Citation Nr: 1432486 Decision Date: 07/21/14 Archive Date: 07/29/14 DOCKET NO. 07-37 941A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to a higher rating for residuals of non-Hodgkin's lymphoma. 2. Entitlement to an initial rating in excess of 10 percent for osteoporosis and hormone replacement therapy, residuals of non-Hodgkin's lymphoma. 3. Entitlement to a higher initial rating for sinusitis/allergic rhinitis, rated noncompensable prior to May 12, 2012, and a 30 percent evaluation beginning that date. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran served on active duty from September 1995 to February 2000. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. The Veteran testified before the undersigned Veterans Law Judge in May 2010. A transcript of the hearing is of record. The issues remaining on appeal were remanded by the Board in September 2010. FINDINGS OF FACT 1. The Veteran is in receipt of the maximum schedular rating for ovarian failure, which is a separately rated residual of treatment of her service-connected non-Hodgkin's lymphoma. 2. Dysparenunia, a residual of treatment for service-connected non-Hodgkin's lymphoma, is manifested by symptoms that require continuous treatment. 3. Effective February 10, 2008, a residual of treatment for service-connected non-Hodgkin's lymphoma, dermatitis with recurrent urticaria is manifested by non-debilitating bouts of extreme pruritis, requiring systemic treatment, and generally covering 20 to 40 percent of the body area; prior to February 10, 2008, the Veteran's skin was asymptomatic. 4. Effective July 1, 2005, the Veteran has suffered from chronic bilateral dry eyes, a residual of treatment for service-connected non-Hodgkin's lymphoma. 5. Osteoporosis and hormone replacement therapy, a residual of treatment for service-connected non-Hodgkin's lymphoma, is manifested by slight bone density loss, stable, but requiring continuous medication. 6. Oral ulcers (aphthous and herpetic), residual of non-Hodgkin's lymphoma, are manifested by periodic recurrences, resulting in some short-term difficulties in eating at least some foods, but without disfigurement or significant impairment in masticatory function. 7. Major depressive disorder results in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 8. Prior to September 18, 2011, sinusitis/allergic rhinitis was manifested by period nasal congestion without obstruction of either or both nasal passages of 50 percent or more, incapacitating episodes requiring prolonged antibiotic treatment, or at least three non-incapacitating episodes manifested by headaches, pain, and purulent discharge or crusting. 9. Beginning September 18, 2011, a nasal polyp has been shown. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for ovarian failure have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.116, Diagnostic Code 7715-7611 (2013). 2. A separate 10 percent rating for dysparenunia, residual of non-Hodgkin's lymphoma, is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.116, Diagnostic Code 7715-7611 (2013). 3. Effective February 10, 2008, but no earlier, the criteria for a 30 percent rating for dermatitis with recurrent urticaria were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.118, Diagnostic Code 7715-7806 (2013). 4. Effective July 1, 2005, the criteria for a 20 percent rating for bilateral dry eyes were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.118, Diagnostic Code 7715-7806 (2013). 5. The criteria for a rating in excess of 10 percent for osteoporosis and hormone replacement therapy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.119, Diagnostic Code 7715-7904 (2013). 6. The criteria for a compensable rating for aphthous and herpetic oral ulcers have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.114, Diagnostic Code 7715-7200 (2013). 7. The criteria for a compensable rating for aphthous and herpetic oral ulcers have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.114, Diagnostic Code 7715-7200 (2013). 8. The criteria for an initial evaluation in excess of 30 percent for major depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9434 (2013). 9. Prior to September 18, 2011, the criteria for a compensable rating for sinusitis/allergic rhinitis were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 6512-6522 (2013). 10. Effective September 18, 2011, the criteria for a 30 percent rating for sinusitis/allergic rhinitis were met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 6512-6522 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). However, the Veteran's appeal arises from her disagreement with the initial evaluations following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In February 2012 and in August 2012, service connection was granted for several disabilities as residuals or secondary to non-Hodgkin's lymphoma. These issues are on appeal, because, as discussed below, the rating criteria for non-Hodgkin's lymphoma provide that residuals of the disease are to be rated under appropriate diagnostic codes. The August 2012 supplemental statement of the case did not separately consider those disabilities. However, the Board finds that the February 2012 and August 2012 rating decisions and enclosures were the functional equivalent of a supplemental statement of the case. They provided a discussion of the evidence and how it affected the rating. In addition, the February 2012 rating decision attached summaries showing the diagnostic codes, and how the criteria for the assignment of the ratings were met, and what was needed for a higher rating. At the same time as the August 2012 rating decision, a supplemental statement of the case was furnished, which included the information that non-Hodgkin's lymphoma is rated on residuals. Moreover, in both rating decisions, the Veteran was informed that the decision was ancillary to the issue on appeal, was regarded as inextricably intertwined with the appellate issue, and that no further action was required. No evidence has been received since the August 2012 rating decision and supplemental statement of the case, and in August 2012, the Veteran asked to have her appeal expedited by the Board. Therefore, because the Veteran and her representative were provided with all information that would have been provided in a supplemental statement of the case, the Board finds that it is not necessary to further delay this appeal by remanding for a supplemental statement of the case, which will simply provide the same information that has already been provided. VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). This duty includes assistance in the procurement of service treatment records and other pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records have been obtained, as have VA treatment records. Although there is evidence that the Veteran has received private treatment, she has not identified or authorized the release of any such records. At the Travel Board hearing in May 2010, the undersigned fully explained the issues, and described the types of evidence the Veteran might wish to obtain to substantiate her claims. The Veteran's Law Judge discussed the elements required for the claims, including the elements found to be missing in the rating decision on appeal. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Based on the hearing testimony, the appeal was remanded in September 2010 to afford the Veteran additional VA examinations. Such examinations were provided in December 2010, January 2011, May 2012, and July 2012. The examinations involved physical examination, interview, and review of the claims file, and, where indicated, a rationale was provided for the opinions rendered. The opinions provide an adequate basis for the Board to decide this appeal. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) ("An adequate medical report must rest on correct facts and reasoned medical judgment so as inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports." The examinations also satisfy the directives in the September 2010 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998) (Board remand instructions are neither optional nor discretionary, and compliance is required); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (the Veteran is entitled to substantial compliance with the Board's remand directives). The Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed. Significantly, neither the appellant nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Higher Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. If a disability has undergone varying and distinct levels of severity throughout the pendency of the claim, staged ratings may be assigned. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, or if the disability is unlisted and must be rated analogously to a closely related disability; the additional code is shown after the hyphen. 38 C.F.R. §§ 4.20, 4.27 (2013). III. Non-Hodgkin's Lymphoma Residuals Service connection is in effect for non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma manifested by active disease or during a treatment phase warrants assignment of a 100 percent evaluation. 38 C.F.R. § 4.117, Diagnostic Code 7715. The 100 percent evaluation shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. If there has been no local recurrence or metastasis, the evaluation is to be based on residuals. Id. Treatment records reflect that Veteran was diagnosed as having non-Hodgkin's lymphoma in February 2004. She received chemotherapy and full body radiation, but the disease was refractory. She underwent an allogeneic bone marrow transplant procedure in June 2004. According to a July 2004 letter from the director of medical oncology at the VA bone marrow transplant unit in Seattle, where the procedure was performed, a prolonged convalescence was required; typically, patients were considered to be completely disabled for at least one year following the transplant. A 100 percent evaluation for Non-Hodgkin's lymphoma was thereby assigned for the period from the date her claim was received in August 2004 through June 2005, a year after the bone marrow transplant. Effective July 1, 2005, the non-Hodgkin's lymphoma has been rated based on residuals. In this case, originally, the only rated residual disability was identified as "osteoporosis and hormone replacement therapy," for which a 10 percent rating was assigned. During the pendency of the appeal, however, additional residuals have received separately compensable evaluations. Specifically, she has been found to have premature ovarian failure, due to the treatment for non-Hodgkin's lymphoma. A 30 percent rating has been assigned for ovarian disease. In addition, the Veteran has been diagnosed with graft-versus-host disease (GVHD) as a result of her therapy for non-Hodgkin's lymphoma, and separate ratings have been assigned for GVHD related manifestations of dermatitis with recurrent urticaria, rated 30 percent disabling and dry eyes, rated 20 percent disabling. Additionally, oral ulcers (aphthous and herpetic) were found to be a residual of non-Hodgkin's lymphoma treatment, but noncompensable. Finally, she was granted service connection for major depressive disorder, rated 30 percent disabling, as secondary to non-Hodgkin's lymphoma. See 38 C.F.R. § 3.310. Combining just those service-connected disability ratings results in a combined rating of 80 percent for non-Hodgkin's lymphoma residuals and associated conditions. See 38 C.F.R. § 4.25. Because they have been rated separately, however, the discussion below will separately consider each condition. A. Gynecological Conditions Gynecological disabilities, including disease or injury of the vagina and disease or injury of the ovaries, are rated under the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs. Under this formula, a 0 percent rating is warranted for symptoms that do not require continuous treatment. A 10 percent rating is warranted for symptoms that require continuous treatment. A 30 percent evaluation is warranted for symptoms not controlled by continuous treatment. 38 C.F.R. § 4.116, Diagnostic Codes 7610 through 7615. Currently, the Veteran is in receipt of a 30 percent rating for premature ovarian failure, due to treatment for non-Hodgkin's lymphoma, under Diagnostic Code 7615. Thus, she is already in receipt of the maximum rating for her ovarian failure. She maintains that she has other symptoms of her ovarian failure, and consequent menopausal symptoms, such as hormone imbalance, sexual dysfunction, infertility, mood swings, and hot flashes, which she identified at her Travel Board hearing. She is rated separately for mood swings, as depression, addressed below. Infertility, which does not affect earning capacity, is therefore not a ratable condition as such. However, she has been awarded special monthly compensation on account of loss of use of a creative organ, which includes the ovaries. See 38 C.F.R. § 3.350(a)(1). Thus, it must be determined whether other symptoms relate to ovarian failure, including hormone imbalance, sexual dysfunction, and hot flashes, are contemplated by the 30 percent rating for ovarian disease. In this regard, "pyramiding," that is, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2013). In interpreting this regulation, the United States Court of Appeals for Veterans Claims (Court) held that separate ratings may be assigned for symptoms which are not " duplicative of or overlapping with the symptomatology " of the underlying condition. Esteban v. Brown, 6 Vet.App. 259, 262 (1994). The Court explained that "[t]he critical element is that none of the symptomatology for any one of [the] conditions is duplicative of or overlapping with the symptomatology of the other two conditions." Id. Disease of the vulva, vagina, cervix, uterus, fallopian tubes, and ovaries are all rated under the same general rating formula for disease, injury, or adhesions of female reproductive organs. 38 C.F.R. § 4.116, Codes 7610-7615. However, in a case involving another general rating formula, for psychiatric conditions, the Federal Circuit Court acknowledged that two separate diagnosed conditions rated under the general formula "could have different symptoms and it could therefore be improper in some circumstances for the VA to treat these separately diagnosed conditions as producing only the same disability." Amberman v Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). The Federal Circuit Court emphasized that it was the manifestations that determined whether a separate rating was warranted, because while 38 C.F.R. § 4.14 "clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder." Id. Therefore, the Board must consider whether there are manifestations present which, even though ultimately caused by the ovarian failure, are not contemplated in the 30 percent rating for ovarian disease. The Board finds that the "hormonal imbalance," i.e., lack of estrogen production, is clearly within the purview of the ovarian disease, since that is a primary function of the ovaries. In addition, the Board finds that the hot flashes, which have not been shown by the medical evidence to be either frequent or severe, are included within the ovarian disease rating. Concerning her reported symptoms of sexual dysfunction, vaginal atrophy, vaginal dryness, and painful intercourse (dyspareunia), VA treatment records show that in March 2005 (during the period covered by the 100 percent rating for non-Hodgkin's lymphoma), the Veteran was referred for gynecology consult regarding her post-menopausal symptoms. She did not currently have hot flashes, mood swings, or any other symptoms except for vaginal dryness, which caused her some discomfort during intercourse. She was prescribed oral contraceptive pills, and in August 2005, her vaginal irritation was slightly better. A VA gynecological examination of the vagina in January 2006 revealed decreased estrogen effect; however, the assessment was normal gynecological examination. In February 2007, the Veteran received an ovarian transplant, which was subsequently rejected. In September 2007, her current medications were noted to include estrogen replacement. She reported that her sexual function had improved. In August 2008, she was noted to be taking Estradiol, 2 mg a day. In September 2008, regarding her vaginal function/dyspareunia, she stated that she had normal function on the current estrogen dose, a significant improvement over the regular oral contraceptive pill, low-dose estrogen program. The Veteran was eventually able to conceive through in vitro fertilization of eggs donated by her sister. She gave birth to a healthy baby in September 2009. In January 2010, it was noted that she was currently on hormone supplementation that she obtained through her private gynecologist. On a VA examination in January 2011, the Veteran reported pain during intercourse and decreased libido. She said that when she did have intercourse, she got a small fissure in her posterior fourchette, which could be quite painful. She stated that she was taking hormone replacement therapy, consisting of estrogen every day. On examination, the external genitalia were normal. There was no obvious fissure on the fourchette, or vulvodynia symptoms. There was atrophic vaginal tissue. The assessment was premature menopause. The examiner believed that her vaginal atrophy was associated with premature menopause. She recommended treatment with local vaginal estrogen. The examiner prescribed Premarin cream; she did not feel that further hormonal replacement would help with her decreased libido. Since then, no specific complaints have been noted. The general formula for rating gynecological conditions does not set forth any symptomatology, only the degree to which symptoms may be controlled. Although the Veteran's vaginal symptoms are clearly caused by her ovarian failure, a separate Diagnostic Code is provided for vaginal disease. Moreover, although the vaginal symptom of dysparenunia was previously successfully treated with the hormone replacement therapy prescribed for the symptoms related to ovarian failure as a whole, in January 2011, she was noted to have vaginal symptoms, including painful intercourse, despite taking both estrogen and progestin supplements. She was prescribed topical Premarin (conjugated estrogen), and no complaints have been recorded since. For these reasons, with the resolution of reasonable doubt in the Veteran's favor, the Board finds that the symptoms may be rated separately, and more closely approximate those of a 10 percent rating for disease or injury of the vagina, as they are controlled with medication. In this regard, although she does not continuously seek treatment, the evidence indicates that medication is continuously required to control her symptoms. A 10 percent rating is warranted for dyspareunia. See 38 C.F.R. §§ 4.3, 4.7. The evidence does not indicate that the symptoms are of such severity that they cannot be sufficiently controlled with medication; therefore, a higher rating is not warranted. B. Dermatitis Dermatitis is rated 0 percent when less than 5 percent of the entire body or of exposed areas is affected, and no more than topical therapy is required during the past 12 month period. A 10 percent rating is assigned when at least 5 percent but less than 20 percent of the entire body or of exposed areas is affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12 month period. A 30 percent rating is assigned when 20 to 40 percent of the entire body or of exposed areas is affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, during the past 12 month period. The highest rating of 60 percent is assigned when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during a twelve month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. Although revisions were made to the rating criteria for evaluating skin disabilities, effective October 23, 2008, the revisions, related to scars, do not affect the criteria for rating dermatitis under Diagnostic Code 7806 in this case where there is no disfigurement or scarring shown. See 38 C.F.R. § 4.118 (2013). On a VA examination in December 2010, the Veteran stated that since developing graft versus host disease, she had experienced dry, itchy skin. The examiner noted that a skin biopsy in July 2004 showed lymphohistiocytic inflammation, folliculitis, consistent with graft versus host disease. The examiner also observed that treatment records showed that the GVHD had caused intermittent urticaria. On examination of the skin, the Veteran indicated some areas where she experienced intense pruritis. These areas were slightly hyperpigmented and measured approximately 1 cm. There were no defined edges. There were several scattered patches of this slightly hyperpigmented skin around both knees and on the forearms. Lesions were not disfiguring as the hyperpigmentation was very subtle, and the skin was flat and smooth. On a VA examination of the skin in May 2012, it was noted that the Veteran had been diagnosed as having dermatitis, urticaria, and pruritis, due to chronic eosinophilia, diagnosed in 2006. It was further noted that she had GVHD with chronic eosinophilia, due to the bone marrow graft. She reported itching which was almost constant. She applied creams to her skin, including hydrocortisone cream for severe itching. About once a year, she had an episode of extreme pruritis, for which she took Benadryl or, if that did not work, a hydrocortisone tablet. During those episodes, she had to rest until the medication took effect, about 2 to 3 hours. The skin conditions did not cause scarring or disfiguring of the head, face or neck. She did not have systemic manifestations. The examiner noted that she was treated on a near constant basis with systemic corticosteroids or other immunosuppressive medications, but he noted that the condition was for chronic eosinophilia due to GVHD. The Veteran also used topical corticosteroids for severe itching. She had not had any debilitating episodes in the past 12 months, but she had had one non-debilitating episode, during which she experienced extreme pruritus, as described above. In describing the characteristics of the episode, the examiner checked boxes indicating that the episode "occurred despite ongoing immunosuppressive therapy;" "required treatment with intermittent systemic immunosuppressive therapy;" and "responded to treatment with antihistamine or sympathomimetics." On examination, she had dermatitis, which the examiner indicated covered approximately 20 percent to 40 percent of the total body area. The diagnoses were eosinophilic dermatitis, recurrent urticaria, and pruritis, all due to chronic eosinophilia due to GVHD. The skin conditions did not impact her ability to work. Here, the Veteran was awarded a 30 percent rating, effective May 16, 2012, the date of the VA examination, for her skin manifestations. The 30 percent rating reflects the coverage of 20 to 40 percent of the entire body, as well as systemic therapy such as corticosteroids or other immunosuppressive drugs for 6 weeks or more during a 12-month period. Symptoms showing that more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs, have not been indicated. The Veteran's symptoms, as described by herself and shown in the record, do not more closely approximate a higher rating of 60 percent. A rating in excess of 30 percent is not warranted. However, the 30 percent rating was granted effective May 16, 2012, whereas the period for consideration in this case extends from July 1, 2005, to the present. July 1, 2005, is the effective date for rating non-Hodgkin's lymphoma on residuals. VA treatment records show that in September 2005, the Veteran was noted to have smooth skin, with no rashes. Such findings were shown on subsequent occasions, until in February 2008, when the Veteran called urgently, reporting she had developed total body hives on Sunday [February 10, 2008], and had sought treatment in a private emergency room. She had been prescribed prednisone, 60 mg per day for 3 days. Her urticaria was thought to be due to hypereosinophilia. When seen for follow-up, she reported that she still felt itchy at night, but the hives had nearly disappeared. Therefore, because the Veteran's skin manifestations began with the urticaria on February 10, 2008, the Board finds that the effective date for the 30 percent rating should be February 10, 2008, the first occasion on which the skin manifestations were demonstrated. In reaching this determination, the benefit-of-the-doubt rule has been applied. See 38 U.S.C.A. § 5107(b). C. Dry Eyes According to a VA examination in December 2010, the Veteran had chronic dry eyes secondary to graft host rejection. She used Restasis drops twice a day, and artificial tears every 1-2 hours; despite this, she still had symptoms of irritation. The evidence shows that she has chronic dry eyes. Based on this, she was granted service connection for bilateral dry eyes, assigned a 20 percent rating under Diagnostic Code 6025, Disorders of the Lacrimal Apparatus. This is the highest rating provided under that Diagnostic Code, and the evidence does not reflect other ocular symptoms as a residual of non-Hodgkin's lymphoma, or its treatment. The RO assigned an effective date of February 20, 2009, for this symptom. However, a VA ophthalmology note dated in January 2006 reported that the Veteran had had placement of collagen punctal plug in the left eye, with no significant relief of dry eye. Treatment records show sufficient instances of pertinent complaints to establish the condition as chronic. Given that by January 2006 a collagen punctal plug had already been attempted, it is reasonable to assume that the condition has been present since July 1, 2005. Therefore, although a higher rating is not warranted, the 20 percent rating is warranted effective July 1, 2005. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C.A. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. Osteoporosis with HRT The condition identified as "osteoporosis and hormone replacement therapy" has been rated as 10 percent disabling since July 1, 2005, by analogy to Diagnostic Code 7904, which refers to hyperparathyroidism. Hyperparathyroidism with generalized decalcification of bones, kidney stones, gastrointestinal symptoms (nausea, vomiting, anorexia, constipation, weight loss, or peptic ulcer), and weakness, warrants a 100 percent rating. 38 C.F.R. § 4.119 , DC 7904. Gastrointestinal symptoms and weakness warrant a 60 percent rating; and, where continuous medication is required for control, a 10 percent rating is warranted. Id. A Note after the rating criteria provides that, following treatment or surgery, the disorder is rated on the basis of digestive, skeletal, renal, or cardiovascular residuals, or as endocrine dysfunction. A bone densitometry was obtained in July 2005. The T-score in the lumbar spine was -2.7 and in the hips, -2.6. The Z-score was -2.6 in both the lumbar spine and the hips. Results between -1 and -2.5 were noted to signify osteopenia (low bone mass). Results lower than -2.5 were indicative of osteoporosis. The assessment was osteoporosis and medication including calcium, vitamin D, bisphosphonate and a course of intravenous Pamidronate were recommended. She was advised that exercise, estrogen and calcium would not likely be sufficient to stabilize the bone loss. Bone density test in December 2010 revealed osteopenia, but not osteoporosis. On a VA examination in December 2010, the examiner noted that the Veteran had osteopenia at this time. The examiner stated that radiology studies, bone density, and pet scans had been normal. Currently, the Veteran took 1 mg of prednisone per day for suppression of eosinophilia, and calcium and vitamin D to prevent osteoporosis. Her current bone density showed eosinophilia. She was a full-time mother, but also exercised by biking quite a bit; recently, she had completed 100 miles of bike riding as part of a cancer fundraiser. She did not have any incapacitating flare-ups. She is able to function as a "full-time mom" without much difficulty, but with some aches and pains. The examiner diagnosed chronic cervical and lumbar strain (which are service-connected disabilities, not on appeal at the current time), left wrist extensor tendonitis, and, most likely, bilateral early degenerative joint disease. On addenda dated in May 2012 and June 2012, the examiner stated that the left wrist, extensor tendinitis and bilateral hip degenerative joint disease were not related to the non-Hodgkin's lymphoma or its treatment. In fact, he stated that x-rays had not confirmed the presence of degenerative joint disease in the hips, and the most likely diagnosis was trochanteric tendinitis, which also was less likely than not related to non-Hodgkin's lymphoma or its treatment. A February 2012 outpatient note reported that the Veteran was "very physically active." Her last bone density test in December 2010 had shown stable T and Z scores. The remainder of the evidence is also consistent with these findings, and reveals the appellant to be a very active individual. Although her bone density is slightly decreased, it is stable, and does not cause any functional impairment at this point. Therefore, the 10 percent rating, contemplating the need for continuous medication, is appropriate. A higher rating is not currently warranted for osteoporosis and hormone replacement therapy. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); see Ortiz, supra; Gilbert, supra. E. Oral Ulcers The Veteran states that she gets ulcers in her mouth and down her throat at times. VA treatment records show that in September 2005, she had ulceration and macerating buccal mucosae, and prominent papillae on the tongue. This was noted to be slightly improved. Numerous subsequent records have shown mouth symptoms, which were clinically associated with GVHD. On a VA examination in December 2010, The Veteran stated that she continued to get mouth sores 1 to 2 times per month, that lasted approximately 2 days. She found it difficult to eat when she had the sores. The sores resolved in about 2 days. On a VA oral and dental examination in July 2012, the examiner diagnosed aphthous ulcers and herpetic ulcers. He stated that the Veteran had had non-Hodgkin's lymphoma, which had been successfully treated, but as a sequelae, she often got ulcerations in her mouth, consistent with aphthous ulcers and herpetic ulcers. She also had some gingival recession. The examiner stated that the Veteran's oral condition did not impact her ability to work. However, he noted that it became very hard to eat with all of the sores in her mouth. The RO granted service connection for aphthous and herpetic ulcers, as associated with service-connected non-Hodgkin's lymphoma, and assigned a noncompensable rating. The condition was assigned a hyphenated Diagnostic Code of 7715-7709. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, or if the disability is unlisted and must be rated analogously to a closely related disability; the additional code is shown after the hyphen. 38 C.F.R. §§ 4.20, 4.27 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). It is permissible to switch Diagnostic Codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the DC associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 7715 refers to non-Hodgkin's lymphoma, but Diagnostic Code 7709 refers to Hodgkin's disease, and like Diagnostic Code 7715, provides for the rating of residuals six months after the cessation of treatment; it does not address mouth ulcers. On the other hand, there is a Diagnostic Code for injuries of the mouth, Diagnostic Code 7200. This calls for rating such an injury as for disfigurement and impairment of function of mastication. Therefore, since "injury of the mouth" is closely analogous, and in the identical anatomical location, whereas the code for Hodgkin's disease is completely irrelevant, the Diagnostic Code should be changed to 7715-7200. In evaluating the Veteran's condition based on the Diagnostic Code 7200, first, the evidence demonstrates that there is no disfigurement. Where the lost masticatory surface cannot be restored by a suitable prosthesis, a 10 percent rating is warranted for the loss of all upper anterior or lower anterior teeth, or a 10 percent rating is warranted for the loss of all upper and lower teeth on one side; a 20 percent rating is warranted for the loss of all upper and lower posterior or upper and lower anterior teeth; a 30 percent rating is warranted for the loss of all upper teeth or all lower teeth; a maximum 40 percent disability rating is warranted for the loss of all teeth. These ratings apply to bone loss through trauma or disease, such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease. 38 C.F.R. § 4.150 , Diagnostic Code 9913. However, here, the Board is rating by analogy, based on loss of masticatory function resulting from the oral ulcers. Although during the times when her mouth ulcers are active, eating is difficult and painful, these instances are relatively infrequent, and last only a couple of days. The evidence does not indicate that the Veteran is precluded from ingesting nourishment, although she may need to avoid foods that cause further irritation. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. However, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). F. Other residuals of GVHD On the VA examination in December 2010, the Veteran stated that she developed liver inflammation in 2004. She also stated, and records confirmed, that her most recent liver function tests were normal. She denied any current liver problems were not an issue, and contemporaneous treatment records did not show active liver problems. The diagnosis was status post liver inflammation due to GVHD resulting in elevated liver function studies, which had currently resolved. VA treatment records show that liver function tests were slightly abnormal in August 2005 and September 2005, but the Veteran did not exhibit symptoms of liver impairment. Liver function tests were normal in September 2006, and have remained so. No other identifiable symptoms of GVHD have been specifically observed during the period under consideration. Therefore, no additional separate ratings are warranted. G. Depressive Disorder The Veteran contends that she has mood swings related to her non-Hodgkin's lymphoma residuals. On a VA examination in December 2010, she stated that she was sick all the time, was never going to have a normal life, and she became tearful. She reported sleeping difficulties. She denied nightmares or problems with anger or irritability. She was able to social socialize appropriately with friends. She reported neurovegetative symptoms of major depression. She had not been in any psychiatric treatment or taking any psychiatric medications. On mental status examination, the Veteran was appropriately dressed and groomed. She was capable of all independent activities of daily living. No impairment was noted in communication and no unusual motor movements or dysfunctional behavior patterns were observed or reported. The Veteran appeared to be depressed and tearful throughout the interview. Her abstract reasoning, concentration, and long and short-term memory were all within normal limits. There was no indication of any thought disorder or paranoia. The Veteran denied any history of overt attempts or risk for harming herself, but acknowledged ongoing passive thoughts of suicide. The diagnosis was major depression, with the global assessment of functioning of 50. It was thought to be likely that the Veteran suffered from major depression as a direct result of her service-connected medical problems and long-term residual effects of her treatment. She denied any clinically significant periods of symptom remission since the onset of the symptoms and about 2004. She felt that her depression had significantly affected her marriage. Psychiatric disabilities are evaluated under a general rating formula for mental disorders. 38 C.F.R. § 4.130. According to the general rating formula, a mental disorder is rated 30 percent when it results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Code 9411. A rating of 50 percent is assigned when it results in occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A rating of 70 percent is warranted when it results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when the condition results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) (also explaining that VA intended the General Rating Formula to provide a regulatory framework for placing veterans on the disability spectrum based upon their objectively observable symptoms). For a higher rating of 50 percent, the Veteran's symptomatology must more closely approximate reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. Here, the Veteran has exhibited none of these symptoms, either during the examination or elsewhere in the record. The examiner assigned a GAF score of 50, reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). However, an evaluation will based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) . Thus, although a GAF score is relevant, it is not dispositive. The examiner himself did not report any social impairment. Furthermore, the evidence reflects that the Veteran has decided to become a full-time mother, not that she is unable to keep a job due to her mental condition. In short, the Veteran's symptoms of major depressive disorder do not exceed those contemplated by the 30 percent rating currently in effect. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); see Ortiz, supra; Gilbert, supra. IV. Sinusitis/Allergic Rhinitis Service connection for sinusitis/allergic rhinitis was granted in a February 2006 rating decision, on the basis of direct service incurrence, evaluated as noncompensably disabling effective August 2, 2004, the date the claim was received. The Veteran appealed the rating, and in an August 2012 rating decision, a 30 percent rating was granted, effective May 17, 2012. Both "staged" ratings remain on appeal. A 10 percent rating is in order for sinusitis with one or two incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment; or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is warranted for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is warranted for chronic osteomyelitis following radical surgery; or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. An incapacitating episode means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Codes 6510-6514. Allergic rhinitis without polyps but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side warrants a 10 percent evaluation; and allergic rhinitis with polyps warrants a 30 percent evaluation. 38 U.S.C.A. § 4.97, Diagnostic Code 6522. At her travel Board hearing in May 2010, the Veteran stated that she took prednisone as needed for her sinus problems. She said that depending on the conditions of the weather, pollution, allergy season, and other factors, her sciences sinuses became extremely inflamed to the point where she cannot breathe out of either side of her nose. This caused sinus headaches. For that she took prednisone to combat the inflammation. She also took Flonase to help with allergy symptoms. She said that she had sought emergency treatment the previous year (2009) because she had complete congestion or sinuses and could not breathe out of either nostril. The evidence of record includes the report of a VA examination in November 2005. The Veteran stated that most of her sinus problems were associated with colds. As for allergic rhinitis, she said she had seasonal allergies with no prior treatment. VA treatment records show that in September 2007, the Veteran complained of sinus congestion; she reported that her allergies were flaring at that time. A PET scan in September 2007 showed deviation of the nasal septum to the left. The right nasal airway contained ample soft tissue density material, either soft tissue or mucus. The bilateral maxillary, frontal, and ethmoid sinuses were clear. In October 2007, it was noted that three days earlier, she had been experiencing a cold with upper respiratory symptoms, including clear nasal secretions and congestion. On examination, she had a nasal voice, a deviated septum, and boggy nasal mucosa. In April 2008, she was noted to have enlarged turbinates and a deviated septum, with findings otherwise normal. In September 2008, she reported feeling better on prednisone, 1 mg daily. She said her sinuses were completely clear. In November 2008, she reported that her asthma and her sinuses were better on the very low dose prednisone. Currently, she had no headache, sinus pain, or nasal drainage. In April 2009, she reported that her nasal symptoms had flared slightly recently, but that the pollen count was very high. She was taking prednisone, 1 mg daily. In August 2009, she said she had not had rhinitis. In January 2010, the nasal passages were within normal limits. On a VA examination in December 2010, the examiner commented that a review of the claims file found only references to upper respiratory infections, and not to sinusitis. On examination, there was no evidence of any sinusitis. She had mild obstruction of the nasal passages, probably a total of 40 percent, with some mucus secretion, which the examiner attributed to a deviated septum. For which service connection is not in effect. In June 2011, the Veteran said that she took prednisone, 1 or 2 mg per day for 3 to 5 days, when sinus congestion was increased. She said she did not take it regularly, and her dosage was no higher than 2 mg. The assessment was sinusitis, stable. A maxillofacial CT scan in September 2011 revealed minimal areas of mucosal thickening in the paranasal sinuses, without erosive changes or destructive osseous lesions. There was also marked, chronic left sided paranasal septum deviation. On a VA examination in May 2012, the examiner stated that the Veteran had been diagnosed as having chronic sinusitis, allergic rhinitis, and deviated nasal septum. The Veteran reported a history of positive skin tests for allergies to dust and trees. She complained of congestion. A CT scan had shown a nasal polyp, which was removed during surgery in February 2012, which also corrected her deviated septum (septoplasty). On examination, the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides, or complete obstruction on one side, but there was noted to be nasal polyps. A CT scan in 2011 had revealed minimal thickening. The examiner concluded that the Veteran's sinus and nose condition did not impact her ability to work. She had had good results from surgery, but had a recurrent polyp on the right that needed treatment. In analyzing the evidence, first, it must be pointed out that service connection is not in effect for a deviated nasal septum. Concerning the Veteran's testimony that she was treated in an emergency room for a complete inability to breathe through her nose, the evidence does not show such findings during the appeal period in any VA records, and the Veteran has not authorized the release of or provided copies of any private records. The medical records on file have not revealed more than mild thickening in the sinuses. Sinus headaches have not been shown in the medical records. Her nasal symptoms have been controlled with low doses of prednisone, and the evidence does not show that prolonged antibiotic treatment has been required. No incapacitating episodes of sinusitis have been demonstrated. Non-incapacitating episodes manifested by headaches, pain, and purulent discharge or crusting have not been shown; her complaints have involved congestion. Therefore, a compensable rating is not warranted under the formula for rating sinusitis, at any time since the effective date of service connection. The 30 percent rating was granted on the basis of the presence of a nasal polyp, which warrants a 30 percent rating under the Diagnostic Code for allergic rhinitis. The effective date was in May 2012, the date of the VA examination which reported the presence of a polyp. However, that examination report, considered in conjunction with the other medical evidence, reveals that the polyp was most likely discovered in September 2011. She underwent surgery in February 2012 to correct her non-service-connected deviated septum, and the polyp was also removed; however, by May 2012, the polyp had recurred. Therefore, the effective date of the 30 percent evaluation should be September 18, 2011, the date of the CT scan which reportedly disclosed the polyp. Before that date, the evidence did not reflect more than 40 percent obstruction of the nasal passages. Complete obstruction on one side has not been demonstrated. Therefore, the preponderance of the evidence is against a compensable rating for sinusitis/allergic rhinitis prior to September 18, 2011. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); see Ortiz, supra; Gilbert, supra. V. Extraschedular Considerations When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. See Thun v. Peake, 22 Vet. App. 111 (2008). The standard for marked interference with employment required for an extraschedular evaluation is less than the standard for a TDIU rating. Id. Under Thun, there is a three-step analysis in determining whether referral for extraschedular consideration is appropriate. The initial step is a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Id. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Each of the disabilities at issue has been discussed above, as to how the criteria for a higher rating have not been met. All of the disabilities have higher ratings available, under the most applicable diagnostic code, but as discussed above, the criteria have not been met. Therefore, the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Finally, when evidence of unemployability is submitted in the course of a claim for a higher rating for one or more service-connected disabilities, and the evidence of unemployability pertains to the service-connected disability or disabilities at issue, a claim for TDIU will be considered part and parcel of the increased rating claim(s). See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, the Veteran has not claimed to be unemployable due to service-connected disabilities. According to a June 2010 VA outpatient treatment record, she had put her plans to become a nurse on hold to stay with her daughter full-time. She explained that her husband had received a promotion, and so they were financially stable at this point. Likewise, on a VA examination of the joints in December 2010, she reported that she was working as a "full-time mom." Thus, the Board finds that a TDIU claim has not been raised, and, hence, is not part of the current increased rating appeal. (CONTINUED ON NEXT PAGE) ORDER A separate 10 percent rating for dysparenunia, a residual of treatment for service-connected non-Hodgkin's lymphoma, is granted. Effective February 10, 2008, a 30 percent rating for service-connected non-Hodgkin's lymphoma, dermatitis with recurrent urticaria is granted. Effective July 1, 2005, a 20 percent rating for chronic bilateral dry eyes, a residual of treatment for service-connected non-Hodgkin's lymphoma, is granted. A rating in excess of 10 percent for osteoporosis and hormone replacement therapy, a residual of treatment for service-connected non-Hodgkin's lymphoma, is denied. A compensable rating for oral ulcers (aphthous and herpetic), residual of non-Hodgkin's lymphoma, is denied. A rating in excess of 30 percent for major depressive disorder is denied. Prior to September 18, 2011, a compensable rating for sinusitis/allergic rhinitis is denied. Effecttive from September 18, 2011, a 30 percent rating for sinusitis/allergic rhinitis is granted. ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs