Citation Nr: 1753423 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 11-33 077 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a skin disorder. 2. Entitlement to an initial disability rating in excess of a 50 percent for obstructive sleep apnea with reactive airway disease. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD T. Talamantes, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1989 to July 1990 and from October 2003 to September 2006. The record reflects he had additional service in the Reserves. These matters come before the Board of Veterans Appeals' (Board) on appeal from rating decisions dated January 2010, July 2010, and June 2014 by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO in March 2012, and before the undersigned Veterans Law Judge (VLJ) in a March 2015 hearing. Transcripts of both hearings have been associated with the file. The Board remanded these matters in May 2015 to have the RO obtain relevant outstanding medical records and for new VA examinations. Upon review of the record, the Board finds that the May 2015 remand directives have been substantially complied with and will therefore proceed with the appeal. See Stegall v. West, 11 Vet. App. 268. When last before the Board, the Veteran was separately rated for obstructive sleep apnea and reactive airway disease. Since then, these have been combined as a single disease entity, and evaluated under the predominant disability, obstructive sleep apnea. This has been assigned a 50 percent rating from June 2009. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's current skin disorder was incurred in or otherwise the result of his active service, or as secondary to a service-connected disability, or that he has any medically unexplained chronic multi symptom illness recognized by VA as related to Persian Gulf service. 2. Prior to March 29, 2016, the Veteran's predominant respiratory condition is his obstructive sleep apnea, which has not caused chronic respiratory failure with carbon dioxide retention or cor pulmonale, or led to a tracheotomy. 3. Since March 29, 2016, the Veteran's predominant respiratory condition is his reactive airway disease, which has been productive of monthly visits to a physician, but has not resulted in FEV-1 less than 40 percent predicted; or FEV-1/FVC less than 40 percent; or more than one attack per week with episodes of respiratory failure; or a requirement for daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. CONCLUSIONS OF LAW 1. Prior to March 2016, the criteria for an initial disability rating in excess of 50 percent for obstructive sleep apnea with reactive airway disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6602-6847 (2017). 2. Effective from March 29, 2016 the criteria for a 60 percent rating for obstructive sleep apnea with reactive airway disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6602-6847 (2017). 3. The criteria for a grant of service connection for a skin disorder are not met, to include as secondary to a service-connected disability and nor is this skin disorder presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.10, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran, nor his representative, has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Legal Criteria Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2017). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to prevail under a theory of secondary service connection, there must be evidence of a current disability; evidence of a service-connected disability; and the medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Additionally, service connection may be granted to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability became manifest during service in the Southwest Asia theater of operations, or to a degree of 10 percent or more, not later than December 31, 2016, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): An undiagnosed illness; a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as: chronic fatigue syndrome; fibromyalgia; functional gastrointestinal disorders (excluding structural gastrointestinal diseases). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to: Fatigue; signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Generally, so long as the disability has existed for six months or more, from the earliest date that it became manifest, the disability will be considered chronic. 38 C.F.R. § 3.317(a)(4). There is no requirement that an undiagnosed illness or medically unexplained chronic multi symptom illness manifested during service or within any set period other than prior to December 31, 2016 or existed for more than 6 months. In making all determinations, the Board must fully consider the lay assertions of record. A lay person is competent to report on the onset and recurrence of his symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 ; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104 (a) (West 2014). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In deciding whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Board has reviewed the entire record, with an emphasis on the evidence relevant to this appeal. Although the Board must provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, in the present claim. Increased Rating Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2014). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2014). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2014); see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7 (2014). Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21(2014). The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes, is to be avoided. See 38 C.F.R. § 4.14 (2014). Thus, separate ratings under different diagnostic codes are only permitted if, for example, those separate ratings are assigned based on manifestations of the Veteran's disability that are separate and apart from manifestations for which the Veteran has already been rated. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Veteran's obstructive sleep apnea and reactive airway disease have been rated under the provisions of DC 6602-6847 throughout the appeal period. When there are two co-existing respiratory conditions (including for DCs 6602 and 6847), a single rating will be assigned under the diagnostic code that reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.96(a). This has been interpreted that VA is to evaluate coexisting service-connected respiratory conditions covered by § 4.96(a) under the criteria enumerated in the predominant disability's diagnostic code. See Urban v. Shulkin, No. 15-3744 *1 (U.S. Vet. App. Sept. 18, 2017). The Veteran's reactive airway disease is rated under Diagnostic Code 6602, as asthma, which provides for evaluation of 30 percent where forced expiratory volume in one second (FEV-1) is 56- to 70 percent of predicted value; or if the ratio of FEV-1 to forced vital capacity (FEV1/FVC) is 56 to 70 percent; or where there is daily inhalational or oral bronchodilator therapy; or inhalational anti-inflammatory medication. See 38 C.F.R. § 4.97, DC 6602. A 60 percent rating is assigned when FEV-1 is 40 to 55 percent of predicted value; or where FEV1/FVC is 40 to 55 percent; or if there are at least monthly visits to a physician for required care of exacerbations; or where is intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. Id. The highest rating of 100 percent is not warranted unless FEV-1 is less than 40 percent predicted; or FEV-1/FVC is less than 40 percent; or there is more than one attack per week with episodes of respiratory failure; or there is a requirement for daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. Id. Under Diagnostic Code 6847, which provides for evaluation of obstructive sleep apnea, a 30 percent rating is assigned if there is persistent daytime hypersomnolence. See 38 C.F.R. § 4.97, DC 6847. A 50 percent disability rating contemplates sleep apnea that requires use of a breathing assistance device such as a CPAP machine; and the highest rating of 100 percent is warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonale, or where a tracheostomy (tracheotomy) is required. Id. Factual Background and Analysis Skin Disorder The Veteran and his wife provided testimony at a DRO hearing and a hearing before the undersigned VLJ. At the February 2012 DRO hearing testimony was provided that the Veteran's skin condition, labeled as a rash, would lay dormant and then return, with its onset occurring when he came from California with Valley Fever. He said he was diagnosed with Valley Fever and or told his condition was a fungus in July 2003, during training. His wife testified that a doctor informed them that the rash was from Valley Fever and that it may be associated with the treatment used for his breathing condition. He stated that he would treat it with over the counter medication and that he had not been prescribed anything for it. At the March 2015 hearing, the Veteran testified that a doctor told him he thought he had Valley Fever, but that he could not recall if a doctor ever told him that Valley Fever is what caused his rash. His wife testified that she was present when a doctor told him that the rash is a possible side effect of the Valley Fever. The Veteran stated that VA refers to Valley Fever as coccidioidomycosis. He reported that his rash would come and go and he had been treated continuously for the rashes after service and no doctor had been able to diagnose it or tell him what caused it. Medical treatment records dated during periods when the Veteran was not in service illustrate that the Veteran's skin was normal, with no skin diseases. See April 1989 medical examination report and June 2002 medical treatment record. A medical treatment record dated July 2003 does not make mention of any skin condition, but does reference a diagnosis of bronchitis and in parentheses next to this diagnosis it states "(can not R/O poss of Valley Fever)." Service treatment records indicated that the Veteran had no skin disease or rashes. See March 2005 and August 2006 service treatment records. Post service medical treatment records and examination reports indicate the Veteran did not complain of nor have any skin related disorder. See December 2006 and February 2007 medical treatment records. A November 2008 private medical treatment note illustrates that the Veteran presented with a rash and in private treatment medical records dated January 2009, and May 2009 the Veteran reported dry skin, and paresthesia. He was diagnosed with acanthosis. An October 2009 private emergency medical note indicated that the Veteran did not present with a rash, edema, lesion. In a July 2010 VA examination the following was noted: rash, sore, scar, and itching of the skin, few patches of eczematous, dry scaly, and papular skin lesions in the bilateral groin area and in anal area. He was diagnosed with eczematous skin rash in the groin and anal area. The examiner opined that the Veteran's skin condition is less likely as not (less than 50/50 probability) a continuation of the skin condition treated during his military service. The rationale provided was that a review of the service medical records did not indicate skin rash or treatment for skin rash while in service. In a March 2016 VA Disability Benefit Questionnaire (DBQ) the Veteran reported "skin rash" in the back of the neck and both lower legs and stated his skin is very dry. He reported being given cream for the rash, but the examiner noted that the record indicates that he was prescribed Eucerin cream that he would mostly use after showering. Upon examination the examiner found that the Veteran had dry skin, also called xerosis on both lower legs and feet and on the back of his neck. She stated it is a skin condition, but not technically a rash. The examiner stated she could not find anything in the Veteran's records to confirm that he was diagnosed with Valley Fever in 2009 as the Veteran had reported. The examiner went on to say she was unable to find skin problems documented in the service treatment records. The examiner stated that clinically the Veteran has dry skin or xerosis and is under treatment with cream prescribed by VA. In a May 2016 VA examination the examiner provided numerous opinions related to the etiology of the Veteran's skin condition. The examiner concluded that the Veteran's xerosis is not an undiagnosed illness, not a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology and not a diagnosable chronic multi symptom illness with a partially explained etiology. She stated that it is a disease with a clear and specific etiology and diagnosed. The examiner opined that the Veteran's xerosis is less likely as not caused by a specific exposure event experienced during service. The rationale provided is that the preponderance of the medical evidence does not support that xerosis is a result of Gulf War environmental hazards. The examiner also opined that the Veteran's xerosis is not caused by or a result of asbestos exposure or Valley Fever. The rationale provided is that xerosis is common dry skin. She explained that it occurs in most people at some point in life and it is the common skin type for many people. The examiner stated that the Veteran has no disability caused by Valley Fever or asbestos exposure according to the core of medical literature. The examiner also opined that the Veteran's xerosis not caused by or a result of his other service-connected conditions to include OSA, depression, neoplasm, scar hiatal hernia, or ankle condition. The rationale provided is that there is no physiological basis upon which to assert that xerosis is caused by any of his service-connection conditions. She explained that the preponderance of the medical evidence, the commonly established medical literature and core knowledge of medical science does not support this claim. She continued to explain, stating there is not a causal association between the current condition and the service-connected conditions. Lastly, this examiner opined that the Veteran's xerosis is not aggravated by his service-connected disabilities or treatment, to include asthma inhalers. The rationale provided is that daily inhaler use does not cause dry skin according to pharmacology side effects and literature and the Veteran had no exacerbations in his skin condition and the xerosis was stable. In a July 2017 VA DBQ the Veteran was diagnosed with xerosis/dry skin. This examiner stated that she completely concurred with the prior opinions given in March 2016 and May 2016. The examiner opined that the Veteran's current dry skin condition (xerosis) is less likely than not caused by his exposures in the Gulf War in 1990. The rationale provided was that there is no evidence that any exposure in the Gulf War causes xerosis, which is dry skin- a condition with a clear etiology. She explained it is not a presumptive diagnosable disease and there is no evidence of a specific event or exposure by this Veteran that caused the condition. She stated that anyone could get dry skin, explaining that skin becomes dry when it loses too much water or oil. The examiner continued to explain, stating that some people are more likely to have dry skin and as people age their skin becomes thinner and drier. During the appeal period the Veteran has been diagnosed with the following skin conditions: rash, acanthosis, skin lesions, eczematous patches, and most recently xerosis. Therefore, the Veteran has a current skin disorder and the question before the Board is whether such skin disorder is etiologically related to service. The theories of entitlement raised by the record are direct, secondary, and undiagnosed Gulf War illness. One of the Veteran's contentions is that he developed a skin condition during training, prior to deployment. The Veteran's service treatment records do not document any complaints of, diagnosis of or treatment for a skin disorder. The earliest medical treatment record to illustrate a skin disorder is dated November 2008, years after service. The July 2010 VA examiner opined that the Veteran's skin condition is not related to his military service. The examiner pointed to the service treatment records to support her conclusion. There is no other medical opinion of record to the contrary and this opinion is supported by rationale. For those reasons, the Board finds this opinion to be probative. The evidence does not support service connection on a direct theory of entitlement. Another of the Veteran's contentions is that his claimed Valley Fever and/or the treatment for his breathing condition caused his skin disorder. Upon review of the record, there is only one medical treatment record that notes the possibility of Valley Fever and there is nothing to indicate an actual diagnosis of Valley Fever. In addition, this undiagnosed Valley Fever is not service connected. The Veteran is service connected for OSA and reactive airway disease. He has used CPAP, BiPAP and inhalers to treat these breathing conditions. The March 2016 VA examiner stated that she was unable to locate documentation in the record to indicate that the Veteran had been diagnosed with Valley Fever and she noted that the Veteran had only been prescribed Eucerin cream for his dry skin. The May 2016 VA examiner opined that the Veteran's xerosis was not caused by asbestos exposure or Valley Fever, as he has common dry skin and medical literature does not support a medical nexus. The examiner also opined that the Veteran's skin condition is not caused by or aggravated by any of his service-connected disabilities, including treatment for these disabilities. The examiner provided detailed rationale such as looking to commonly established medical literature and science. There is no medical opinion to the contrary and the examiners provided clear rationale. Therefore, the Board finds these opinions to be highly probative. The evidence does not support service connection on a secondary theory of entitlement. The Veteran's last contention is that his skin disorder qualifies as a Gulf War illness as he contended doctors were unable to diagnose his condition and he served in the Gulf War. As previously stated, the Veteran's skin condition has been diagnosed throughout the appeal period. The May 2016 VA examiner concluded that the Veteran's xerosis not an undiagnosed illness, not a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology and not a diagnosable chronic multi symptom illness with a partially explained etiology, as it is a diagnosed disease with a clear and specific etiology. The examiner went on to explain that the Veteran's xerosis was not caused by exposure in service as the preponderance of the medical evidence does not support that this condition would result from Gulf War environmental hazards. The July 2017 VA examiner completely concurred, stating that there is no evidence that any exposure in the Gulf War causes xerosis, as it is dry skin -a condition with a clear etiology which anyone can get when the skin loses too much water or oil. All of the medical opinions of record reach the same conclusion and have provided adequate rationale. Therefore, the Board finds these opinions to be highly probative. The evidence does not support service connection on a Gulf War illness theory of entitlement. The Board notes that the Veteran is competent to report symptoms such as itching and dry skin, as that requires only personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, he is not competent to attribute this symptom as part of a skin condition diagnosis, as he has not demonstrated that he is an expert in determining the etiology of skin conditions and is a layperson in this regard. Similarly, his wife is likewise a lay person and is not competent to render an opinion regarding the etiology of the Veteran's skin condition. While the Veteran and his wife are competent to report that the Veteran experienced itchy, dry skin since service, they are not competent to provide a medical diagnosis as to how and what caused this skin condition. The Board finds that the Veteran's skin condition is not directly connected to service, and is not related to any service-connected disabilities or treatment for those disabilities, or qualifies as an undiagnosed Gulf War illness. The Veteran's service treatment records and VA medical records do not indicate that he suffered from any skin condition during or within the presumptive period after service. Likewise, no probative treatment records or lay contentions support the existence of any skin disorder at or within one year of separation from service. The Veteran contends he experienced symptoms of a skin disorder prior to service and continuously thereafter. There are no credible, probative medical opinions of record to support such a contention and the Veteran is not shown to possess any medical expertise as to afford his view on the subject any probative weight. All of the VA medical opinions of record agree that there is no nexus between the Veteran's skin disorder and military service. In arriving at this conclusion, the Board has carefully considered the lay assertions of the Veteran and his wife. The Board understands the Veteran's belief that his disability warrants service connection. However, the VA examinations, service treatment records, and the medical opinions the Board found most probative, outweigh the Veteran's contention that his skin disorder should be service connected. In sum, the evidence establishes that the Veteran's skin condition did not first manifest until years after service, and is not related to any in-service events, or any service-connected disabilities. 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); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Obstructive Sleep Apnea with reactive airway disease As of June 2014, the Veteran's reactive airway disease has been assigned under a single rating under the diagnostic code (DC) 6847, as OSA was the predominant disability. The disability rating is 50 percent. As stated above, the Veteran and his wife provided testimony at a DRO hearing and a hearing before the undersigned VLJ. At the February 2012 DRO hearing the Veteran testified that he had been prescribed an inhaler (Proventil) prior to September 2011, that he uses his inhaler almost daily, and that he had not been prescribed a nebulizer for his breathing. He also stated that he uses the BiPAP machine every night to treat his OSA and he has been hospitalized for his breathing condition. In the March 2015 hearing the Veteran's representative argued that the active airway disease warrants a 30 percent evaluation. The Veteran testified that he has been using an inhaler (albuterol) since June 2009 and that he uses it daily. His wife testified that he was prescribed a nebulizer machine a year ago and that he would use at least twice a day. He stated that he has been hospitalized for this condition in 2000, and in 2010 or 2011. He reported that he would go to an outpatient clinic periodically and had one to two visits to the emergency room. The Veteran was afforded a VA examination in December 2009. The examiner diagnosed the Veteran with esophageal reflux and severe OSA. The examiner noted that the Veteran was unable to produce acceptable and reproducible spirometry data when doing the pulmonary function tests (PFTs). The examiner noted that the Veteran used a BiPAP machine for his sleep apnea and that he fell asleep during the interview. The Veteran was afforded another VA examination in July 2010. The following was noted: soreness, hoarseness, problems with chewing, swallowing and speech. The Veteran reported difficulty sleeping, regurgitation and acid reflux burning in the throat at times. The examiner found no evidence of bronchiectasis of emphysematous bleb, or any findings of abnormal respiratory. The Veteran was diagnosed with chronic cough, shortness of breath, and throat irritation. It was noted that he had OSA. The examiner noted that PFTs were attempted during a previous visit and the Veteran passed out during the test, so PFTs were not performed in this examination as they were not requested. During a December 2010 VA examination there was no evidence of abnormal breath sounds. During a May 2011 VA examination, the Veteran reported having severe sleep apnea, rating his sleep problems as a 9 on a scale of 1 to 10 and reported using a BiPAP machine. The Veteran was afforded another VA examination in July 2011. He reported the following symptoms: coughing, day time sleepiness, difficulty breathing and ceasing to breathe at times. He reported wearing a BiPAP every night, with his number as 14/8. The examiner noted that 14/8 is the BiPAP setting and BiPAP is a stronger form of CPAP. Pulmonary examination revealed no evidence of abnormal breath sounds. He was diagnosed with severe OSA. A February 2013 VA medical examination was positive for shortness of breath and wheezing and negative for apnea, cough, chest tightness and stridor. The Veteran was afforded another VA examination in March 2016. He was diagnosed with asthma. In describing the frequency and severity of exacerbations, the Veteran reported being seen in the emergency room for his asthma five to six times a year. He reported that the most recent time he was seen in the emergency room was three months ago. He stated that he was not admitted but was treated with nebulizer. The examiner noted that the Veteran does not require the use of oral or parenteral corticosteroid medications or outpatient oxygen therapy, but that he does require the use of inhalational bronchodilator therapy, and that he uses an albuterol inhaler three to five times a day. It was noted that the Veteran had not had asthma attacks with episodes of respiratory failure in the past 12 months. The examiner also noted that the required care for exacerbations for the last 12 months had been at least monthly visits to a physician. The examiner noted that the Veteran is incapable of walking over 25 yards without significant shortness of breath. The examiner also noted that the Veteran is unable and has been unable to perform PFTs and that additional testing would not yield results helpful for rating purposes. He requested that his disability be granted as "severe" asthma. In July 2014, the RO found the predominant disability to be obstructive sleep apnea. As reactive airway disease and OSA need to under a single rating, finding OSA as the predominant disability allowed for a higher rating under DC 6847, than the Veteran would have met under DC 6602. The Board agrees that during that time OSA was the predominant disability. The evidence indicates that throughout the appeal period the Veteran has required the use of a breathing assistance device, as he previously used the CPAP machine and more recently uses the BiPAP machine, which warrants a 50 percent disability rating under DC 6847. The evidence also shows that throughout the appeal period the Veteran has required the use of daily inhalational or oral bronchodilator therapy, which would only warrant a 30 percent disability rating. Therefore, the predominant disability from the beginning of the appeal period to March 2016 is OSA. However, the most recent VA examination illustrates that due to the Veteran's severe asthma, he undergoes at least monthly visits to a physician for required care of exacerbations, which would warrant a disability rating of 60 percent under DC 6602. Therefore, the Board finds that as of March 2016, the predominant disability is reactive airway disease. As the Veteran has been unable to complete PFTs there is not much spirometry data. The PFTs of record do not reflect such a severity for asthma to warrant a rating in excess of 60 percent. In addition, there is no evidence of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or the necessity for a tracheostomy as to have OSA be the predominant disability over asthma. Instead, the 60 percent rating for asthma contemplates a more severe level of disability, including the required monthly physician's care for exacerbations. Because the Veteran's asthma is the predominant disability of these coexisting respiratory conditions, OSA need not be analyzed any further. See 38 C.F.R. § 4.96(a); Urban at *13. As to the severity of the Veteran's asthma, the March 2016 VA examination illustrates that the Veteran requires the care of a physician on at least a monthly basis for exacerbations. This level of severity is contemplated by the 60 percent rating under DC 6602. The Veteran has also not been found to have FEV-1 less than 40 percent predicted; or FEV-1/FVC less than 40 percent; or more than one attack per week with episodes of respiratory failure; or a requirement for daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications at any time during the appeal. Accordingly, the criteria for a disability rating higher than 50 percent, prior to March 29, 2016, are not met and the criteria for a disability rating higher than 60 percent from March 29, 2016 are not met. ORDER Service connection for skin disorder is denied. An initial disability rating in excess of 50 percent for obstructive sleep apnea with reactive airway disease prior to March 29, 2016, is denied. Subject to the law and regulations governing the payment of monetary benefits, from March 29, 2016, a disability rating of 60 percent, but no higher for obstructive sleep apnea with reactive airway disease is granted. ____________________________________________ M. E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs