Service connection for left knee disability is granted.

Citation Nr: A26069909 Decision Date: 07/30/26 Archive Date: 07/30/26 DOCKET NO. 260212-642125 DATE: July 30, 2026 ORDER Service connection for left knee disability is granted. Service connection for bilateral hearing loss is granted. Service connection for psychiatric disability, diagnosed as posttraumatic stress disorder (PTSD) and insomnia, is granted. A 20 percent rating for right knee disability, based on limitation of motion, is granted. A 10 percent rating for allergic rhinitis is granted. A 10 percent rating for hemorrhoids is granted. A compensable rating for acne is denied. FINDINGS OF FACT 1. The evidence favors a finding that the Veteran's left knee disability is proximately due to his service-connected right knee disability. 2. The Veteran's bilateral hearing loss had its onset in service. 3. The Veteran's psychiatric disability had its onset in service. 4. Considering the Veteran's pain and corresponding functional impairment, the Veteran's right knee disability is manifested by, at most, flexion functionally limited to 30 degrees. 5. The Veteran's service-connected allergic rhinitis more nearly approximates rhinitis with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. 6. The Veteran's hemorrhoids are manifested by external hemorrhoids with three or more episodes per year of thrombosis. 7. The Veteran's acne has not been manifested by deep inflamed nodules and pus-filled cysts, or one characteristic of disfigurement. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee disability have been met. 38 U.S.C. §§ 1110, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385. 3. The criteria for service connection for psychiatric disability have been met. 38 U.S.C. §§ 1110, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309. 4. The criteria for a 20 percent rating for right knee disability have been met. 38 U.S.C. §§ 1154(a),1155, 5107(b); 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.49, 4.71a, Diagnostic Codes 5260-5261. 5. The criteria for a 10 percent rating for allergic rhinitis have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.7, 4.97, Diagnostic Code 6522. 6. The criteria for a 10 percent rating for hemorrhoids have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7336. 7. The criteria for a compensable rating for acne have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800, 7828. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from September 2001 to October 2023, including service in Iraq from April 2003 to May 2004, from October 2007 to January 2008 and from July 2010 to January 2011. The Veteran also served in the United Arab Emirates from June to December 2012 and in Qatar in December 2012. This matter is before the Board of Veterans' Appeals (Board) on appeal from two separate Appeals Modernization Act (AMA) rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) -an April 2024 rating decision as to the issues of service connection for hearing loss, psychiatric disability, and left knee disability, a May 2024 rating decision as to the issue of compensable rating for allergic rhinitis, and a June 2024 rating decision as to the issues of increased ratings for right knee disability, hemorrhoids, and acne. The rating decisions were then subject to a higher-level review in June 2025. In the February 2026 VA Form 10182 (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the respective agency of original jurisdiction (AOJ) decision. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decisions, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. Additionally, the Board recognizes that the Veteran initially claimed service connection for a stress disorder. The Veteran's claim for psychiatric disability has been characterized broadly consistent with Clemons v. Shinseki, 23 Vet. App. 1,5 (2009). As a final preliminary matter, the record indicates the Veteran was able to work during the period on appeal. See May 2024 VA examination. Therefore, a claim of total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is not currently before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection on a secondary basis is warranted for any incremental increase in disability, regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Secondary service connection may be granted where a non-service-connected disability would have been less severe but for a service-connected disability. Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection). The Board notes that this broad language applies to the natural progression of a condition not caused by a service-connected injury or disease, but that, nonetheless, would have been less severe were it not for the service-connected disability. Stated another way, § 1110 provides for compensation for a worsening of functionality-whether through an inability to treat or a more direct, etiological cause. The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that nothing in the statute limits § 1110 to onset or etiological causes of a worsening in functionality. Thus, the Court in Spicer found the phrase "proximately due to" under 3.310(b) inconsistent with § 1110 and, therefore "unlawful," consequently, for "aggravation of non-service-connected disabilities" it is enough to show that "but for" the service-connected disability the incremental-increase in severity of a nonservice-connected disease or injury would not have occurred. Id. Finally, the Federal Circuit further held that 38 C.F.R. § 3.310(b), which addresses the aggravation prong of secondary service connection, was inconsistent with 38 U.S.C. § 1110 and was therefore unlawful to the extent that VA applied it to reject the Veteran's theory of compensation. Spicer, 61 F.4th at 1366. Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). The Board also notes that under certain circumstances, lay evidence may be sufficient to establish a nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay evidence has been found to be competent regarding a disease that has "unique and readily identifiable features" that are "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). When the evidence is in approximate balance in the Veteran's favor or nearly equal regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). 1. Service connection for left knee disability is denied. The Veteran seeks service connection for left knee disability, which he contends started in service over the course of his twenty-year career. See May 2023 VA Form 21-526EZ, Fully Developed Claim (Compensation). Alternatively, the Veteran maintains that his left knee disability is due to overcompensating for his service-connected right knee disability. In February 2026 written argument, the Veteran's attorney argued that the RO improperly denied service connection for left knee disability based on a lack of diagnosis but that the RO failed to address the Veteran's statements that he feels grinding and popping when he moves his left knee, received treatment in service for bilateral knee pain, and an MRI showed a slight tear in his meniscus. Here, in the June 2023 VA examination, the VA examiner stated that they found no evidence of a left knee condition on the examination. However, in Saunders v. Wilkie, the United States Court of Appeals for the Federal Circuit held that "pain in the absence of a presently diagnosed condition can cause functional impairment," which may qualify as a "disability" for VA compensation purposes. Saunders, 886 F.3d 1356, 1368 (Fed. Cir. 2018). The Federal Circuit in Saunders, however, cautioned against the notion that "a veteran could demonstrate service connection simply by asserting subjective pain" because, to establish that a disability is present, the veteran "will need to show that... pain reaches the level of a functional impairment of earning capacity." Id. at 1367-68. "Functional impairment," the Federal Circuit noted, is defined as the inability of the body or a constituent part of it "to function under the ordinary conditions of daily life including employment." Id. at 1363 (quoting 38 C.F.R. § 4.10). In addition, citing Saunders, the United States Court of Appeals for Veterans Claims (Court) held in Wait v. Wilkie, 33 Vet. App. 8, 17 (2020) that "to establish the presence of a disability pursuant to Saunders, there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." In this case, the Board finds that the above criteria, what can be considered to be a disability for VA purposes, has been met. In a February 2024 Statement, the Veteran stated the discomfort in his left knee is due to overcompensating for his right knee. The Veteran reported having an MRI, which showed a slight tear in his meniscus, and has continuous pain and sensations of knee popping. These symptoms indicate a functional impairment similar to the severity, frequency, and duration that would cause impaired earning capacity. As noted above, the Veteran is already service connected for his right knee disability. Thus, the remaining question for the Board is whether the Veteran's left knee strain is proximately due to or the result of or aggravated beyond its natural progress by his service-connected right knee disability. The Board finds that the Veteran's consistent lay statements constitute competent and credible evidence that the Veteran's left knee pain is due to his service-connected right knee disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr, 21 Vet. App. at 310; 38 C.F.R. § 3.159 (a)(2). In reaching this determination, the Board notes that the Veteran has consistently reported that he has overused and overexerted his left knee to compensate for his right knee injury, pain, and decreased functionality, and the Board finds that he is competent and credible to report having left knee problems due to the severity of his service-connected right knee disability, which the Board observes is now evaluated as 20 percent disabling, which will be discussed further below. The Veteran, in his lay capacity, has reported that he has had to rely on and overuse his left knee since his right knee reconstruction, and that, due to overcompensation, he experiences pain when moving his left knee and experiences popping. The Board has considered and weighed the evidence of record. The competent and credible evidence is at least approximately balanced in favor of the Veteran, and benefit of the doubt doctrine applies. 38 U.S.C. § 5107 (b); see Lynch, 21 F.4th 776. In light of the foregoing, as functional impairment of the left knee has been shown, the Board finds that Veteran's left knee disability is caused by his service-connected right knee disability. As such, the last prong of secondary service connection is met. As such, after resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for left knee disability due to the Veteran's service-connected right knee disability is warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Service connection for bilateral hearing loss is granted. The Veteran seeks service connection for bilateral hearing loss. First, the Veteran contends that his hearing loss had its onset in the Air Force and has continued since service. 38 C.F.R. § 3.303(a). Second, he asserts that his hearing loss, diagnosed after discharge, should be service connected because the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the February 2026 brief, the Veteran's attorney stated that the Veteran is entitled to a new VA examination, as the VA examiner failed to consider the Veteran's statements that he has difficulty hearing, particularly with speech discrimination. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even if a disability is not demonstrated at separation, a Veteran may establish service connection for a current hearing disability by submitting evidence that a current disability is causally related to service. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). Here, as explained below, the Board finds that all three elements of service connection are established by the competent and credible lay and medical evidence of record as to bilateral hearing loss. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Shedden, 381 F.3d at 1166-67. As the Board is granting service connection on a direct basis, no other theories of service connection will be discussed. As an initial matter, in the June 2025 rating decision, the RO made the following favorable finding - the RO favorably found that the evidence shows that a qualifying event, injury, or disease had its onset during your service. The Veteran's military occupational specialty was as an All-Source Intelligence Analyst Craftsman with a low probability of noise and an Electrical Systems Craftsman with a moderate probability of noise. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). In the January 2024 VA examination, the VA examiner found that the Veteran had normal hearing in both ears. Puretone thresholds, in decibels, are as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 20 25 LEFT 20 20 15 20 25 The examiner, however, noted that speech recognition ability using the Maryland CNC test was 90 percent in the right ear and 86 percent in the left ear. The examiner did not opine as to the etiology of the Veteran's hearing loss. The Board finds that the competent and credible evidence of record shows that the Veteran's current bilateral hearing loss began during service and has been recurrent since that time. Moreover, the VA examination was conducted within a year of the Veteran's October 2023 discharge from active duty and shows that he had bilateral hearing loss for VA compensation purposes. 38 C.F.R. § 3.385. Accordingly, presumptive service connection for bilateral hearing loss is warranted. 3. Service connection for psychiatric disability is granted. The Veteran seeks service connection for psychiatric disability, which he contends is due to his service in Iraq and subsequent role as an intelligent analyst conducting remote aircraft missions, in which he saw death after missile strikes and mass graves. See February 2024 Statement. In the February 2026 brief, the Veteran's attorney echoed the Veteran's contentions and argued that the June 2023 VA examination was inadequate, as it focused on the Veteran's upbringing, childhood, and family dynamics, as opposed to his deployments. First, the Board finds that the Veteran has a current diagnosis - February and July 2025 VA Medical Center (VAMC) records show that a VA clinical psychologist diagnosed the Veteran as having PTSD following military combat and insomnia. Next, the Board notes that the Veteran received in-service mental health counseling for intrusive symptoms and memories related to drone missions and his deployments. See March, April, and June 2023 STRs. The Veteran was diagnosed as having reaction to severe stress, unspecified, prior to his retirement from service. Id. As noted above, the Veteran served in Iraq from April 2003 to May 2004, October 2007 to January 2008, and July 2010 to January 2011, and the United Arab Emirates from June 2012 to December 2012. In the June 2023 VA examination, the VA examiner opined that the Veteran did not have a current psychiatric disability. The examiner, however, failed to consider the Veteran's entire medical history, to include that the Veteran was diagnosed with reaction to severe stress, unspecified, in service. See March 2023 STR; see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). The Board notes that under the AMA, the February 2025 and July 2025 VAMC records would not normally be considered within the evidence under consideration, as it was documented withing VAMC records submitted in July 2025. However, the AMA evidence submission windows are claim-processing rules that may be waived. Bolds v. McDonough, 37 Vet. App. 359, 365-66 (2024) ("section 7113(b)'s and § 20.302(a)'s evidence submission limits are claims-processing rules subject to Secretarial waiver"). Because the above diagnosis is critical to the Veteran's claim, and remand for consideration of this evidence would only serve to delay the Veteran's compensation award, the Board will waive this claims-processing rule for this particular decision. In light of the foregoing, the Board finds that service connection for psychiatric disability, diagnosed as PTSD and insomnia, is warranted. Increased Rating Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has 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); 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). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Mitchell, 25 Vet. App. at 32; see also 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 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." 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. 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."). The Court has held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis. Burton v. Shinseki, 25 Vet. App. 1 (2011). 38 C.F.R. § 4.59 is not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. See Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). 1. A 20 percent rating for right knee disability is granted. The Veteran seeks a higher rating for his right knee disability based on any and all manifestations during the period on appeal. In a February 2024 Statement, the Veteran reported that he experiences pain and swelling during activities such as jogging, using the elliptical, or walking, that he has restricted range of motion, and that he notices a rubbing noise with any knee movement. In the February 2026 brief, the Veteran's attorney argued that the June 2023 VA examination was inadequate and that the Veteran has consistently reported flare-ups of the knee from mild use, such as walking. The Veteran's right knee disability is rated as 10 percent disabling from November 1, 2023, under Diagnostic Codes 5010-5206. Separate ratings can be assigned for knee disabilities when none of the symptoms overlap and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). In this regard, the Court has held that the rule against pyramiding does not categorically prohibit VA's assignment of separate evaluations for residuals of a meniscectomy (surgical removal of meniscal cartilage) under Diagnostic Code 5259 and lateral instability of the knee under Diagnostic Code 5257 if the veteran is assigned an evaluation under Diagnostic Code 5259 for meniscectomy symptoms that do not include lateral instability. See Walleman v. McDonough, 35 Vet. App. 294, 303-07 (2022). Indeed, following Walleman, the Court held, "[t]aken together, Lyles and Walleman direct VA, when considering the appropriate evaluation under a meniscal DC, to catalog a veteran's manifestations of a service-connected knee disability and the resulting functional impairment and assign all independently supportable knee evaluations that correspond with these manifestations." See Estevez v. McDonough, 36 Vet. App. 157, 169-170 (2023). A rating(s) for the Veteran's right knee disability should not exceed 60 percent because this would run afoul of the amputation rule under 38 C.F.R. § 4.68. See Hrvatin v. Principi, 3 Vet. App. 426, 430 (1992) (noting that any error in not awarding a higher disability rating was "harmless error" because of the "amputation rule" set out in § 4.68, which caps a disability award to the equivalent of an amputated limb). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). In addition, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board notes that the recent amendments to the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries did not alter the rating criteria for limitation of motion. See 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). Under Diagnostic Code 5260, limitation of flexion of the leg is rated 0 percent when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, knee extension limited to 5 degrees warrants a 0 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear that causes persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair, which requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. Id. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. at Note (2). As noted above, the rating schedule provides that the combined rating for disabilities of an extremity cannot exceed the rating for the amputation at the elective level were amputation to be performed. 38 C.F.R. § 4.68. The rating schedule provides that a 60 percent rating is warranted where there is amputation at the middle or lower third of thigh. See Diagnostic Code 5162. This means the left or right knee cannot be assigned a rating higher than 60 percent. The Board, as a finder of fact, finds that a 20 percent rating, but no higher, based on limitation of motion for the right knee, is warranted. In the May 2024 VA examination, the VA examiner noted the Veteran's right knee posttraumatic arthritis and right knee meniscal tear, anterior cruciate ligament tear. During the examination, the Veteran reported that he experienced dull and sharp pain, stiffness, and limited range of motion in his right knee. The Veteran further reported difficulty with prolonged sitting, walking, and climbing stairs and received orthopedic treatment and steroid injections. The examiner noted that the Veteran did not report flare-ups. Testing revealed right knee active and passive range of motion from 0 degrees to 115 degrees. The examiner did not note pain on weight-bearing, active, and passive range of motion, with no objective evidence of crepitus, but did note objective evidence of localized tenderness or pain on palpation. The examiner noted no additional loss of range of motion on repetitive-use testing with at least three repetitions. The examiner noted no muscle atrophy, ankylosis, or any recurrent subluxation or persistent instability. The examiner further noted no recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment. Here, the Board finds that the Veteran has experienced ongoing chronic pain, persistent and ongoing decrease in motion, but reported no symptoms of weakness or instability. The Board makes this finding, noting that the record reflects considerable medication for the right knee throughout the appeal period. The Board acknowledges that, in Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), the Court held that when a Diagnostic Code does not specifically contemplate the effects of medication, the Board must discount the ameliorative effects of any medication taken by the claimant. The Board further acknowledges recently the Court observed that VA is required "to discount beneficial medication effects when relevant rating criteria do not specifically contemplate medication use." Ingram v., 38 Vet. App. 130. The schedule of ratings-musculoskeletal system contains the knee ratings, which do not specifically contemplate the effects of medication. 38 C.F.R. § 4.71a; see also McCarroll v. McDonald, 28 Vet. App. at 267 (2016) (en banc) (holding that the Rating Schedule for hypertension contemplated the effects of medication in part because, under 38 C.F.R. § 4.104, Diagnostic Code 7101, "either a veteran's blood pressure is controlled by medication, warranting a 10 percent evaluation..., or it is not, in which case the actual blood pressure level determines the disability rating"). The Board concludes that a 20 percent rating based on limitation of motion is more nearly approximated considering the impact of the medications and the Veteran's pain and corresponding functional impairment. However, the Board finds that a higher or separate rating is not warranted as the Veteran did not report instability, did not report pain on extension, and flexion is not limited to less than 30 degrees. Thus, the Veteran's right knee disability warrants a 20 percent rating based on limitation of motion. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. A 10 percent rating for allergic rhinitis is granted. The Veteran seeks a compensable rating for allergic rhinitis, which is currently rated as 0 percent disabling from November 1, 2023. In the February 2026 brief, the Veteran's attorney argued that the Veteran is entitled to at least a 10 percent rating for allergic rhinitis as the evidence shows that the June 2023 examiner found evidence of greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. The Veteran's allergic rhinitis is evaluated under Diagnostic Code 6522, which provides ratings for allergic or vasomotor rhinitis. Under this code, allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, is rated at 10 percent disabling. Allergic or vasomotor rhinitis with polyps is rated at 30 percent disabling. 38 C.F.R. § 4.97. A polyp is defined as "an abnormal protruding growth from a mucous membrane." Dorland's Illustrated Medical Dictionary, 1514 (31st ed. 2007). A 30 percent evaluation is the maximum rating assignable under this diagnostic code. Here, in the June 2023 VA examination, the VA examiner diagnosed the Veteran with allergic rhinitis. The examiner noted that the Veteran's symptoms included congestion, runny nose, and medication use. The examiner noted that there was greater than 50 percent obstruction of the nasal passage on both sides but no complete obstruction on the left and right side due to rhinitis. Further, there was no evidence of nasal polyps seen on the examination. As such, the Board finds that his allergic rhinitis is manifested by rhinitis with greater than 50-percent obstruction of nasal passage on both sides. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. However, a rating in excess of 10 percent is not warranted, as the evidence does not show nasal polyps. As such, entitlement to an initial, 10 percent rating is warranted under Diagnostic Code 6522. 38 C.F.R. § 4.97, Diagnostic Code 6522. In reaching this determination, the Board acknowledges that VA is required "to discount beneficial medication effects when relevant rating criteria do not specifically contemplate medication use." Ingram, 38 Vet. App. 130. Here, the beneficial effects of medication are not known, and, thus, the Board has considered it in the adjudication of this matter, resolving all reasonable doubt in the Veteran's favor. 3. A 10 percent rating for hemorrhoids is granted. The Veteran seeks a higher rating for hemorrhoids throughout the appeal period. The Veteran's service-connected hemorrhoids are currently rated under Diagnostic Code (DC) 7336. In a February 2024 Statement, the Veteran stated that he experiences episodes of bleeding in the stool, which he reports occur at intervals of approximately every two to three months and that they persist for around three days each time. The Veteran further stated that he further experiences instances where he detects protruding skin while wiping. In the February 2026 brief, the Veteran's representative stated that the severity of the Veteran's hemorrhoids warrants a higher rating, noting that the Veteran reported days of significant blood in his stool and protruding skin with sensitivity to the touch. Under Diagnostic Code 7336, a noncompensable rating is assigned for mild or moderate hemorrhoids, external or internal. A 10 percent rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. In the May 2024 VA examination, the VA examiner diagnosed the Veteran as having internal or external hemorrhoids. During the examination, the Veteran reported occasional bleeding with stools, external hemorrhoids, and hard stools with straining. The examiner noted that the Veteran's symptoms were mild or moderate. In light of the medical and lay evidence of record, including the Veteran's statements, support finding the Veteran's hemorrhoids are productive of bleeding every two to three months throughout the appeal period. The Board finds the Veteran's statements that hemorrhoids result in bleeding and occasional prolapse are competent and credible. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Thus, the Board finds the Veteran's hemorrhoids most nearly approximate a 10 percent rating, but no higher, throughout the appeal period. The Board finds a rating in excess of 10 percent for the Veteran's hemorrhoids is not warranted for any period throughout the appeal. The Board notes all the Veteran's symptoms (namely bleeding three or more times per year with prolapse on occasion) have been considered in assigning the 10 percent for internal hemorrhoids throughout the appeal period. The evidence does not show, nor does the Veteran contend, that he experiences persistent bleeding or continuously prolapsed hemorrhoids. In light of the foregoing, the Board finds that the weight of the competent evidence is persuasively against a rating in excess of 10 percent for the Veterans hemorrhoids throughout the appeal period. 4. A compensable rating for acne is denied. The Veteran seeks a compensable rating for acne. In a February 2024 Statement, the Veteran reported that his acne is better managed than in service but that it left considerably noticeable scarring. In the February 2026 brief, the Veteran's representative echoed the Veteran's contentions and stated that the VA examiner did not consider the Veteran's reports of scaring. The Veteran's acne is rated as noncompensable from November 1, 2023, pursuant to Diagnostic Code 7828. Under Diagnostic Code 7828, a 0 percent rating is warranted for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck; or deep acne other than on the face and neck. A 30 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. A note to Diagnostic Code 7828 instructs to rate as disfigurement of the head, face, or neck (Diagnostic Codes 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. Diagnostic Code 7802 provides disability ratings for burn scars or scars due to other causes, not of the head, face, or neck, which are not associated with underlying soft tissue damage. Under Diagnostic Code 7802, a 10 percent rating is warranted for area or areas of 114 square inches or greater. Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. Under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) under Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. Note (2) under Diagnostic Code 7804 provides that a scar or scars that is both unstable and painful on examination may be assigned an additional 10 percent rating. In the June 2023 VA examination, the VA examiner diagnosed the Veteran as having acne. During the examination, the Veteran reported lifelong recurrent papular pustular skin changes to face. The examiner noted that the Veteran's acne did not require medication over the past twelve months, that the acne currently covered five percent of total body area, and that the acne was superficial, with post inflammatory hyperpigmentation. The examiner further found that the Veteran's acne did not cause any scarring or disfigurement of the head, face, or neck. In the May 2024 VA examination, the VA examiner noted the Veteran's acne diagnosis. During the examination, the Veteran reported that he previously tried prescription medications but that his acne has improved and now uses over the counter face wash. The examiner noted that the Veteran's acne did not require medication over the past twelve months, that the acne currently covered no exposed area, and that the acne was superficial. The examiner further found that the Veteran's acne did not cause any scarring or disfigurement of the head, face, or neck. Further, the Board notes that, in the June 2023 VA scars examination, the VA examiner did not note any scarring on the Veteran's face. The Board finds that the VA examiners' reports and descriptions of the Veteran's scar are highly probative as they both present the medical opinion of a competent expert, based on the physical examination of the Veteran. Nieves, 22 Vet. App. 295. Accordingly, the evidence of record persuasively weighs against a finding that the Veteran's acne does not more nearly approximate the criteria for a compensable rating under Diagnostic Code 7828, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107 (b). Further, the Board finds that a compensable rating is warranted based on disfigurement or scarring. In light of the foregoing, the Board finds that a compensable rating for acne must be denied. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Mountjoy, 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.