Citation Nr: 1753864 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 08-28 774 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to a disability rating higher than 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a compensable disability rating for bilateral onychomycosis, with tinea pedis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. D. Logan, Associate Counsel INTRODUCTION The Veteran served on active duty from August 2001 to August 2006. This matter is before the Board of Veterans' Appeals (Board) on appeal of the an April 2007 rating decision of the Los Angeles, California, Regional Office (RO) of the Department of Veterans Affairs (VA). By way of procedural history, in the April 2007 rating decision the Veteran was granted service connection for PTSD, at an initial rating of 10 percent, effective August 15, 2006. In addition, service connection was granted at a non-compensable rating for bilateral onychomycosis, effective August 15, 2006. The Veteran submitted a notice of disagreement in June 2007. In response to an August 2008 statement of the case, the Veteran perfected his appeal in September 2008. In a July 2011 Board decision, the Veteran was granted service connection for bilateral tinea pedis, claimed as skin rash. The case was remanded for further development. In a July 2012 rating decision, the RO increased the rating for PTSD from 10 percent to 50 percent, effective August 15, 2006. As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claims are still in controversy and on appeal. The 50 percent increase is not a full grant of benefits sought, and the claim for increase remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). Subsequently, in a July 2017 rating decision, the RO combined the claims of bilateral onychomycosis, with tinea pedis, claimed as skin rash, as both were fungal conditions of the feet, and rated them together. A non-compensable rating for the skin condition was continued. The case has since returned for further appellate consideration. FINDINGS OF FACTS 1. For the entire rating period on appeal, the Veteran's PTSD has not more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. For the entire rating period, the Veteran's bilateral onychomycosis, with tinea pedis, covers less than five percent of the entire body and exposed areas and has been treated by topical anti-fungal creams only. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.21, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for a compensable rating for bilateral onychomycosis, with tinea pedis, have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, DCs 7806, 7813 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify The Veteran appealed the propriety of the initially assigned rating from the original grant of service connection for PTSD and bilateral onychomycosis, with tinea pedis. VA's General Counsel has held that no additional notice is required for such downstream issues. VAOPGCPREC 8-2003. The Court specifically held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Pertinent Legal Criteria for Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, 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. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 (2017). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a), When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. PTSD The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. In this case, the Veteran's PTSD is current rated as 50 percent disabling, effective August 15, 2006, under DC 9411 of the General Rating Formula. See 38 C.F.R. § 4.130, DC 9411 (2017). The Veteran seeks a rating higher than 50 percent for his psychiatric disability. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id A 70 percent rating under DC 9411 is warranted if the evidence establishes there is 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); and/or inability to establish and maintain effective relationships. Id A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2017); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV or DSM 5). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100 reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. 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 obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated "DSM-5." As the Veteran's claim was certified to the Board prior to August 4, 2014, the DSM-5 is not applicable to this case. Nonetheless, according to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider the assigned GAF score; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a) (2017). Turning now to the relevant evidence in this case, in an August 2006 PTSD nurse practitioner note, the Veteran reported moderate anxiety, which could be provoked by crowds or war news. He also reported being easily irritated and frustrated, but denied anger, panic attacks, rage or violence. He stated that his feelings were "numb", that he was feeling moderately depression and "out of sorts", had lack of interest in usual activities and had poor concentration. The examiner noted the Veteran was appropriately dressed, made eye contact, and had a slightly constricted affect. The Veteran expressed hope for the future and interest in becoming an RN. The Veteran was given a diagnosis of PTSD, and a GAF score of 52 was assigned. In October 2006, the Veteran was afforded a VA-sponsored special psychiatric examination. The examiner, a psychologist, noted upon examination that the Veteran appeared to be of average grooming and hygiene, alert, cooperative and not in acute distress. The Veteran was pleasant, and not fearful and hostile, and did not have bizarre posturing, gait or mannerisms. The Veteran reported that his mood was "not well." He did not appear depress or anxious, however, his affect was constricted. The Veteran denied suicidal or homicidal ideation or intent. His speech was fluent, and he denied having hallucinations, delusions or psychotic symptoms. The examiner observed the Veteran's judgment and insight were good. The Veteran reported having social interaction with his relatives and family members, however, he indicated that he "just felt awkward" in relating to others. The Veteran reported having panic attacks at least once a month, difficulty staying asleep, being irritated easily, having outburst of anger, and difficult concentrating. The Veteran expressed his intent to start college classes. The examiner determined the Veteran met criteria for Axis I diagnosis of PTSD, and a GAF score of 66 was assigned. According to a September 2007 polytrauma social work assessment note, the Veteran reported memory loss, disinterest in activities, feelings of isolation, and difficulty sleeping. During the December 2013 VA compensation PTSD examination, the Veteran reported being married, although he lived alone due a move for his job. He worked in a full-time clerical position and reported "getting along with people." The examiner noted the Veteran was involved with a local Buddhist center and took on-line classes for his degree. The Veteran stated had to force himself to shop, was anxious driving, and avoided many social situations. However, the examiner noted he was capable of routine self-care and able to manage his own financial affairs. The Veteran reported experiencing anxiety, panic attacks, sleep impairment, problems getting along with others, and only had passive suicidal thoughts without plan or intent. The examiner determined the Veteran had occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although his general function was satisfactory, with normal routine behavior, self-care and conversation. In a December 2013 VA traumatic brain injury (TBI) examination, the Veteran reported diminished concentration, although he had no difficulty with memory. He complained of insomnia, irritability, anxiety, and anger management issues. His wife indicated he "talked in his sleep and mumbled." The examiner determined that his symptoms were attributable to his PTSD diagnosis and not related to TBI. According to a June 2017 VA PTSD compensation examination, the examiner noted the Veteran appeared to have good grooming and hygiene. The Veteran did not demonstrate thought disorder or memory deficits, made appropriate eye contact, and was cooperative and alert. His affect was slightly anxious. The Veteran reported that he lived with his wife; however, she complained that he was "cold and distant." Despite the martial problems, the couple continued to work on their issues. The Veteran socialized with his friends occasionally, communicated on Facebook, saw his family regularly, joined a martial arts class, and completed his degree. Although he was less active at his church, he played the guitar at home, and was promoted at his job. The Veteran reported getting better at "masking" or hiding his PTSD symptoms from others, but continued having mood problems, with periods of "waves of emotion" in which he felt depressed. He denied any suicidal ideation, or having a plan or intent to harm himself, but would sometimes get "dark thoughts" where he felt things would be better off if he were dead. The examiner noted continued symptoms of anxiety, panic attacks, sleep impairment, mild memory loss, and disturbances in motivation and mood. The Veteran was found to be capable to manage his financial affairs. The examiner assessed the Veteran's symptoms to be chronic, but determined they were mild to moderate in severity in his social functioning, and only mild in his occupational functioning. Based upon review of all the evidence of record, both lay and medical, the Board finds that throughout the entire rating period on appeal, the Veteran's PTSD has not more nearly approximated 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; spatial disorientation; neglect of personal appearance and hygiene; and difficulty in adapting to stressful circumstances. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. With this in mind, the weight of the evidence demonstrates that the Veteran's overall PTSD picture is adequately contemplated by the 50 percent rating currently assigned. His experiences with anxiety, difficulty sleeping, and occasional panic attacks (weekly or less) is specifically contemplated under the criteria for a lower 30 percent rating. Similarly, his symptoms of disturbance of motivation and mood (depression) and constricted affect are specifically contemplated in the 50 percent rating criteria. Moreover, the Veteran socialized with friends and participated in outside activities, such as joining a martial arts group and a Buddhist center. Although the Veteran reported depression, it has not been shown to affect the ability to function independently. For example, the Veteran is responsible for his own grooming and hygiene, keeping with social contacts through Facebook, and managing his own financial affairs. The Veteran has been found to be able to complete his degree and perform competently at his place of employment, which led to a promotion. The Veteran reported keeping in contact with his family and playing the guitar. This does not suggest to the Board that the Veteran has deficiencies in family relations or social functioning. The Veteran's GAF scores have ranged from 52 to 66. The Board finds that these GAF scores are consistent with the level of social and occupational impairment discussed above. For these reasons, the Board finds that the weight of the evidence of record does not demonstrate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Accordingly, a rating in excess of 50 percent for PTSD is not warranted. Bilateral onychomycosis, with tinea pedis. The Veteran seeks a compensable rating for his skin condition. The Veteran's bilateral onychomycosis, with tinea pedis, has been rated non-compensable under DC 7813. DC 7813 applies to dermatophytosis, including the feet, and directs the rater to rate dermatophytosis as disfigurement of the head, face or neck under DC 7800, scars under DCs 7801-7805, or dermatitis pursuant to 7806, depending on the predominant disability. As the Veteran's bilateral onychomycosis, with tinea pedis, affects his bilateral feet, DC 7806 is applicable. Under DC 7806, a non-compensable rating is warranted if less than 5 percent of the entire body or less than 5 percent of exposed areas are affected and the Veteran requires no more than topical therapy during a 12 month period. 38 C.F.R. § 4.118, DC 7806 (2017). A 10 percent rating is warranted for dermatitis or eczema that involves at least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected, or; requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. Id Dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or requiring systemic therapy for a total duration of 6 weeks or more, but not constantly, during the past 12-month period, warrants a 30 percent disability rating. Id A 60 percent rating is warranted for dermatitis or eczema with more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or requiring constant or near-constant systemic therapy during the past 12-month period. A September 2006 psych resident note indicates a topical anti-fungal cream (Clotrimazole) on the Veteran's medication list. Id During an October 2006 VA examination, the Veteran was diagnosed with bilateral onychomycosis. The examiner noted bilateral discoloration on the Veteran's toenails. No ulceration, flakiness, exfoliation or edema of the skin of the feet were found. There was no crusting, hyper or hypopigmentation or loss of underlying tissue. The examiner found the ratio of the lesion to the whole body area was less than 1 percent, and the ratio of the lesion to the exposed area was less than 1 percent. In a September 2007 PACC intern/resident note, the Veteran complained of having "athlete's feet", which had been present since service, but was now spreading. He reported experiencing increased itching. Treatment with topical cream (Lamisil) and nystatin powder was recommended. In a December 2007 polytrauma clinic note, a topical antifungal cream (terbinafine) was noted on the outpatient medication list. The Veteran was afforded a VA compensation examination in March 2017. The Veteran reported having brittle, discolored nails and flaky, itchy skin on both feet. The Veteran indicated he used topical anti-fungal medication in the past, but had not used any medication the year prior. Upon examination, the examiner noted thick and discolored bilateral toenails, consistent with onychomycosis, and scaly and flaky skin, with slight erythema in the toe webs, consistent with tinea pedis. He determined the ratio for the skin condition was less than 5 percent of the total body area and zero percent of the exposed area. There was no impact on the Veteran's ability to work. Based on the foregoing, the Board finds that a compensable disability rating is not warranted. The evidence does not indicate that at least 5 percent of the exposed or unexposed areas are affected, or that the Veteran required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during any 12-month period. In this regard, the only medications shown to be prescribed are antifungal (Clotrimazole, Lamisil, nystatin and terbinafine) topical medications. Furthermore, the Veteran denied using any medications within the past year. The topical antifungal cream that the Veteran used is not a corticosteroid or immunosuppressive drug. Moreover, the topical antifungal creams, such as clotrimazole, lamisil, not like or similar to a corticosteroid or immunosuppressive drug. See Warren v. McDonald, No. 28 Vet. App. 194 (2016) (under DC 7806, "[c]ompensation is available for all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs"). In that decision, the Court relied on the VA Adjudication Procedure Manual (M21-1), for the definition of "systemic therapy," as "any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder." Id. at n.2. Medical dictionaries have defined "systemic" therapy as pertaining to or affecting the body as a whole. See, e.g., Dorland's Illustrated Medical Dictionary 1848 (32nd ed. 2012). A corticosteroid is "any of the 21-carbon steroids elaborated by the adrenal cortex . . . in response to corticotropin released by the pituitary gland or to angiotensin." Id. at 425. Corticosteroids "are used clinically for hormonal replacement therapy, for suppression of ACTH secretion by the anterior pituitary, as antineoplastic, anti-allergic, and anti-inflammatory agents, and to suppress immune responses." Id. An immunosuppressive or immunosuppressant agent is "an agent capable of suppressing immune responses." Id. at 915. Clotrimazole is a "broad-spectrum antifungal agent." Id. at 379. An antifungal medication is "an agent that is destructive to fungi." Id. at 102. Despite the fact that the list of systemic therapies included in DC 7806 is not exhaustive, topical antifungal cream is not "like or similar to corticosteroids or other immunosuppressive drugs." In sum, the Veteran's skin condition resulting from his bilateral onychomycosis, with tinea pedis has only affected less than 5 percent of total body and exposed area. Furthermore, the Veteran only used topical anti-fungal therapy for treatment. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial compensable rating for bilateral onychomycosis, with tinea pedis. 38 U.S.C.A. § 5107 (b) (West 2014); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 7813 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, the Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that a request for TDIU is part and parcel of a higher rating when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran in this case has not alleged, and the evidence does not show, that he is unemployable due to his service-connected PTSD or skin condition. According to the December 2013 and June 2017 PTSD VA examinations, the VA examiner assessed the Veteran's occupational impairment to only be of occasional decrease in efficiency and intermittent periods of inability to perform occupational tasks. Furthermore, in the May 2017 VA skin compensation examination, the Veteran's skin condition was found to have no functional impact on his ability to work. Accordingly, the issue of entitlement to a TDIU rating has not been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009). Finally, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to a disability rating higher than 50 percent for PTSD is denied. Entitlement to a compensable disability rating for bilateral onychomycosis, with tinea pedis, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs