Citation Nr: 22010752 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 16-45 443 DATE: February 24, 2022 ORDER Entitlement to a rating of 20 percent, but no higher, for left shoulder strain, arthritis, and rotator cuff tendonitis (left shoulder disability) for the period prior to December 20, 2020, is granted. Entitlement to a rating in excess of 20 percent for left shoulder strain, arthritis, and rotator cuff tendonitis (left shoulder disability) from December 20, 2020, is denied. Entitlement to service connection for a psychiatric disorder is denied. FINDINGS OF FACT 1. Throughout the appeal period, the most probative evidence reflects that the Veteran's left shoulder disability was manifested, at worst, by flexion of the minor extremity limited to 90 degrees and abduction limited to 100 degrees. 2. The Veteran does not have a psychiatric disorder related to service or service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating of 20 percent, but no higher, for the period prior to December 20, 2020, for left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 2. The criteria for a rating in excess of 20 percent for left shoulder disability for the period from December 20, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 3. The criteria for service connection for a psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1975 to June 1979. The Board sincerely thanks the Veteran for his service to our country. This matter comes before the Board of Veterans' Appeals (Board) from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Veteran testified at a Travel Board Hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. These claims were previously before the Board in September 2019, when they were remanded for additional development. The Board finds that there has been substantial compliance with its remand directives. Entitlement to an initial staged rating in excess of 10 percent for the period prior to December 20, 2020, and in excess of 20 percent thereafter, for left shoulder disability The Veteran contends that he is entitled to an initial rating in excess of 10 percent disabling for his service-connected left shoulder disability, asserting that the impairment is more severe than the assigned rating reflects. This claim arises on appeal from the initial rating determination accompanying the original grant of service connection for the left shoulder disability. Accordingly, the rating period for consideration in this matter begins with the May 14, 2013, effective date of the award of service connection for the left shoulder disability. An interim July 2021 rating decision granted a 20 percent rating for the Veteran's left shoulder disability from December 20, 2020. During the pendency of the instant appeal, VA promulgated new regulations governing ratings for musculoskeletal system and muscle disabilities, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. The Veteran's left shoulder disability is rated under Diagnostic Code 5003-5201, for degenerative arthritis manifested by limitation of motion of the arm. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200, etc.). 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level (identified in the amended regulations as flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating, whether involving the major or the minor extremity. Limitation of motion of the arm midway between side and shoulder (identified in the amended regulations as flexion and/or abduction limited to 45 degrees) 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 (clarified in the amended regulations as flexion and/or abduction) 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. The normal range of motion of the shoulder is forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. Id., Plate I. The language of the former version of 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 revised VA regulations, effective February 7, 2021, clarify that limitation of motion of the arm under Diagnostic Code 5201 includes either flexion or abduction. The revised regulations also clarify that "shoulder level" equates to flexion and/or abduction limited to 90 degrees, "midway between side and shoulder level" equates to flexion and/or abduction limited to 45 degrees, and "[t]o 25 degrees from side" equates to flexion and/or abduction limited to 25 degrees from side. Disability ratings are determined by comparing a Veteran's symptomatology during the pertinent period on appeal with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive, as in this case. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran's disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. 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 directly 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."). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pain, in and of itself, that does not result in additional functional loss does not warrant a higher rating; the Court held that pain alone does not constitute functional loss but is just one factor to be considered when evaluating functional impairment. Id. VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). It is the intention of the VA rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. 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 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. 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 Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. At the February 2019 hearing before the undersigned, the Veteran reported that pain from his left shoulder disability prevents him from woodworking, or otherwise working with his hands, for extended periods. An October 2014 VA examination report documents that the Veteran reported that he always experiences pain with range of motion and grinding in the left shoulder joint with range of motion. The Veteran also reported decreased range of motion and increased with repetitive motions over time. The examiner stated that the Veteran experiences pain with range of motion and cannot lift more than 10 lbs. above 90 degrees with the left arm. He reported weekly moderate flare-ups lasting 4 hours. The examiner described that during flare-ups, the Veteran's flexion and abduction are each limited to 100 degrees, and internal and external rotation to 50 degrees. As discussed in the September 2019 Board remand, the October 2014 VA examination report does not comply with Correia standards. The Board notes that the Veteran has undergone a more recent VA examination of his shoulder disability for VA rating purposes. The December 2020 VA examination report shows the Veteran reported constant low-grade pain with lifting or reaching. The Veteran described an inability to lift 5 lbs. with the left arm. The Veteran's shoulder disability was clinically observed to have flexion to 90 degrees, abduction to 110 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees, meeting the criteria for a 20 percent rating. The Board finds the Veteran's October 2014 report that he was unable to lift 10 lbs. above 90 degrees and the examiner's estimation that flare-ups limit flexion and abduction to 100 degrees reasonably comparable to the December 2020 VA examination report that the Veteran was unable to lift 5 lbs. above his head and flexion and abduction were similarly limited to 90 and 100 degrees, respectively, and this shows clinical observation of functional impairment statistically similar in October 2014 and December 2020. The Board observes that the Veteran has not asserted worsening of his left shoulder disability during the period on appeal, rather he has asserted that the initial rating did not correctly reflect the symptoms of his disability. Resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence from the earlier portion of the appeal period is consistent with the December 2020 VA examination. The Board furthermore finds that there is no significantly contrary indication regarding the severity of the Veteran's shoulder condition disability between the October 2014 and December 2020 VA examination reports. Furthermore, as the Veteran's left shoulder symptoms were manifested by limitation of motion that was painful, such warrants a 20 percent rating for his service-connected left shoulder disability, but no higher, as painful motion is entitled to at least the minimum compensable rating for a joint under the applicable Diagnostic Code. Burton, 25 Vet. App. at 4; Sowers v. McDonald, 27 Vet. App. 472, 481-82 (2016) (noting that while there is a 10 percent rating available for the shoulder across all diagnostic codes, a 20 percent rating is the minimum compensable rating for the shoulder for limitation of motion). The Board finds that the award of 20 percent rating is warranted for the period prior to December 20, 2020. The Board concludes that the evidence is persuasively against a finding that the Veteran's symptoms warrant a rating in excess of 20 percent for his left shoulder disability at any time during the appeal. As discussed above, the October 2014 VA examiner documented the Veteran had flexion to 100 degrees, abduction to 100 degrees, external rotation to 50 degrees, and internal rotation to 50 degrees, while the December 2020 examiner documented the Veteran had flexion to 90 degrees, abduction to 110 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. These findings do not more nearly approximate limitation of motion of the arm midway between side and shoulder level of the major extremity or limitation of motion of the arm to 25 degrees from the side of the major extremity. Regarding the period from December 20, 2020, the Board finds that the evidence is persuasively against a rating in excess of 20 percent for the Veteran's left shoulder disability. The Board acknowledges the Veteran's lay reports of symptoms and that there is functional loss due to pain, to include preventing him from extended use of the hands, working with his hands, and woodworking. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level of the minor extremity or limitation of motion of the arm to 25 degrees from the side of the minor extremity. The evidence of record, to include the December 2020 VA examination report, demonstrates that the Veteran's right hand is dominant, so the rating addresses the minor shoulder. As discussed above, under the prior version of Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating, limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity, and limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The revised VA regulations, effective February 7, 2021, clarify that limitation of motion of the arm under Diagnostic Code 5201 includes either flexion or abduction. In this regard, the December 2020 VA examiner documented that the Veteran's left shoulder disability, at worst, results in flexion to 90 degrees, abduction to 110 degrees, external rotation to 90 degrees and internal rotation to 90 degrees. These findings do not support a higher rating under the old or new criteria for Diagnostic Code 5201, nor do the Veteran's clinical treatment records associated with the claims file. In sum, a rating of 20 percent disabling, but no higher, for the Veteran's left shoulder disability is warranted for the period prior to December 20, 2020. However, the evidence is persuasively against a rating in excess of 20 percent at any time during the appeal. Entitlement to service connection for a psychiatric disability is denied. The Veteran contends that he has PTSD due to witnessing the death by suicide of 5 refugees at Camp Horno in 1975 or 1976, and hearing the shot that resulted in the death by suicide of a fellow Marine in 1978 up on a hill some distance away. See October 2015 Notice of Disagreement; February 2019 Hearing Transcript, p.22. In his report to the clinician at the time of the June 2021 VA examination, the Veteran stated that when they looked up on the hill "we . . . saw his rifle towards his midsection. Next, we heard a gunshot and he fell to the ground. I am not sure that he died, but I never saw him again." The Board has expanded the characterization of the disability to include any psychiatric disability. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303; see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition to the general criteria for service connection, service connection for PTSD requires: (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a), i.e., a diagnosis conforming to specified diagnostic criteria (currently the DSM-5, previously the DSM-IV); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). Alternatively, a veteran can receive compensation via secondary service connection, which can be established when a disability is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. To be awarded secondary service connection, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson reports a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. In fact, competent medical evidence is not necessarily required when the determinative issue involves medical etiology or a medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Where, however, VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy, but the claimed stressor is unrelated to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the reported stressor. Instead, the record must contain evidence that corroborates the veteran's testimony as to the occurrence of the claimed stressor. Fear of hostile military or terrorist activity may constitute a valid stressor, if (1) a psychologist or psychiatrist confirms that the claimed stressor is adequate to support a diagnosis of PTSD; (2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; and (3) the Veteran's symptoms are related to the claimed stressor. See 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304(d), (f). The Veteran's claimed stressor is not specifically related to fear of hostile military or terrorist activity. It is not in dispute that the Veteran has a current diagnosis of PTSD. See June 2021 VA examination report. In a June 2021 VA examination report, the examiner diagnosed the Veteran with PTSD, pedophilic disorder, alcohol use disorder, and stimulant use disorder in sustained remission. The examiner did not diagnose the Veteran with depression or anxiety, explaining that his prior diagnoses are better described as a symptom of his PTSD. Regarding the diagnosis of alcohol use disorder, the examiner stated that it is not possible to differentiate the symptoms attributable to the Veteran's PTSD and alcohol use disorder because they are co-morbid, frequently occurring together with significant overlap of symptoms. Regarding the Veteran's diagnoses of pedophilic disorder and stimulant use disorder, the examiner explained that they are in sustained remission, thus there are no symptoms attributable to these diagnoses. The June 2021 examiner noted that the Veteran's reported stressors involving the refugees and the Marine on the hill were adequate to support the diagnosis of PTSD and opined that the Veteran's PTSD is at least as likely as not related to his reported in-service stressors. However, with respect to the incident involving the Marine on the hill, further development could not be provided as the Veteran did not know the Marine's name and has reported variously that the Marine died by suicide and also that he did not know what happened to the Marine. Further development to corroborate the Veteran's stressor statements regarding the incident involving the refugees was undertaken, and VA has been unable to verify the Veteran's claimed stressor. This is evidenced by a June 2021 response to a VA request for information, stating that command chronologies dated July 1, 1975, to June 30, 1976, were reviewed in an attempt to substantiate the Veteran's stressor event, but no evidence was located to support documentation of the claimed stressor event. Although PTSD has been reported, the question of whether the Veteran was exposed to a stressor in-service is a factual determination. The law requires that non-combat stressors such as those the Veteran describes must be corroborated. Here, there is no evidence of corroboration of any stressor. Therefore, the claim of service connection for PTSD is denied. The June 2021 VA examiner additionally opined as to whether the Veteran's psychiatric disorder is caused or aggravated by the Veteran's service-connected left shoulder, left ear hearing loss, and/or tinnitus. The examiner provided a negative nexus opinion as to causation, reasoning that the Veteran's psychiatric disability is PTSD with symptoms of depression and anxiety and there is no evidence that his service-connected diagnoses caused his PTSD. The examiner noted, however, that there is evidence that chronic pain can cause and/or increase depression and anxiety and the Veteran's records document this as well as medications he is on for his chronic pain. The examiner observed that a May 2014 treatment note includes the comment, "...his chronic pain has contributed to his depression...," and reasoned that the term "contributed" means that there is already a condition rather than being the sole cause. The examiner further reasoned that it is common for individuals with symptoms of depression that have life stressors to have an increase in their depression but that does not mean that the added stressors are the cause of the depression and reiterated that the Veteran's depression and anxiety are a symptom of his depression. The June 2021 VA examiner opined that it is at least as likely as not that the Veteran's psychiatric disability is aggravated by the Veteran's service-connected left shoulder, left ear hearing loss, and/or tinnitus disabilities. She reasoned that, although the formal diagnosis is PTSD, the symptoms of depression and anxiety are prone to increase and decrease with life stressors. The examiner further reasoned that it could take years before symptoms of PTSD and chronic pain develop to the point that the degree of depression and anxiety require medication, and that tinnitus and hearing loss have also been associated with depression and anxiety due to the duration of the problems. However, the examiner was unable to quantify the degree of aggravation of the Veteran's PTSD and associate symptoms, other than to state that his medication appeared to be managing his symptoms of depression and anxiety prior to the above-noted May 2014 treatment record. The examiner indicated that the baseline would be prior to the initial session with the nurse practitioner in January 2012. Th examiner noted that prior to May 2014 records from the nurse practitioner, there was no mention of a connection between the PTSD symptoms of depression and anxiety and his chronic pain. The Board notes that 38 C.F.R. § 3.310(b) contemplates a baseline to assess the severity of a nonservice-connected disability that is aggravated by a service-connected disability. The evidence of record does not establish a precise pre-aggravation baseline level of severity of PTSD in this case. The June 2021 medical opinion in essence found that a baseline level of severity could not be established by medical evidence created before the onset of aggravation as there was no mention of a connection prior to May 2014 and medication was managing symptoms of anxiety and depression. As a baseline has not been established, service connection on a secondary aggravation basis is not warranted. The sole diagnosis noted by the VA examiner in this case was PTSD, and symptoms of anxiety and depression, as well as co-morbid alcohol use disorder, have been linked to that diagnosis. The Board notes that VA treatment records reflect that major depressive disorder and dysthymic disorder was also diagnosed and anxiety was noted. An August 22, 2014 VA psychology note diagnosed major depressive disorder and found variation in the reports regarding nightmares and when his depression started. The provider noted that the Veteran reported in April 2014 that his depression started after being in the Marines but that he told a nurse practitioner that his depression started after high school. Regardless of the characterization of the Veteran's mental health disorder, the 2021 opinion explained that anxiety and depression were not caused by a service-connected disability and were not aggravated by a service-connected disability as a baseline level of severity could not be established by medical evidence created before the onset of aggravation. Further development is not warranted with respect to any depressive disorder as the medical records reflect that the Veteran's statements as to when his depression started and with respect to the stressor regarding the Marine were inconsistent and thus, the Board finds his statements lack credibility. Accordingly, the Board does not find that the evidence indicates a connection between any other diagnosed psychiatric disability and service so as to warrant further development. This decision is in no way meant to diminish the Veteran's service to our country. However, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for PTSD is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O. Halpern 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.