Citation Nr: 1534533	
Decision Date: 08/12/15    Archive Date: 08/20/15

DOCKET NO.  09-32 530	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Denver, Colorado


THE ISSUES

1.  Entitlement to an initial disability rating greater than 70 percent for the entire appeal period for posttraumatic stress disorder (PTSD). 

2.  Entitlement to an initial disability rating greater than 60 percent for urticarial rash due to idiopathic anaphylaxis with possible mastocytosis for the entire appeal period.  

3.  Entitlement to an initial disability rating greater than 40 percent for angioneurotic edema due to idiopathic anaphylaxis with possible mastocytosis for the entire appeal period.

4.  Entitlement to an initial disability rating greater than 10 percent for intermittent inhalational use due to idiopathic anaphylaxis with possible mastocytosis.  

5.  Entitlement to service connection for bladder cancer.

6.  Entitlement to special monthly compensation for aid and attendance.   

(Pursuant to BVA Directive 8430 (May 17, 1999), a separate decision will be issued to address other claims in appellate status.)


REPRESENTATION

Veteran represented by:	Joseph A. Whitcomb, Esq.


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

J. J. Tang, Associate Counsel


INTRODUCTION

The Veteran served on active duty from January 1971 to November 1977.
	
This case is before the Board of Veterans' Appeals (Board) on appeal from June 2012, January 2013, and July 2014 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA).

All documents on the Virtual VA paperless claims processing system and the Veterans Benefits Management System have been reviewed, to include a transcript of the June 2015 Board hearing presided over by the undersigned Veterans Law Judge. 

The issues of entitlement to a total disability rating based on individual unemployability (TDIU) and entitlement to special monthly compensation (SMC) based on the schedular housebound criteria have been resolved for the respective applicable periods on appeal.  See June 2015 rating decision (granting TDIU for the entire appeal period for the claim for increased compensation for idiopathic anaphylaxis with mastocytosis, and granting SMC based on the schedular housebound criteria for the entire period during which this matter is raised).  

In June 2015, the RO granted an increased evaluation of 70 percent for PTSD for the entire appeal period.  However, as this increase did not constitute a full grant of the benefits sought, the Veteran's claim for a higher evaluation for PTSD remains on appeal.  See AB v. Brown, 6 Vet. App. 35, 38-39 (1993).  

In a January 2013 rating decision, pursuant to the Board's grant of service connection, the RO granted service connection and an initial rating by analogy of 30 percent for idiopathic anaphylaxis with possible mastocytosis under 38 C.F.R. § 4.118, DC 7899-7806.  Subsequently, the RO recharacterized this disability and granted an increased rating for urticarial rash due to idiopathic anaphylaxis with possible mastocytosis, rated as 60 percent for the entire appeal period under 38 C.F.R. § 4.118, DC 7899-7806.  See June 2015 rating decision and supplemental statement of the case.  The RO has also granted analogous ratings for angioneurotic edema due to idiopathic anaphylaxis with possible mastocytosis, rated as 40 percent for the entire appeal period, and for intermittent inhalational use due to idiopathic anaphylaxis with possible mastocytosis, rated as 10 percent effective from April 28, 2010.  See id.  However, these increased evaluations for idiopathic anaphylaxis with possible mastocytosis do not constitute a full grant of the claim for increased compensation on appeal, and the separately rated urticarial rash, angioneurotic edema, and intermittent inhalational use are part and parcel of the Veteran's claim for increased compensation for idiopathic anaphylaxis with possible mastocytosis.  Accordingly, all three of these issues are on appeal for increased compensation and are before the Board at this time.  See AB v. Brown, 6 Vet. App. 35, 38-39 (1993).  

The record shows that the issue of entitlement to SMC for aid and attendance is raised.  In February 2013, the Veteran submitted a formal claim for SMC for aid and attendance in conjunction with the claim for increased compensation due to idiopathic anaphylaxis with possible mastocytosis.  See also July 2014 Veteran statement (claiming SMC for aid and attendance due to skin disability).  In an August 2014 rating decision, the RO denied the claim for entitlement to SMC based on aid and attendance.  Under Akles v. Derwinski, 1 Vet. App. 118 (1991), the issue of entitlement to SMC is part and parcel of a claim for increased rating.  Akles supports the inference that as long as an increased rating claim remains pending, the SMC issue remains pending.  The Board also notes that though the RO has granted SMC based on housebound status, the issue of SMC for aid and attendance is a greater benefit than SMC based on housebound status, and entitlement to each SMC is based on distinct criteria.  See 38 C.F.R. § 3.350.  Thus, though the Veteran did not submit a notice of disagreement with the August 2014 rating decision, entitlement to SMC based on the need for aid and attendance must still be considered in conjunction with the claim for increased compensation on appeal.  

The issues of entitlement to SMC for aid and attendance and to an initial disability rating greater than 10 percent for intermittent inhalational use due to idiopathic anaphylaxis with possible mastocytosis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1.  For the entire period on appeal, the Veteran's service-connected PTSD is manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgement, thinking, or mood, due to such symptoms as chronic sleep impairment with low daytime energy; nightmares; anxiety; hypervigilance; mild memory loss; impairment of concentration; disturbances of motivation and mood; occasional periods of suicidal ideation; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with quick escalation of anger and angry outbursts); occasional neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and, difficulty in establishing and maintaining effective relationships; and, it is not manifested by total occupational and social impairment.  

2.  For the entire appeal period, the Veteran's skin manifestations due to idiopathic anaphylaxis with mastocytosis is manifested by flushing and urticaria with more than 40 percent of the entire body or more than 30 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period.

3.  For the entire appeal period, the Veteran's edema due to idiopathic anaphylaxis with mastocytosis is manifested during the entire appeal period by attacks with laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year.  

4.  For the entire appeal period, the Veteran's gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis are manifested by severe symptoms with diarrhea, or alternative diarrhea and constipation, with more or less constant abdominal distress.

5.  The Veteran does not currently have bladder cancer and has not had such disability during the pendency of the claim.


CONCLUSIONS OF LAW

1.  For the entire appeal period, the criteria for an initial disability rating greater than 70 percent for PTSD have not been met or approximated.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2014).

2.  For the entire appeal period, the criteria for an initial disability rating greater than 60 percent for skin manifestations due to idiopathic anaphylaxis with mastocytosis, have not been met or approximated.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.118, Diagnostic Codes 7800, 7806, 7817, 7825 (2014).

3.  For the entire appeal period, the criteria for an initial disability rating greater than 40 percent for edema due to idiopathic anaphylaxis with mastocytosis have not been met or approximated.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.104, Diagnostic Code 7118, 7120 (2014).

4.  For the entire appeal period, the criteria for a disability rating of 30 percent, but no higher, for gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis, have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.114, Diagnostic Code 7203, 7301, 7305, 7306, 7319, 7321 (2014).

5.  Bladder cancer was not incurred in or aggravated by service.  38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Compliance with Prior Remand

In March 2015, the Board remanded the matters regarding PTSD, bladder cancer, and idiopathic anaphylaxis with possible mastocytosis to afford the Veteran a hearing before the Board, and a Board hearing was held in June 2015.  The claims were then readjudicated in June 2015 supplemental statements of the case.  Thus, the Board's prior remand instructions have been substantially complied with.  See Stegall v. West, 11 Vet. App. 268, 271 (1998).  

Duties to Notify and Assist

VA has met all the duty to notify and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA).  See 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326 (2014).  



Duty to Notify

When VA receives a complete or substantially complete application for benefits, it will notify the Veteran of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).  VA must also provide the Veteran with information regarding how VA determines effective dates and disability ratings.  Dingess v. Nicholson, 19 Vet. App. 473 (2006).  The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO.  Pelegrini v. Principi, 18 Vet. App. 112 (2004).  

Regarding increased initial ratings for idiopathic anaphylaxis with possible mastocytosis and for PTSD, the RO provided pre-adjudication notice by letters in January 2008 and May 2012, in which the Veteran was notified as to the evidence necessary to support the underlying claims for entitlement to service connection for idiopathic anaphylaxis with possible mastocytosis and for PTSD and regarding the manner with which VA determines disability ratings and effective dates.  Because entitlement to service connection for idiopathic anaphylaxis with possible mastocytosis and PTSD has been granted and an effective dates have been assigned, the purpose for serving notice has been fulfilled and further VCAA notice as to these increased rating claims is unnecessary.  Dingess v. Nicholson, 19 Vet. App. 473, 490-91 (2006).

Regarding service connection for bladder cancer, the RO provided pre-adjudication VCAA notice by letter in September 2011, in which the Veteran was notified of how to substantiate his claim for service connection for bladder cancer, information regarding the allocation of responsibility between the Veteran and VA, and information on how VA determines effective dates and disability ratings.  The Board finds that VA has fulfilled its duty to notify.




Duty to Assist

VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claim.  Service treatment records, relevant post-service treatment records, and lay statements have been associated with the record. 

Further, regarding PTSD, the Veteran has been afforded VA examinations in June 2014 and April 2015.  The examiners each conducted an examination and provided sufficient information regarding the Veteran's psychological manifestations such that the Board can render an informed determination.  The Board finds that the VA examinations regarding PTSD are adequate for rating purposes.   

Regarding idiopathic anaphylaxis with possible mastocytosis, the Veteran has been afforded VA examinations in May 2009, June 2014, and April 2015, and a May 2015 addendum opinion followed.  The examiners each conducted an examination and provided sufficient information regarding the Veteran's manifestations of idiopathic anaphylaxis and mastocytosis such that the Board can render an informed determination.  The Board acknowledges that the Veteran has argued that the May 2009 VA examination is inadequate because he only took his shirt off at the examination.  See August 2009 Form 9.  However, the Veteran argues that this examination is inadequate for purposes of establishing a diagnosis and service connection for mastocytosis, and the issue of entitlement to service connection for mastocytosis has been resolved.  Because the May 2009 VA examination provides adequate information regarding the Veteran's symptoms and manifestations of idiopathic anaphylaxis with mastocytosis at the time of examination, the Board finds that this examination is adequate for rating purposes.  The Board finds that the VA examinations regarding idiopathic anaphylaxis with mastocytosis in this case are adequate for rating purposes.   

Regarding bladder cancer, the Veteran was afforded a VA examination in June 2014.  The examiner conducted an examination, reviewed the claims file, and provided sufficient information regarding whether the Veteran has bladder cancer such that the Board can render an informed determination regarding service connection.  Thus, this examination is adequate.  

The Board acknowledges that the Veteran reported that he was taken to the Poudre Valley hospital via ambulance on December 11, 2014 for an allergic reaction, and that such private treatment records are outstanding.  See December 2014 VA treatment records.  However, in March 2015, VA sent a letter to the Veteran requesting him to provide information as to private treatment providers and to complete and return a VA Form 21-4142 so that VA can obtain outstanding private treatment records on his behalf.  The AOJ advised the Veteran that he may want to obtain and send the information himself.  However, to this date, the Veteran has not responded regarding such updated treatment from Poudre Valley Hospital.  The duty to assist is not a one-way street.  Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).  Therefore, without the Veteran's participation, the VA is unable to obtain the identified relevant private treatment records.  No additional actions were available or required of the VA.    

The Board acknowledges that updated private treatment records from Peak Gastroenterology Associates may be outstanding and may be relevant to the claim for increased compensation for idiopathic anaphylaxis with mastocytosis.  See March 2015 Form 21-4142 (noting treatment at Peak Gastroenterology Associates from March 2014 to March 2015) (records from May 2014 to June 2014 are associated with the claims file).  The AOJ has made sufficient efforts to obtain the outstanding records.  See March 2015 request for records; April 2015 Report of General Information (AOJ then faxed the request for records two more times in March 2015, and there was no response).  The AOJ provided the Veteran with notice as to the unavailability of these records in April 2015, pursuant to 38 C.F.R. § 3.159(e), including notifying the Veteran that it is ultimately his responsibility to obtain relevant evidence and submit such in support of his claim; however, the Veteran has not submitted these updated private treatment records.  For these reasons, the Board concludes that VA has satisfied its duty to assist.    

Rating Principles

In evaluating the severity of a certain disability, it is essential to consider its history.  38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Separate ratings may be assigned for separate periods of time based on the facts found.  This practice is known as "staged ratings."  Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007).  

If the evidence for and against a claim is in equipoise, the claim will be granted.  A claim will be denied only if the preponderance of the evidence is against the claim.  See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990).  Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant.  38 C.F.R. § 4.3.  Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  

VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991).

The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show.  The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein.  See Timberlake v. Gober, 14 Vet. App. 122 (2000).  

Evaluation for PTSD

The Veteran's service-connected PTSD is currently rated as 70 percent disabling for the entire period on appeal under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (PTSD).  The Veteran contends that this rating does not accurately depict the severity of his disability.  

The General Rating Formula for Mental Disorders provides that mental disorders are to be rated under 38 C.F.R. § 4.130 as follows:

70 percent disabled for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with 
routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal 
appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.

100 percent disabled for 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 name. 

The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category.  See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002).  However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous."  Id.   The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating."  Id.  Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples.  Put another way, the severity represented by those examples may not be ignored.

A Global Assessment of Functioning (GAF) score can indicate the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  See Richard v. Brown, 9 Vet. App. 266 (1996).  A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders.  
See Massey v. Brown, 7 Vet. App. 204, 207 (1994).  However, disability ratings are not assigned based solely on GAF scores.  See 38 C.F.R. § 4.130.  

GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).  Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job).  Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work).  

GAF scores ranging from 21 to 30 reflect behavior considerably influenced by delusions or hallucinations or serious impairment in communication, or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).  Scores ranging from 11 to 20 reflect some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or occasionally fails to maintain minimal personal hygiene (e.g., smears feces), or gross impairment in communication (e.g., largely incoherent or mute).  

The Veteran is competent to report his psychiatric symptoms and observations, and the Board finds these reports as to his psychiatric symptoms credible.  

The Veteran's PTSD is currently rated under DC 9411.  The Board acknowledges that the Veteran has also been diagnosed with other psychiatric disorders other than PTSD, including depressive disorder and anxiety disorder.  See e.g., March 2015 VA treatment records.  However, the medical evidence shows that it is not possible to differentiate what symptoms are attributed to the diagnosis of PTSD or to the nonservice-connected psychiatric disorders.  See e.g.,  April 2015 VA examination (noting that the Veteran's PTSD includes symptoms of panic attacks and depression).  Therefore, the Board must consider all of the Veteran's psychiatric symptoms in rendering an evaluation for PTSD.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998).

The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."  Butts v. Brown, 5 Vet. App. 532, 538 (1993).  The Veteran's PTSD is currently rated under DC 9411.  Any psychiatric disorder is rated under the General Rating Formula for Mental Disorders, and the criteria under this formula shall be considered no matter what diagnostic code is assigned.  Because DC 9411 contemplates the Veteran's service-connected diagnosis of PTSD and his psychiatric symptoms, the Board concludes that the Veteran is appropriately rated under DC 9411.

For the entire period on appeal, the evidence shows that the Veteran's service-connected PTSD is manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgement, thinking, or mood, due to such symptoms as chronic sleep impairment with low daytime energy; nightmares; anxiety; hypervigilance; mild memory loss; impairment of concentration; disturbances of motivation and mood; occasional periods of suicidal ideation; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with quick escalation of anger and angry outbursts); occasional neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and, difficulty in establishing and maintaining effective relationships.  See e.g., VA treatment records from September 2011 to March 2015; May 2014 VA mental health treatment note; June 2014 VA examination; July 2014 private medical opinion and DBQ by Dr. F.; April 2015 VA examination.  

The Board finds that the preponderance of the evidence is against a finding that the Veteran has psychiatric symptoms are of a severity, frequency, and duration so as to cause total social and occupational impairment.  For example, though the Board acknowledges that the Veteran's speech is noted as occasionally loud when he is angry, because the medical evidence shows logical and linear thought processes and speech generally within normal limits, gross impairment in thought processes or communication is not shown.  See e.g., VA treatment records from September 2011 to March 2015; April 2015 VA examination (showing that though processes are consistently logical and goal-oriented; Veteran presented as polite and cooperative in manner); December 2014 VA mental health note (noting that Veteran's speech is loud at times, but at a normal rate and volume).  Also, persistent delusions or hallucinations and disorientation to time and space are not shown.  See e.g., VA treatment records from September 2011 to March 2015 (showing Veteran is consistently oriented to time and space); April 2015 VA examination. 

The Board acknowledges that the Veteran has some mild memory loss.  See e.g., April 2014 private examination and DBQ by Dr. F.  However, memory loss for names of close relatives, own occupation, or name is not shown.  See e.g., December 2014 VA mental health note (noting no gross memory problem).  Thus, the Board finds that the Veteran's symptoms of mild memory loss are not of a severity, frequency, and duration so as to result in total social and occupational impairment.  

The Board acknowledges that the Veteran has symptoms of recurrent impaired impulse control, to include unprovoked irritability with quick escalation of anger and angry outbursts.  See e.g., VA treatment records from September 2011 to March 2015.  The Board also notes that the Veteran's treatment records show that the Veteran's angry outbursts occur frequently and can result in some inappropriate behavior.  See e.g., October 2012 VA treatment record (Veteran was noted as screaming and angry at staff during an idiopathic anaphylaxis with mastocytosis reaction; VA provider noted that Veteran was aggressive grabbing his arm at one point and that his behavior was inappropriate; VA provider noted that when Veteran returned to the VA facility, he rudely dropped his medications for fill on the nurse's desk and walked out without any comment).  However, the evidence does not show that the Veteran's symptoms are of such a severity so as to constitute grossly inappropriate behavior.  Significantly, there is no evidence that the Veteran becomes violent with his VA providers, with whom he is shown to be frequently angry, and there is evidence that the Veteran is able to act cooperatively and communicate his concerns with VA providers and others despite his anger.  See e.g., April 2012 VA homeless program note (noted Veteran was highly irritable and periodically tearful, but cooperative with the assessment); February 2013 VA social worker notes (nothing quick escalation of anger and loud ranting, but also that Veteran accepts feedback from social worker; notes that raised voice and pressured speech when speaking about contentious and sensitive topics may be received as "yelling" and volatile by others); March 2013 VA mental health intake and assessment note (behavior is polite and cooperative, though irritable); March 2013 VA mental health note (mood was angry while discussing physical issues, behavior was completely appropriate though he is frustrated and disappointed with the system, in that though expressing his anger, he was appropriate and careful with staff, and he states he knows that his anger is harming him physically and wants to learn how to manage them); December 2014 VA mental health note (noting that Veteran's behavior is cooperative with good eye contact, though with angry affect).  The Board also notes that the Veteran has attended anger management sessions at VA and reports trying to maintain control when he is angry.  See e.g., March 2013 VA mental health intake and assessment note; May 2013 VA anger management group note.  Thus, the Board finds that the Veteran's symptoms of recurrent impaired impulse control, to include unprovoked irritability with quick escalation of anger and angry outbursts are not of a severity, frequency, and duration so as to result in total social and occupational impairment.  

The Board acknowledges that the Veteran has noted occasional thoughts of suicide.  See July 2014 private medical opinion and DBQ by Dr. F.  However, because the vast majority of medical evidence during the appeal period shows that the Veteran denies suicidal ideation and homicidal ideation, persistent danger of hurting self or others is not shown.  See e.g., VA treatment records from September 2011 to March 2015 (recurrently denying suicidal and homicidal ideation); February 2013 VA social worker note (noted that Veteran is future oriented and does care about his horse of 25 years, which gives him a reason to live); April 2015 VA examination (Veteran denies current thoughts of suicide).  Thus, the Board finds that the Veteran's symptom of occasional thoughts of suicide is not of a severity, frequency, and duration so as to result in total social and occupational impairment.  

The Board acknowledges that the Veteran was homeless and was living in his truck from April 2011 to February 2013 because he could not afford to pay rent.  See November 2011 VA mental health note; April 2012 VA treatment record (Veteran has been homeless for one year, and cannot pay rent); February 2013 VA homeless program note (Veteran moved in with a friend of a friend).  The Board also acknowledges that the Veteran occasionally presents with decreased grooming or with body odor, including when the Veteran was homeless and living in his truck.  See e.g., February 2013 VA social worker note (Veteran is appropriately dressed, but there is body odor and soiled clothing); December 2014 VA mental health note (Veteran was unshaven, hair longer).  However, because the vast majority of medical evidence during the appeal period, to include when the Veteran was homeless, shows that the Veteran is able to feed himself, take himself to medical appointments, and consistently maintains minimal cleanliness and dresses appropriately, the Board finds that intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) is not shown.  See e.g., September 2011 to March 2015 VA treatment records; April 2015 VA examination (showing that the Veteran was dressed in clean casual clothes).  

The Board also notes that even when the Veteran was homeless, he was working with the VA homeless program and taking steps to find an affordable place to live that would also accommodate his horse and his healthcare needs.  See e.g., February 2013 VA social worker note (noting that Veteran was angry but calm when speaking with the VA social worker, and he shows that he understands the dangers of exposure to triggers to anaphylactic reactions and that he wishes to continue with the VA housing program); March 2013 VA mental health note (Veteran noted continued homelessness because he was unable to find a suitable place due to the crime or allergies).  The Board also notes that the Veteran has not been shown as incapable of managing his financial affairs.  See e.g., April 2014 private examination and DBQ by Dr. F.; April 2015 VA examination.  For these reasons also, the Board finds that the Veteran's homelessness does not approximate the severity reflected in the symptom of intermittent inability to perform activities of daily living.  

The Board acknowledges that the Veteran has consistently reported that when he was employed in construction and real estate, his PTSD symptoms caused problems if he had to be around crowds, and particularly if it involved a group of black men, and that he can't be around people when it got dark.  See April 2015 VA examination; June 2015 Board hearing transcript at p. 25.  However, the Board notes that though the Veteran is unable to be around crowds, he generally attends his mental health treatment appointments on a regular basis, including anger management group therapy, and he has lived with a roommate and has a few friends during the current appeal period.  See e.g., March 2013 VA mental health intake and assessment note (Veteran reported having a few friends); May 2013 VA anger management group notes; August 2013 VA mental health treatment note (living with a female friend who gives him his space; he reports that he has a few friends).  Further, the Veteran reported that he also has some interaction with his daughter.  See e.g., June 2012 VA homeless program note (Veteran reported increased social and/or family contacts in the past 30 days); April 2014 private examination and DBQ by Dr. F.  For these reasons, the Veteran's symptoms are not shown to be of a severity, frequency, and duration so as to result in total social impairment.  

The evidence also shows that the Veteran has chronic sleep impairment and nightmares with low daytime energy.  The Board also acknowledges that the Veteran has symptoms of panic attacks more than once per week, and that the Veteran stated he would get panic attacks after his allergic reactions and this would affect work performance.  See e.g., April 2015 VA examination.  However, the evidence does not show that the Veteran's symptoms such as anxiety, panic attacks, fatigue, and inability to be around crowds, particularly black men and when it is dark, are of a severity, frequency, and duration so as to result in total occupational impairment.  The record shows that the Veteran has consistently taken care of his pet horse during the appeal period, including when he was homeless, and that the Veteran has a history of training horses.  See e.g., April 2012 VA treatment record; March 2013 VA mental health note (Veteran has a horse that he boards which he will not give up as he has had him for 35 years and is very attached to him; Veteran rides his horse when he can get there and has a history of training horses).  For these reasons, the Veteran's symptoms are not shown to be of a severity, frequency, and duration so as to result in total occupational impairment.  

On review, the Board finds that the evidence does not show that the Veteran's psychiatric symptoms are of a severity, frequency, and duration so as to meet or approximate total social and occupational impairment.  Accordingly, the Board finds that the evidence does not show that the Veteran has symptoms of such severity, frequency, and duration so as to approximate the level of impairment provided for a 100 percent rating in the rating schedule.  The Board also notes that the Veteran has not argued that a rating greater than 70 percent is warranted.  See June 2015 Board hearing transcript at p. 7; August 2014 Veteran statement (arguing that a 70 percent rating is warranted).  Therefore, the Board finds that during the entire appeal period, the preponderance of the evidence is against a finding that the Veteran has total social and occupational impairment due to his service-connected PTSD.  Thus, during the entire appeal period, the criteria for a disability rating of 100 percent have not been met or approximated.  See 38 C.F.R. § 4.130, DC 9411.  Therefore, for the entire period on appeal, a disability rating greater than 70 percent for PTSD is not warranted.  38 C.F.R. § 4.7.

The Board also notes that during the entire appeal period, the Veteran's GAF scores do not support a finding that the Veteran's overall disability picture is consistent with a rating greater 70 percent.  During the appeal period, the Veteran's lowest given GAF score was 35, and the majority of his GAF scores fall within the range of 41-50.  See July 2014 private medical opinion and DBQ by Dr. F.; see e.g., VA treatment records from September 2011 to March 2015.  Though the Veteran's lowest GAF score indicates major impairments in occupational and social functioning and in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work), impairment in reality testing is not shown, and his GAF scores do not show total impairment in occupational and social functioning.  

At no point during the appeal period have the criteria for a rating greater than 70 percent been met or approximated for PTSD.  The Board has considered the applicability of the benefit of the doubt doctrine.  However, because the preponderance of the evidence is against a finding that a rating greater than 70 percent is warranted, the benefit of the doubt doctrine is not applicable.  38 U.S.C.A. § 5107(b).   

Evaluation for Idiopathic Anaphylaxis 
with Mastocytosis

The Veteran's service-connected idiopathic anaphylaxis with possible mastocytosis is currently separated rated by analogy under various diagnostic codes.  The Veteran contends that his current ratings do not depict the severity of his disability.  

Because the rating schedule does not specifically list idiopathic anaphylaxis and mastocytosis, the Board will rate the Veteran's manifestations thereof by analogy under a closely related disability with similar anatomical localization and symptomatology.  38 C.F.R. § 4.20.  

The Board notes that the medical evidence does show that the Veteran has cutaneous (involving the skin) mastocytosis and mastocytic enterocolitis.  See April 2015 VA examination; June 2014 VA examination; June 2014 private treatment record from Peak Gastroenterology.  The April 2015 VA examiner reviewed the claims file and stated that the Veteran's idiopathic anaphylaxis with mastocytosis can include a variety of symptoms, and he noted that the following symptoms are common to many (if not all) of the Veteran's episodes: a decrease in blood pressure (hypotension), difficulty breathing, facial and oral swelling and a skin rash.  See also June 2014 VA examination.  The medical evidence shows that some of the symptoms he has with cutaneous mastocytosis are similar to the symptoms he has due to anaphylaxis reaction.  See April 2015 VA examination.  The medical evidence also shows that the Veteran uses routine and daily medications to treat both anaphylaxis and mastocytosis, including prednisone, an immunosuppressive drug for treatment of the skin symptom of urticaria, and diphenhydramine (Benadryl), an antihistamine that is not an immunosuppressive drug for treatment of anaphylaxis, mastocytosis, and urticaria.  Id.

Because the Veteran's appeal for increased compensation for his service-connected idiopathic anaphylaxis is characterized to include the possibility of mastocytosis, the Board will evaluate the symptoms and manifestations of both diagnoses.  The Board acknowledges the Veteran's argument that increased compensation is warranted because he is diagnosed with both idiopathic anaphylaxis and mastocytosis.  However, the Board must avoid assigning separate evaluations for the same symptoms and manifestations under different diagnoses, and the Board will evaluate the Veteran's same symptoms and manifestations attributed to both idiopathic anaphylaxis and mastocytosis under whichever diagnostic code(s) allows for the highest possible rating for such symptoms and manifestations.  See 38 C.F.R. § 4.14.  

Skin Manifestations

The Veteran's skin manifestations due to idiopathic anaphylaxis with mastocytosis are rated by analogy as 60 percent for the entire appeal period under 38 C.F.R. § 4.118, DC 7899-7806 (pertaining to dermatitis and eczema). 

The Board notes that though the medical evidence shows that the Veteran's idiopathic anaphylaxis and mastocytosis both manifest skin symptoms, an urticarial rash (hives) would be more consistent with anaphylaxis, while flushing of the skin would be more consistent with mastocytosis, the Veteran does have both types of skin manifestations.  See April 2015 VA examination.  Because the diagnostic codes for evaluation of skin disabilities do not specifically contemplate the Veteran's idiopathic anaphylaxis with mastocytosis, skin symptoms due to these disabilities should be rated by analogy under a closely related diagnostic code for a related disease or injury.  38 C.F.R. § 4.20.  

The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."  Butts v. Brown, 5 Vet. App. 532, 538 (1993).  The Board finds that the Veteran's symptoms, specifically to include flushing of the skin and hives and usage of immunosuppressive drug therapy, are contemplated by the diagnostic code for dermatitis and eczema under DC 7806.  See 38 C.F.R. § 4.118; see also DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (32nd ed. 2012) at 494 and 592 (showing that dermatitis and eczema feature inflammation of the skin, occurring as reactions to endogenous or exogenous agents, and that in chronic types there may be lichenification, skin thickening, signs of excoriation; and areas of hyperpigmentation or hypopigmentation; and, a common type is allergic or atopic dermatitis).  The Board acknowledges that the Veteran's prior representative has argued that the Veteran's urticaria (hives) should be rated under DC 7825, which specifically pertains to urticaria.  See June 2012 Form 646.  However, the Board notes that a 60 percent rating is the maximum rating provided under DC 7825.  Therefore, a rating greater than 60 percent would not be warranted under DC 7825.  See 38 C.F.R. § 4.118.  Further, though the evidence tends to show debilitating episodes of urticaria with use of immunosuppressive therapy, which is contemplated by DC 7825, the Board notes that the Veteran's hyperpigmentation or hypopigmentation of the skin is not contemplated by DC 7825.  Because DC 7806 contemplates all of the Veteran's skin manifestations, including hives, itching, and flushing of the skin, the Board concludes that the Veteran's skin manifestations of idiopathic anaphylaxis with mastocytosis are appropriately rated under DC 7806.  

Under DC 7806, a 60 percent maximum rating is warranted for more than 40 percent of the entire body or more than 30 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period.  38 C.F.R. § 4.118, DC 7806.  

For the entire appeal period, the evidence shows that the Veteran's idiopathic anaphylaxis with mastocytosis is manifested by flushing of the skin and urticarial rash that includes red itchy bumps affecting diffuse areas of the body and, beginning in February 2013, requires constant or near-constant systemic therapy with immunosuppressive medication in the past 12 months.  See e.g., November 2007 VA treatment record (reporting skin hives during anaphylactic reactions); May 2009 VA examination (noting that urticaria rash can be all over the body, mostly from the waist down and in the lower extremities; Veteran takes prednisone for five days for treatment of allergic reaction); June 2010 VA dermatology consult (noting videotape showing total body urticaria and lesion on right upper lateral cutaneous lip); January 2011 private treatment record from Dr. C. (noting that an August 2010 National Jewish Health private treatment record showed symptoms of daily urticaria); August 2010 private treatment record from Poudre Valley Hospital (hives on upper extremities); August 2012 Longmont United Hospital Emergency Department record (noting diffuse urticaria, and Veteran was treated with antihistamines and steroids); October 2012 VA treatment record (noting hives on abdomen to mid chest, entire legs into groin, arms and elbows, veteran taken to Poudre Valley Hospital); October 2012 private treatment record from Poudre Valley Hospital (hives on abdomen, arms, and legs); October 2012 Veteran statement; February 2013 private treatment record from Dr. C.; February 2013 private treatment record from Dr. C. (showing that daily use of prednisone was prescribed and started that day); February 2015 VA treatment record (Veteran is prescribed prednisone for use every day); April 2015 VA examination (showing that prednisone is not used for treatment of the Veteran's shortness of breath due to anaphylaxis with mastocytosis).  Based on this evidence, the Board finds that for the entire period on appeal the Veteran's skin manifestations due to idiopathic anaphylaxis with mastocytosis is manifested by flushing and urticaria with more than 40 percent of the entire body or more than 30 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period.  38 C.F.R. § 4.118, DC 7806.  The Board also notes that the Veteran has not argued that a rating greater than 60 percent is warranted for his skin manifestations.  See July 2014 Veteran statement (arguing that a 60 percent rating for urticarial rash is warranted).  Because a 60 percent rating is the highest rating available under DC 7806, a rating higher than 60 percent under DC 7806 is not warranted.  38 C.F.R. § 4.118.  Therefore, a 60 percent rating is appropriate for the skin manifestations due to idiopathic anaphylaxis with mastocytosis for the entire appeal period under DC 7806.  38 C.F.R. § 4.118.

The Board has considered DC 7800, which pertains to skin disability that causes disfigurement of the head, face or neck, to include the characteristic of disfigurement of skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.).  See 38 C.F.R. § 4.118, Note (1) (providing the 8 characteristics of disfigurement for purposes of evaluation).  The Board acknowledges that the Veteran's idiopathic anaphylaxis with mastocytosis causes diffuse urticaria that can cause flushing and discoloration of the skin of the face and neck.  See e.g., October 2012 Veteran statement; May 2009 VA examination.  However, because visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) is not shown, and only one characteristic of disfigurement, namely hypo- or hyper-pigmentation of the skin is shown, a disability rating of 10 percent, and no higher, would be warranted under DC 7800.  38 C.F.R. § 4.118.  As such, a rating greater than 60 percent is not warranted under DC 7800.  

The Board has considered the applicability of other analogous diagnostic codes in determining whether a higher rating is warranted for the Veteran's skin symptoms due to idiopathic anaphylaxis with mastocytosis.  The Board notes that though DC 7817, regarding exfoliative dermatitis (erythroderma), contemplates the Veteran's redness of the skin and the use of constant or near-constant systemic therapy with immunosuppressive medication in the past 12-month period, the medical evidence shows that the Veteran does not have removal of scales or flakes from the surface of the skin.  See e.g., April 2015 VA examination.  As such, the Veteran does not have symptomatology that is analogous to that of exfoliative dermatitis.  See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (32nd ed. 2012) at 495, 645 and 659 (showing that exfoliative dermatitis or erythroderma features symptoms of abnormal redness of the skin, hyperkeratosis, and the removal of scales or flakes from the surface of the skin).  Therefore, DC 7817 is not for application.  See 38 C.F.R. §§ 4.118, DC 7817, 4.20.  

The Board acknowledges that the Veteran's idiopathic anaphylaxis with mastocytosis presents with a clinical picture that is similar only in part to dermatitis or eczema, and will evaluate the Veteran's other symptoms as discussed below.  See August 2014 private treatment record by Dr C. (stating that idiopathetic anaphylaxis with mastocytosis are much more serious life-threatening conditions than dermatitis or eczema).  

Edema

The Veteran's edema due to idiopathic anaphylaxis with mastocytosis is rated as 40 percent for the entire appeal period under 38 C.F.R. § 4.104, DC 7118 (pertaining to angioneurotic edema).

The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."  Butts v. Brown, 5 Vet. App. 532, 538 (1993).  Because DC 7118 specifically contemplates the Veteran's diagnosis of angioneurotic edema and all his symptoms of edema, the Board finds the Veteran's angioneurotic edema due to idiopathic anaphylaxis with mastocytosis is appropriated rated under DC 7118.  

Under DC 7118, pertaining to angioneurotic edema, a 40 percent maximum rating is warranted for attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year.  38 C.F.R. § 4.104, DC 7118.

For the entire appeal period, the evidence shows that the Veteran has attacks of idiopathic anaphylaxis with mastocytosis, which are manifested by swelling of multiple parts of the Veteran's body lasting one to seven days or longer and occurring more than eight times a year.  See e.g., August 2010 private treatment record from Poudre Valley Hospital (swollen lips); October 2012 private treatment record from Poudre Valley Hospital (swelling of upper lip); February 2013 and April 2013 private treatment records by Dr. C.; April 2015 VA examination (noting that hypotension during anaphylaxis and mastocytosis reaction causes swelling of the feet; diagnosing the Veteran with angioneurotic edema associated with the idiopathic anaphylaxis with mastocytosis, which is manifested by edema of both lower extremities with laryngeal involvement that lasts 1 to 7 days and occurs more than 8 times per year).  Because the Veteran's edema is manifested during the entire appeal period by attacks with laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, the criteria for a 40 percent rating are met for edema due to idiopathic anaphylaxis with mastocytosis for the entire appeal period under DC 7118.  38 C.F.R. § 4.104.  Because a 40 percent rating is the highest rating available under DC 7118, a rating higher than 40 percent under DC 7118 is not warranted.  Id. 

The Board has considered the applicability of other analogous diagnostic codes in determining whether a higher rating is warranted for the Veteran's manifestations of edema.  It is noted that the April 2015 VA examiner stated that the Veteran's hypotension due to idiopathic anaphylaxis is not considered a diagnosis and would be considered a vascular condition that is part of the overall clinical picture of anaphylaxis.  The April 2015 VA examiner stated that hypotension is often manifested by dilation of peripheral blood vessels, which can lead to peripheral edema (swelling in the feet).  The April 2015 VA examiner also noted that the Veteran reports that he does not always have swelling in his feet when he has a reaction.  The Board notes that 38 C.F.R. § 4.104, DC 7120, pertaining to varicose veins, contemplates the Veteran's symptoms of peripheral edema due to a vascular condition.  

Under DC 7120, pertaining to varicose veins, a 10 percent rating is warranted for intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery.  A 20 percent rating, a 40 percent rating, and a 60 percent rating is warranted if there is persistent edema.  A 100 percent maximum rating is warranted for varicose veins resulting in massive board-like edema with constant pain at rest.  

For the entire appeal period, there is no lay or medical evidence of massive board-like edema, and the Veteran himself has reported that his symptoms of swelling of the feet are not always present and are therefore are not persistent.  Therefore, a 10 percent rating, but no higher, is warranted for the Veteran's edema under DC 7120.  Accordingly, a disability rating greater than 40 percent is not warranted under DC 7120 for the Veteran's edema due to idiopathic anaphylaxis with mastocytosis.  38 C.F.R. § 4.104.

The Board notes that the issue of entitlement to SMC for loss of use of the lower extremity or extremities is not raised by the medical evidence or by the Veteran.  The evidence shows that the Veteran is able to walk without assistive devices, and the medical evidence does not show that there is functional impairment of either lower extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis.  See April 2015 VA examination and May 2015 addendum opinion; June 2014 VA examination; June 2014 VA aid and attendance or housebound examination (noting that the Veteran has imbalance affecting the ability to ambulate less than weekly and occasionally).  Accordingly, the Board does not infer this matter and it is not before the Board at this time.  See Akles v. Derwinski, 1 Vet. App. 118 (1991).
  
Other Ratings by Analogy 

The medical evidence shows that the Veteran has other symptoms of idiopathic anaphylaxis with mastocytosis that have not been rated by analogy under appropriate diagnostic codes by the AOJ.  Thus, the Board will do so, as discussed below.  See 38 C.F.R. § 4.20.  

The medical evidence shows that the Veteran's reported gastrointestinal symptoms during the appeal period can be attributed to idiopathic anaphylaxis with mastocytosis, and that the Veteran's mastocytosis has gastrointestinal component.  See June 2014 private treatment record from Peak Gastroenterology (diagnosing mastocytic enterocolitis, mastocytosis, and other nonservice-connected gastrointestinal disabilities); June 2014 VA examination (noting that the Veteran has cutaneous mastocytosis and mastocytic enterocolitis).  Because the Veteran's gastrointestinal symptoms cannot clearly be separately attributed to the service-connected idiopathic anaphylaxis with mastocytosis and to his nonservice-connected gastrointestinal disabilities, the Board will consider all of the Veteran's gastrointestinal symptoms as attributed to his service-connected anaphylaxis with mastocytosis in rendering an evaluation for the same.  See Mittleider v. West, 11 Vet. App. 181 (1998).  

The Veteran's gastrointestinal symptoms and manifestations are contemplated by multiple diagnostic codes pertaining to the digestive system.  However, it is noted that the Veteran is diagnosed with mastocytic enterocolitis, and the medical evidence shows that the Veteran's gastrointestinal symptoms are recurrent.  See e.g., June 2014 private treatment record from Peak Gastroenterology Associates.  DC 7326 provides that chronic enterocolitis is to be rated as for irritable colon syndrome.  38 C.F.R. § 4.114.  Irritable colon syndrome is rated under DC 7319.  Id.  Because DC 7319 specifically contemplates the Veteran's diagnosis of mastocytic enterocolitis and his gastrointestinal symptoms, the Board finds the Veteran's gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis are to be rated by analogy under DC 7319.  See 38 C.F.R. § 4.20; Butts v. Brown, 5 Vet. App. 532, 538 (1993) (assignment of a particular diagnostic code is completely dependent on the facts of a particular case).

Under DC 7319, pertaining to irritable colon syndrome, a 0 percent rating is warranted for mild irritable colon syndrome with disturbances of bowel function with occasional episodes of abdominal distress.  A 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress.  A maximum rating of 30 percent is warranted for severe irritable colon syndrome with diarrhea, or alternative diarrhea and constipation, with more or less constant abdominal distress.  38 C.F.R. § 4.114.  

During the entire appeal period, the Veteran's gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis are manifested by diarrhea, nausea, indigestion, vomiting, occasional epigastric and abdominal pain, intermittent rectal bleeding and bloody stool, heartburn, excessive gas, and some weight loss.  See e.g., January 2008 and February 2008 VA treatment records (Veteran reported daily diarrhea and there was objective pain to palpation in the epigastric area and tenderness of the abdomen, which he reportedly gets when he has an allergic  reaction); February 2009 VA treatment record (noting chronic diarrhea); August 2010 private treatment record from National Jewish Health (Veteran reported indigestion, nausea, diarrhea, constipation, and heartburn); June 2014 private treatment record from Peak Gastroenterology Associates; October 2014 VA treatment record (complains of abdominal pain); December 2014 VA MHV Dialog note (Veteran reported daily nausea, each episode lasting a few minutes to an hour, 3 to 4 times a week he suffers through vomiting); April 2015 medical opinion by Dr. C. (stating that anaphylaxis is characterized gastrointestinal symptoms and that common symptoms of mastocytosis includes abdominal cramping and diarrhea); April 2015 VA examination (noting that when the Veteran has an anaphylactic reaction he has nausea and vomiting).  Based on the evidence, the Board finds that severe symptoms with diarrhea, or alternative diarrhea and constipation, with more or less constant abdominal distress, are shown.  Accordingly, the criteria for a 30 percent rating under DC 7319 have been met.  38 C.F.R. § 4.114.  Because 30 percent is the maximum rating provided under this diagnostic code, a disability rating of 30 percent, but no higher, is warranted for the Veteran's gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis for the entire period on appeal under DC 7319.  Id.  

The Board has also considered the applicability of DC 7321, pertaining to amebiasis.  38 C.F.R. § 4.114.  The Board notes that a potential cause for amebiasis is similar to a possible cause of the Veteran's idiopathic anaphylaxis with mastocytosis.  See December 2012 Board decision (granting service connection for idiopathic anaphylaxis with possible mastocytosis and noting that there is medical evidence to show that such disabilities may have been caused by reported chemical exposure); DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (32nd ed. 2012) at 58,  576 (showing that intestinal amebiasis, or amebic dysentery is dysentery, or inflammation of the intestines and colon, manifested by pain in the abdomen, tenesmus, and diarrhea or frequent defecation containing blood and mucus; causes include chemical irritants; amebic dysentery is due to intestinal ulceration caused by severe amebiasis; it may be associated with spread of the infection to the liver and other distant sites).  Accordingly, the Board finds that the Veteran's gastrointestinal symptoms may be rated by analogy under the closely related diagnosis code of DC 7321.  38 C.F.R. §§ 4.114, 4.20.  Under DC 7321, a maximum rating of 10 percent is provided for amebiasis with mild gastrointestinal disturbances, lower abdominal cramps, nausea, gaseous distention, and chronic constitution interrupted by diarrhea.  Though DC 7321 contemplates the Veteran's gastrointestinal symptoms and potential cause of idiopathic anaphylaxis with mastocytosis, because 10 percent is the maximum rating provided by this diagnostic code, a rating greater than 30 percent for the Veteran's gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis is not warranted under DC 7321.  38 C.F.R. § 4.114.

The Board has considered the applicability of other analogous diagnostic codes in determining whether a higher rating is warranted for the Veteran's gastrointestinal symptoms due to anaphylaxis with mastocytosis.  The Board acknowledges that DC 7301, pertaining to adhesions of the peritoneum, DC 7305, pertaining to duodenal ulcer, and DC 7306, pertaining to ulcer, marginal (gastrojejunal), contemplate the majority of the Veteran's gastrointestinal symptoms, such as nausea, diarrhea, vomiting, abdominal pain, and weight loss.  However, there are no medical findings to support that the Veteran has adhesions of the peritoneum or any ulcer due to idiopathic anaphylaxis with mastocytosis.  See e.g., October 2008 EGD results (noting no ulcer, diagnosed with hypersensitivity syndrome and referred Veteran to allergist/ immunologist).  Since adhesions of the peritoneum and ulcer are both conditions of a functional origin, and the Veteran's idiopathic anaphylaxis with mastocytosis are due instead to an organic disease process, the Board finds that a rating by analogy under DC 7301, 7305, or 7306 is not warranted.  See 38 C.F.R. § 4.20 (conjectural analogies will be avoided, as will the use of analogous rating for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings; nor will ratings assigned to organic disease and injuries be assigned by analogy to conditions of functional origin); see also DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (32nd ed. 2012) at 1996-97 (showing that ulcer is a local defect, or excavation of the surface of an organ or tissue, which is produced by the sloughing of inflammatory necrotic tissue).  For these reasons, DCs 7301, 7305, and 7306 are not for application.  See 38 C.F.R. § 4.118.

The Board also acknowledges that the evidence shows that the Veteran has the symptom of difficulty swallowing.  See June 2014 private treatment record from Peak Gastroenterology Associates.  However, because the Veteran's difficulty swallowing has been evaluated under DC 7118 for angioneurotic edema, which, as discussed above, contemplates the symptom of laryngeal edema, and because there are no medical findings showing stricture of the esophagus, the Board concludes that DC 7203, pertaining to stricture of the esophagus, is not for application.  See 38 C.F.R. §§ 4.14, 4.20, 4.104, 4.118. 

At no point during the appeal period have the criteria for higher ratings than those discussed above been met or approximated.  The Board has considered the applicability of the benefit of the doubt doctrine.  However, because the preponderance of the evidence is against a finding that ratings greater than those discussed above are warranted, the benefit of the doubt doctrine is not applicable.  38 U.S.C.A. § 5107(b).   

The Board has addressed the evaluation of the Veteran's respiratory symptoms due to idiopathic anaphylaxis with mastocytosis in the remand, below.  

Extraschedular Rating
 
While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1).  The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical.
 
The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate.  There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. 
 
If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required.  Thun v. Peake, 22 Vet. App. 111 (2008).
 
The Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology pertaining to his service-connected PTSD, which is manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgement, thinking, or mood, due to such symptoms as chronic sleep impairment with low daytime energy; nightmares; anxiety; hypervigilance; mild memory loss; impairment of concentration; disturbances of motivation and mood; occasional periods of suicidal ideation; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with quick escalation of anger and angry outbursts); occasional neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and, difficulty in establishing and maintaining effective relationships.  Further, the ratings expressly contemplate psychiatric symptoms that are not listed specifically in the General Rating Formula for Mental Disorders.  

The Board also finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology pertaining to his skin manifestations due to idiopathic anaphylaxis with mastocytosis, which is manifested by flushing and urticaria with more than 40 percent of the entire body or more than 30 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period.  The Board also finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology pertaining to his edema due to idiopathic anaphylaxis with mastocytosis, which is manifested during the entire appeal period by attacks with laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year.  The Board also finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology pertaining to his gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis, which is manifested by severe symptoms with diarrhea, or alternative diarrhea and constipation, with more or less constant abdominal distress.  

Further, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions.  Thus, the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are therefore adequate.  Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1).  

The Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the Veteran's conditions fail to capture all the service-connected disabilities experienced.  Johnson v. McDonald, 762 F.3d 1362 (2014).  However, in this case, there is no evidence or lay allegation of additional symptoms or disabilities that have not been attributed to a specific service-connected disability or to an impairment due to a service-connected disability that has been remanded for further evaluation.  The Veteran is evaluated for PTSD, rated as 70 percent disabling; skin manifestations due to idiopathic anaphylaxis with mastocytosis, rated as 60 percent disabling; edema due to idiopathic anaphylaxis with mastocytosis, rated as 40 percent disabling; intermittent inhalational use due to idiopathic anaphylaxis with mastocytosis, rated as 10 percent disabling; gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis, rated by the Board as 30 percent disabling; bilateral tinnitus, rated as 10 percent disabling; and, right 5th metacarpal fracture, rated as noncompensable.  The Veteran has at no time during the period under consideration indicated that he believes that the schedular criteria for these disabilities do not adequately describe or reflect his symptomatology.  Further, the Veteran has at no point during the current appeal indicated that his service-connected PTSD or that his service-connected skin manifestations and edema idiopathic anaphylaxis with mastocytosis results in further disability when looked at in combination with his other service-connected disabilities not discussed on appeal.    

Service Connection for Bladder Cancer

A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service.  38 U.S.C.A. §§ 1110; 1131.  

Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The Veteran has recurrently reported that he has bladder cancer during the current appeal period.  The Veteran is certainly competent to testify as to his observations.  However, the Board considers the diagnosis of bladder cancer beyond its own competence to evaluate based upon its own knowledge and expertise.  It follows that the Veteran's lay diagnosis of bladder cancer is not competent evidence, although the Veteran's described observations may be useful to an expert in determining whether the Veteran has bladder cancer.  See Jandreau v. Nicholson, 492 F.3d 1372 (2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011).  Because there is no evidence that the Veteran has medical expertise in the field of oncology, the Board finds the Veteran's lay diagnosis of bladder cancer during the appeal period is of no probative value.   

Here, though the medical evidence shows regular testing for bladder cancer, and the Veteran has a history of bladder cancer prior to the appeal period, the Veteran's bladder cancer is not shown to have returned and has not been diagnosed during the appeal period.  See VA treatment records from August 2011 to March 2015; June 2014 VA medical opinion (noting that Veteran was diagnosed with bladder cancer, shown as transitional cell carcinoma, in 2003, and that Veteran's serial cystoscopies have shown no recurrence of this tumor).  Furthermore, the Veteran has denied currently experiencing symptoms of bladder cancer.  See June 2015 Board hearing transcript at p. 20-21 (reporting that he experienced bladder cancer symptoms when he first applied for mastocytosis, but denying current symptoms); see generally November 2007 initial claim for mastocytosis.    

The Board acknowledges that the Veteran has a history of bladder cancer and that the Veteran has reported in-service occurrences, to include exposure to chemicals, toxins, and radiation in service.  However, given that bladder cancer is not shown by the medical evidence since 2003, which was prior to the appeal period, bladder cancer is not shown at any point during the pendency of the claim.  For these reasons, the Board finds that the first Shedden element, a present disability, is not met, and service connection for bladder cancer is not warranted.  38 C.F.R. § 3.303; see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992).  As the preponderance of the evidence is against the Veteran's claim for service connection for bladder cancer, the claim must be denied.  38 U.S.C.A. § 5107.   


ORDER

Entitlement to an initial disability rating greater than 70 percent for the entire appeal period for PTSD is denied.

Entitlement to an initial disability rating greater than 60 percent for skin manifestations (previously characterized as urticarial rash) due to idiopathic anaphylaxis with mastocytosis for the entire appeal period is denied.

Entitlement to an initial disability rating greater than 40 percent for edema (previously characterized as angioneurotic edema) due to idiopathic anaphylaxis with mastocytosis for the entire appeal period is denied.  

Entitlement to a disability rating of 30 percent, but no higher, for gastrointestinal impairments due to idiopathic anaphylaxis with mastocytosis for the entire appeal period, is granted, subject to the law and regulations governing the payment of monetary benefits.    

Entitlement to service connection for bladder cancer is denied.  


REMAND

As noted above, the issue of entitlement to SMC for aid and attendance is on appeal.  The Veteran was last afforded a VA examination regarding aid and attendance in June 2014, in which the Veteran reported that he needs to live with someone who is able to give him an Epi-pen when needed, or call 911 or perform CPR.  However, the June 2014 VA examiner did not provide an opinion as to whether the Veteran's service-connected disabilities render him so helpless as to require regular aid and attendance of another person, to include consideration of whether the Veteran's service-connected disabilities causes incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment (e.g., allergens).  The Board notes that the record tends to indicate that the Veteran's reactions of idiopathic anaphylaxis with mastocytosis can happen often and unexpectedly, and the medical evidence shows that the Veteran's idiopathic anaphylaxis with mastocytosis can be life-threatening.  See May 2009 VA examination (noting that when the Veteran has a reaction, he is unable to drive and must be driven to the emergency room).  However, the evidence shows that between reactions, the Veteran is able to eat, drink, take care of personal hygiene, and drive.  See May 2009 VA examination.  As such, it remains unclear whether the Veteran is in need of regular aid and attendance of another person.  Because the June 2014 VA examination regarding aid and attendance did not provide enough detail for purposes of determining entitlement to SMC for aid and attendance, the Veteran should be afforded a new VA examination to determine the same.  38 C.F.R. § 4.2.  

Regarding the Veteran's respiratory symptoms due to idiopathic anaphylaxis with possible mastocytosis, the Veteran is currently rated for intermittent inhalational use due to idiopathic anaphylaxis with possible mastocytosis by analogy as 10 percent effective from April 28, 2010, under 38 C.F.R. § 4.97, DC 6699-6602 (pertaining to bronchial asthma).  The Veteran was last afforded a VA examination regarding the Veteran's respiratory symptoms in April 2015, in which the VA examiner stated that the Veteran is also shown to have chronic obstructive pulmonary disease.  Significantly, a April 2015 private medical opinion by Dr. C. noted that idiopathic anaphylaxis can cause cardiovascular symptoms, and the Veteran has recurrently complained of chest pains during the appeal period.  On review, it is unclear whether the Veteran has pulmonary symptoms that can be separately attributed to his service-connected  anaphylaxis with possible mastocytosis or his diagnosed nonservice-connected respiratory disability.  See Mittleider v. West, 11 Vet. App. 181 (1998).  

The Board also notes that the Veteran has recurrently reported respiratory symptoms of runny nose and sneezing during a reaction of idiopathic anaphylaxis with mastocytosis that the medical evidence shows can be attributed to idiopathic anaphylaxis with mastocytosis.  See April 2015 private medical opinion by Dr. C.; February 2013 private treatment record by Dr. C.  However, the Veteran has not been afforded a VA examination to determine the nature and severity of these particular symptoms, and such symptoms may require an evaluation by analogy under additional diagnostic code(s).  The Board also acknowledges that the Veteran has recurrently complained of headaches during a reaction due to idiopathic anaphylaxis with mastocytosis, and the Board notes that the General Rating Formula for Sinusitis contemplates headaches.  See e.g., 38 C.F.R. § 4.97, DCs 6510-6514; October 2012 Board hearing transcript at p. 19; May 2011 VA treatment record.  However, on review of the medical evidence, it is unclear whether the Veteran's headaches may be attributed to his idiopathic anaphylaxis with mastocytosis and whether the diagnostic codes pertaining to sinusitis are for application.  

Because the prior VA examination did not provide enough detail for rating purposes, the matter is remanded to afford the Veteran a new VA examination to determine the current nature and severity of the Veteran's respiratory symptoms due to idiopathic anaphylaxis with mastocytosis, to include whether any pulmonary symptoms and/or headaches may be attributed to the same.  See 38 C.F.R. § 4.2; Mittleider v. West, 11 Vet. App. 181 (1998).  

Accordingly, the case is REMANDED for the following action:


1. Please schedule the Veteran for VA examinations with a physician of appropriate expertise to determine:     (a) the nature and severity of the Veteran's respiratory symptoms due to idiopathic anaphylaxis with mastocytosis, and (b) if the Veteran has a need for regular aid and attendance or is housebound due to his service-connected disabilities.  Forward the claims file to the examiner for review of the case (including Virtual VA and VBMS).  The examiner is asked to note that this case review took place.

a. The examiner is asked to please provide information as to the nature and severity of all respiratory symptoms due to the Veteran's idiopathic anaphylaxis with mastocytosis, to include the following:

(i) testing for the FEV-1 percent predicted and FEV-1/FVC percent; 

(ii) any respiratory symptoms pertaining to the nose, including sneezing and runny nose during the entire appeal period (November 2007 to present); and 

(iii) the nature and all symptoms of any found sinusitis/ rhinitis during the entire appeal period (November 2007 to present), including the frequency of any incapacitating or non-incapacitating episodes of sinusitis per year, and with what symptoms these episodes are characterized.   

For purposes of this opinion, the examiner is requested to please attempt (to the extent possible) to distinguish the respiratory effects of the service-connected idiopathic anaphylaxis with mastocytosis, and any separate nonservice-connected disability.  In so doing, the examiner is asked to specifically address: (a) whether the Veteran's reported headaches during a reaction of idiopathic anaphylaxis with mastocytosis may be attributed to the service-connected idiopathic anaphylaxis with mastocytosis, specifically to include any sinusitis-type episodes due to the same; and (b) whether the Veteran has any pulmonary or cardiovascular symptoms that may be attributed to the service-connected idiopathic anaphylaxis with mastocytosis, specifically to include any respiratory symptoms due to the same.  Please note if it is not possible to attribute the Veteran's symptoms to each disability separately.  

The examiner's attention is invited to the following: 

(1) April 2015 private medical opinion by Dr. C, noting  that idiopathic anaphylaxis can cause cardiovascular symptoms.

(2) The Veteran's recurrent complaints of chest pains and tightness during the appeal period.  

(3) The Veteran's complaints of runny nose and sneezing.

(4) The Veteran's complaints of headaches during a reaction due to idiopathic anaphylaxis with mastocytosis.  See e.g., October 2012 Board hearing transcript at p. 19; May 2011 VA treatment record.

b. The examiner is asked to provide an opinion as to whether, at any point during the current appeal period (November 2007 to present), it is at least as likely as not (a probability of 50 percent or greater) that the Veteran's service-connected disabilities alone (1) render him so helpless as to require the regular aid and attendance of another person; or (2) result in physical or mental impairment that leaves him substantially confined to him dwelling and immediate premises (with reasonable certainty that such disability or disabilities and resultant confinement will continue throughout his lifetime). 

In so doing, the examiner is asked to consider each of the Veteran's existing disabilities and their impact on the Veteran's ability to perform acts of daily living; including keeping himself clean and presentable; feeding, dressing and undressing himself; attending to the needs of nature; and incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment.  

The examiner's attention is invited to the frequency, nature, and impact of the Veteran's reactions due to idiopathic anaphylaxis with mastocytosis.  See e.g., May 2009 VA examination (noting that when the Veteran has a reaction, he is unable to drive and must be driven to the emergency room); April 2011 private medical opinion from Dr. C.; October 2012 Veteran statement.  

The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached.  The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it.  

	Please note that the April 2015 VA respiratory examination is inadequate because the examiner did not provide enough information as to whether any pulmonary symptoms or headaches may be attributed to idiopathic anaphylaxis with mastocytosis, and no information was provided regarding the nature and severity of the Veteran's sneezing and runny nose symptoms that are shown by the medical evidence to be attributed to the Veteran's idiopathic anaphylaxis with mastocytosis.  

Please note that the June 2014 VA examination regarding aid and attendance, in which the Veteran reported that he needs to live with someone who is able to give him an Epi-pen when needed, or call 911 or perform CPR, is not adequate as the examiner did not provide an opinion as to whether the Veteran's service-connected disabilities render him so helpless as to require regular aid and attendance of another person, to include consideration of whether the Veteran's service-connected disabilities causes incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment (e.g., allergens).  

2. Thereafter, adjudicate the matter of an increased rating for respiratory symptoms of due to idiopathic anaphylaxis and the matter of SMC for aid and attendance during the entire appeal period, and furnish the Veteran and his attorney a supplemental statement of the case if a matter is not resolved to the Veteran's satisfaction.  Provide an opportunity to respond before the case is returned to the Board.  

The appellant has the right to submit additional evidence and argument on the matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



______________________________________________
MICHAEL A. PAPPAS
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs