records. Second, the Board finds that there was not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran reports that in 1984, his left great toe was stepped on during an athletic event. However, the Veteran's service treatment records are silent for an injury to the Veteran's left great toe nor reports of any left great toe disability on any of the Veteran's physical evaluations. The Board notes that the Veteran's service treatment records do reflect that the Veteran reported painful left big toenail and pain on his 4th and 5th toes. See August 30, 1985 Service Treatment Records. However, the reported toenail issue is not a diagnosis of hallux rigidus of the left great toe which is a form a degenerative arthritis that causes pain and stiffness. In this regard, a review of the record on appeal does not show the Veteran being diagnosed with hallux rigidus of his left great toe while on active duty. See 38 C.F.R. § 3.303(a). Likewise, the record does not show the Veteran had a problem with hallux rigidus of his left great toe in and since service because the record does not reflect him being diagnosed with hallux rigidus of his left great toe until 2011; over 10 years after service. See 38 C.F.R. § 3.303(b). The Board also notes that there are records of pes planus during the Veteran's active service, however the Veteran is already service connected for pes planus and therefore the issue of pes planus is not pertinent to the present claim. Thus, without more, the preponderance of the evidence is against a finding of an in-service incurrence of a left great toe disability. The second element of service connection has not been met, and an award of service connection is not warranted. See Holton, supra. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to service connection for right wrist disability 8. Entitlement to service connection for left wrist disability Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that his arthritis of his bilateral wrists began during service and has existed since that time. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran is diagnosed with bilateral osteoarthritis of the wrists. See February 2020 VA examination, p. 2. Second, affording the Veteran the benefit of the doubt, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran reported that he fell during a track meet in 1985 (during active duty), however the Veteran's service treatment records are silent for any wrist injury beyond the report of pain over the past two weeks shortly before his retirement. See August 2000 Rheumatology Consultation (Standard Form 600). Third, the Board finds that the evidence of record does not support a finding that the Veteran's bilateral wrist osteoarthritis is related to active service. The February 2020 VA examiner opined that the Veteran's bilateral wrist disabilities are less likely than not (less than 50 percent probability) to have incurred during his active service because there is no evidence of chronicity, residuals, nor recurrence. Accordingly, entitlement to service connection for bilateral wrist disabilities is denied. Furthermore, the Board notes that because the Veteran did not have a diagnosis of osteoarthritis of his bilateral wrists within 1-year of his retirement, the presumption of service connection is not applicable. 38 C.F.R. §§ 3.307, 3.309. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 9. Entitlement to service connection for knee scars The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. In the present case, before the Board promulgated a decision, the RO granted the Veteran's claim for entitlement to service connection for a surgical scar of the right knee and entitlement to service connection for a surgical scar of the left knee and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. 10. Entitlement to service connection for a low back disability, to include as secondary to service-connected degenerative joint disease of the cervical spine The Veteran asserts that his low back disability began during service and has existed since that time. Alternatively, the Veteran asserts that his low back disability is associated with his service-connected degenerative joint disease of the cervical spine with IVDS. First, the Board finds that there is evidence of a current disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran's private treatment records from North State Imaging dated August 28, 2014 reflect that the lumbar alignment is maintained without evidence of spondylolisthesis, no compression fracture deformity or significant disc space narrowing, and the distal facet hypotrophy is present with intact sacroiliac joints. The Veteran was afforded a VA examination in February 2020 in which he was diagnosed with degenerative arthritis of the spine (2012) and spinal stenosis (2018). See February 2020 VA examination. Second, the Board finds that there is evidence of a service-connected disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran is service connected for degenerative joint disease of the cervical spine with IVDS, previously rated as mild degenerative joint disease of the cervical spine (claimed as pinched nerve). Third, the Board finds that there is not medical nexus evidence establishing a connection between the Veteran's service-connected disability and the current disability. The February 2020 VA examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's low back disability is due to or aggravated beyond its natural progression by the Veteran's degenerative joint disease of the cervical spine with IVDS because there is not anatomical, pathological, hormonal, or neuronal correlation of causation due to the Veteran's mild degenerative joint disease of the cervical spine with IVDS. Accordingly, entitlement to service connection on a secondary basis for low back disability is denied. As to direct service connection under 38 C.F.R. § 3.303, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). On June 15, 1982, the Veteran was treated for acute back pain after he fell against a large metal cargo hatch. The Board finds that the evidence of record does not support a finding that the Veteran's degenerative arthritis of the spine nor his spinal stenosis are related to active service. The February 2020 VA examiner opined that it is less likely than not (less than 50 percent probability) that his lumbar spine disabilities are related to his service because the 1982 back acute pain/injury was treated and resolved until 30 years later, now showing mild facet degenerative change in L4-5 and L5-S1 and are unrelated to service because there is no chronicity or residuals since the June 15, 1982 injury was resolved. Accordingly, entitlement to service connection for low back disability is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 11. Entitlement to service connection for fibromyalgia (also claimed as joint pain, polyarthritis) 12. Entitlement to service connection for chronic fatigue syndrome 13. Entitlement to service connection for a respiratory disability, to include chronic bronchitis and/or tuberculosis Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that he is entitled to service connection for fibromyalgia (also claimed as joint pain, polyarthritis); chronic fatigue syndrome; and chronic bronchitis and/or tuberculosis. The Veteran asserts "with all my joint aches and pains, I should be service connected for fibromyalgia." See February 2020 Fibromyalgia Disability Benefits Questionnaire, p. 2. As for chronic fatigue syndrome, the Veteran asserts that because he has sleep apnea, that entitles him to service connection for chronic fatigue syndrome. See February 2020 Chronic Fatigue Syndrome Disability Benefits Questionnaire, p. 2. The Board finds that there is not evidence of a current disability of either fibromyalgia, chronic fatigue syndrome, nor tubereculosis. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen v. Brown, 8 Vet. App. 374 (1995). The Veteran was afforded VA examinations in February 2020. The February 2020 VA examiner found that the Veteran does not currently have, nor has he ever had, a diagnosis of either fibromyalgia nor chronic fatigue syndrome. See February 2020 Fibromyalgia Disability Benefits Questionnaire, p. 2; see also February 2020 Chronic Fatigue Syndrome Disability Benefits Questionnaire, p. 2. Finally, the February 2020 Tuberculosis Disability Benefits Questionnaire reflects that the Veteran was diagnosed and treated for tuberculosis in 1986 for six months and the condition resolved without any further treatment, nor residual findings. See February 2020 Tuberculosis VA examination. However, the Board notes that the April VA examiner noted that imaging studies have been performed and the chest x-ray noted COPD changes with no acute pathology, and diagnosed the Veteran with asthma. See February 2020 Tuberculosis VA examination; see also February 2020 Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) VA examination. Finally, the Board notes that the Veteran is already service connected for COPD and asthma. In the absence of a disability (that isn't already service connected for) during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea (also claimed as insomnia) is remanded. The Veteran was afforded a VA examination in February 2020. The February 2020 VA examiner opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) due to the Veteran's service because "VA files show no evidence of signs/symptoms during service." However, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for sleep apnea (also claimed as insomnia) because no VA examiner has opined whether the symptoms described by January 2020 buddy statements (received after the February 2020 VA examination, on July 20, 2020) from the Veteran's spouse and a Major that shared quarters with the Veteran were symptoms of sleep apnea. Additionally, the Board notes that disabilities, including those arising from a single disease entity, are generally rated separately before ratings are then combined in accordance with 38 C.F.R. § 4.25. However, VA is prohibited from pyramiding (rating the same disability, or the same manifestation of a disability, under different diagnostic codes). 38 C.F.R. § 4.14. When disabilities have duplicative or overlapping symptoms, the rule against pyramiding prohibits VA from compensating the Veteran more than once for the same symptom or impairment. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017). 2. Entitlement to service connection for right ankle disability is remanded. 3. Entitlement to service connection for left ankle disability is remanded. Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for the Veteran's bilateral ankle disabilities because at the time of the February 2020 VA examination, the examiner found that the Veteran did not have a current disability. However, the record indicates that the Veteran's private treatment records reflect that although there is no evidence of acute fracture or dislocation, the mortise is intact with each ankle on these nonstressed views; however degenerative changes are present with plantar calcaneal spur noted on the left and focal plantar soft tissue in the region of the calcaneus is unchanged and vascular calcification is also prsent. However, no opinion was provided as to the nature and etiology of the Veteran's bilateral ankle disabilities (that appear to have resolved during the period on appeal) if the disabilities are related to the Veteran's active military service, or were permanantly aggravated beyond their natural progression from the Veteran's bilateral ankle injuries in high school. Therefore, remand is required. 4. Entitlement to service connection for right hip disability is remanded. 5. Entitlement to service connection for left hip disability is remanded. The Veteran was afforded a VA examination in February 2020. The February 2020 VA examiner opined that the Veteran's bilateral hip disability is less likely than not (less than 50 percent probability) due to service because he reported subjective bilateral hip pain in February 2020 with no evidence of a fall, injury, trauma, or chronicity from service. However, the February 2020 VA examiner did not address the September 2000 in-service note "osteoarthritis SI joints..." from his separation evaluation nor the results from the rheumatology evaluation(s), if any. Specifically, the Board must know if the osteoarthritis of the SI joints began during service. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's sleep apnea disability (also claimed as insomnia) is at least as likely as not (50 percent probability or greater) related to his active service, to include but not limited to having its onset during active service. The examiner must specifically address the fact that the Veteran's service-connected posttraumatic stress disorder includes service-connection for circadian sleep disorder and recognize that VA is prohibited from rating the same disability, or the same manifestation of a disability, under different diagnostic codes (pyramiding is prohibited). 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's bilateral ankle disabilities from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral ankle disabilities had onset in, or is otherwise related to, active service. The examiner must specifically address if the disabilities are related to the Veteran's active military service, or were permanently aggravated beyond their natural progression from the Veteran's bilateral ankle injuries in high school. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's bilateral hip disabilities from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral hip disability had onset in, or is otherwise related to, active service. The examiner must specifically address the Veteran's service treatment records that indicate possible osteoarthritis in his bilateral hips. R.R. WATKINS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Deemer, 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.