Citation Nr: 18141489 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 15-31 745 DATE: October 11, 2018 ORDER Entitlement to service connection for a right shoulder strain, to include as secondary to left shoulder degenerative joint disease, is denied. Entitlement to service connection for a left foot condition, variously claimed as plantar fascitis and bone spurs, is denied. Entitlement to service connection for sinusitis is granted. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression and anxiety, to include as secondary to status-post thyroidectomy with scar, is denied. Entitlement to an initial rating higher than 10 percent prior to August 14, 2013, and higher than 20 percent thereafter, for degenerative joint disease of the left shoulder is denied. Entitlement to a compensable evaluation for pseudofolliculitis barbae (PFB) is denied. Entitlement to an initial rating higher than 10 percent for status-post thyroidectomy with residual scar, prior to July 28, 2014, is denied; however, an evaluation of 30 percent for status-post thyroidectomy with residual scar, from July 28, 2014, is granted. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service connected status-post thyroidectomy, is remanded. Entitlement to service connection for hypertension, to include as secondary to service connected status-post thyroidectomy, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service connected status-post thyroidectomy, is remanded. Entitlement to service connection for diabetes mellitus, also claimed as hyperglycemia, to include as secondary to service connected status-post thyroidectomy, is remanded. FINDINGS OF FACT 1. The Veteran’s right shoulder strain was not manifested during his active military service, is not shown to be causally or etiologically related to his active military service, and is not shown to be caused or aggravated by the service-connected left shoulder degenerative joint disease. 2. The preponderance of the evidence is against finding that the Veteran has a left foot condition, claimed as plantar fascitis and bone spurs, due to an in-service event, injury, or disease. 3. The evidence of record demonstrates that is likely that currently diagnosed sinusitis was incurred during active service. 4. There is no competent and credible evidence establishing that the Veteran currently suffers from an acquired psychiatric disorder, to include depression and anxiety. 5. Prior to August 14, 2013, the Veteran’s left shoulder disability manifested with pain and limited motion overhead. 6. From August 14, 2013, the Veteran’s left shoulder disability manifested with limitation of motion at the shoulder level. 7. The Veteran’s pseudofolliculitis barbae covers less than 5 percent of the exposed area, and no more than topical therapy has been required during the past 12-month period. 8. Prior to July 28, 2014, the Veteran’s status-post thyroidectomy with residual scar, requires the continuous use of medication for control. 9. From July 28, 2014, and resolving all reasonable doubt in favor of the Veteran, his status-post thyroidectomy with residual scar, manifests in fatigability, constipation, and mental sluggishness. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder strain are not met. 38 U.S.C. § 1131; 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. 2. The criteria for service connection for a left foot condition, variously claimed as plantar fascitis and bone spurs have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for sinusitis have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 4. The criteria for service connection for an acquired psychiatric disorder, claimed as depression and anxiety, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310. 5. The criteria for a rating higher than 10 percent prior to August 14, 2013, and higher than 20 percent thereafter, for a degenerative joint disease of the left shoulder, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.130, DCs 5010, 5201 (2017). 6. The criteria for entitlement to a compensable evaluation for pseudofolliculitis barbae have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). 7. The criteria for entitlement to an initial rating higher than 10 percent prior to July 28, 2014, for status-post thyroidectomy with residual scar have not been met; however, beginning July 28, 2014, the criteria for a 30 percent rating have been met. 38 U.S.C. 1155, 5103, 5103A, 5107; 38 C.F.R. 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.119, Diagnostic Code 7903 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from July 1979 to July 1996. This matter is before the Board of Veterans’ Appeals (Board) on appeal from November 2010, June 2013, and September 2014, rating decisions of the Denver, Colorado, Department of Veterans Affairs (VA) Regional Office (RO). 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 active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). This is taken to mean that establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§ 3.310(a)-(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). 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. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). 1. Entitlement to service connection for a right shoulder strain, to include as secondary to left shoulder degenerative joint disease The Veteran contends that he suffers from a right shoulder condition, that is either secondary to his service-connected left shoulder disability, or directly related to his service. He has a current diagnosis of a shoulder strain, and service connection is in effect for left shoulder degenerative joint disease. Service treatment records are void for any specific complaints of or treatment for, or diagnosis of any right shoulder problems. The question that remains is whether the current right shoulder disability is at least as likely as not related to an in- service injury; or in the alternative, whether it is proximately due to or was aggravated by the service-connected left shoulder disability. The Board concludes that the preponderance of the evidence is against finding that the Veteran’s right shoulder condition is directly due to his military service, or caused or aggravated by his left shoulder disability. In July 2014, he underwent a VA examination. The examiner noted in 2006 he developed right shoulder aching and pain, and he was diagnosed with a right shoulder strain. X-rays were taken, and were negative for any abnormality. The examiner concluded it was less likely than not that his right shoulder strain was incurred in or caused by an in-service injury, event or illness. His right shoulder condition is new and separate, and began post-service. The Veteran was afforded another examination in February 2017. He reported he began having right shoulder problems two years prior. He stated he believed his right shoulder condition is due to overcompensating as a result of his left shoulder condition. The examiner concluded it is less likely than not that his right shoulder condition is due to or the result of the Veteran’s left shoulder condition. The examiner explained an orthopedic condition of the left shoulder does not cause an orthopedic condition of the right shoulder. The shoulder functions in open chain dynamics, and there are not weight bearing forces being transmitted up the kinetic chain. His right and left shoulder are near equally bad. When a joint, typically in the lower limb, causes biomechanical problems to another joint, the primary should be worse than the secondary joint. Compensation causes are extremely rare in the upper limbs. Rather, the Veteran had many years of physical activities with his right shoulder post service. His right shoulder condition is the result of those activities directly, as well as a result of aging, and not related to his left shoulder condition. Although the Veteran believes his right shoulder condition is proximately due to or aggravated by the service-connected left shoulder disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiners’ opinions. Additionally, taken together, the July 2014, and February 2017, examinations and opinions, establish that the Veteran’s right shoulder condition, is not at least as likely as not related to an in-service injury, event, or disease, nor is it due to or aggravated by his service connected left shoulder disability. The combined rationale was that there is no basis in medical fact to support the claim, service treatment records do not show treatment for any right shoulder disability (or for many years following service). The examiners’ combined opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In other words, the most probative evidence of record does not show that the Veteran’s claimed right shoulder disorder is directly due to service or secondary to a service-connected disability. Therefore, the claim is denied. 2. Entitlement to service connection for a left foot condition The Veteran has asserted that he suffers from a left foot condition due to service. The question for the Board is whether the Veteran has a current disability that began during service or is at least a likely as not related to an in-service injury event or disease. The service treatment records are negative for any complaints or reports of a foot condition. There is one entry during service of a wart that was removed, with no further complaints of left foot problems during service. The Veteran underwent an examination in October 2010. X-rays revealed hallux valgus. There was no evidence of a fracture, and no significant spurring of the calcaneus. He reported pain, and treated it with ibuprofen. He reported being able to stand for 15 to 30 minutes at a time, and being able to walk up to ¼ of a mile. There is no additional evidence of any foot condition. The foot examination revealed no evidence of painful motion, edema, instability, weakness, or tenderness. His gait was normal, and there were no signs of abnormal weight bearing. There were no skin changes, vascular changes. There were no hammertoes, high arch, or clawfoot. No evidence of flat foot. He had left foot hallux valgus. Angulation at the first metatarsophalangeal joint was abnormal, by 10 degrees. Dorsiflexion at the first metatarsophalangeal joint was normal. The examiner concluded the Veteran’s left foot condition, claimed as left foot heel spurs, is less likely than not associated with service. The examiner noted, no significant heel spurs were found, and his hallux valgus is unrelated to left foot problems noted during service. The Board concludes, that, although the Veteran has a diagnosis of left foot hallux valgus, the preponderance of the evidence weighs against finding that his current diagnosis of hallux valgus began during service or is otherwise related to an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran is competent to report having experienced symptoms of pain on an intermittent basis since service, but he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a left foot condition, to include bone spurs, plantar fascitis, or hallux valgus. The issue is medically complex, as it requires knowledge of a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the October 2010 examiner, opined that the Veteran’s left foot condition of hallux valgus is less likely than not related to the wart removal during service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Service connection for a left foot condition is not warranted. 3. Entitlement to service connection for a sinus condition The Veteran asserted that he suffers from sinus headaches that originated during service. His service treatment records contain reports of and complaints related to headaches throughout, however no diagnosis was ever made. In July 2014 he underwent a VA examination. The Veteran reported that during and since his time in service, he has experienced chronic sinusitis that then causes headaches. He reported being treated with antibiotics to relieve the sinusitis. He was treating with over the counter sinus headache medication as needed. His symptoms included tenderness in the ethmoid sinuses with headaches, and discharge. The examiner concluded it was more likely than not that the Veteran’s sinus condition, claimed as sinus headaches, is related to service. The Veteran has consistently reported sinus headaches since service. There is a positive medical opinion linking his sinus condition to service. The Board finds the VA examiner’s opinion to be competent and probative in addressing whether the Veteran’s sinus condition is related to service. Therefore, service connection for sinusitis is warranted. 4. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression and anxiety, to include as secondary to his thyroidectomy The Veteran submitted a claim for service connection for depression and anxiety. He later asserted that he suffers from depression and anxiety as a result of his thyroidectomy. The term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2017). The requirement that a current disorder be present, however, is satisfied when a claimant has a disorder at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disorder resolves prior to the adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Nevertheless, in the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service treatment records are negative for any complaints of psychiatric symptoms or treatment for a psychiatric condition. The Veteran has submitted no evidence of a diagnosed psychiatric condition. VAMC treatment records have been reviewed, and contain two instances of a positive depression screen, once in 2013 and 2015. Aside from those two positive screens, there are no further reports of depressive symptoms. From 2011 through 2018, there are only two mentions of complaints of depression, and nothing further. Most recently in 2016, 2017, and 2018, the Veteran had negative screens for depression, and the record is void for any diagnosis of or treatment for any psychiatric condition. The Veteran is competent to describe his symptoms, but he has not been shown to have medical expertise to render a competent medical opinion as to a diagnosis or etiology of what he observes. The Board concludes that the medical evidence, which reveals no findings of a diagnosis of or treatment for an acquired psychiatric disorder, is of greater probative value than a lay contention. VA and private treatment records show the Veteran’s contacts with health professionals have been numerous, during which no complaints or treatment for an acquired psychiatric disorder was shown—other than the two positive depression screenings. As indicated above, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See U.S.C. §1110. In the absence of proof of a present disability, there can be no valid claim. Accordingly, in the absence of competent and credible evidence of an acquired psychiatric disorder during the period of the claim, service connection is not warranted on any basis and the claim must be denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Veteran bears the burden of presenting and supporting his claim for benefits. See 38 U.S.C. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. 5. Entitlement to an increased initial rating higher than 10 percent prior to August 14, 2013, and higher than 20 percent thereafter, for degenerative joint disease of the left shoulder The Veteran’s left shoulder is rated under Diagnostic code 5010-5201. DC 5201 rates limitation of motion of the arm, assigning a 20 percent rating for limitation of motion at the shoulder level of both major and minor joints. Limitation of motion of the major and minor joint midway between the side and shoulder level warrants a 20 and 30 percent rating for the minor and major joints, respectively. Limitation of motion of the major and minor joint to 25 degrees from side warrants a 30 and 40 percent rating for the minor and major joints, respectively. Normal shoulder flexion and abduction is from zero to 180 degrees (90 degrees at shoulder level), and normal internal and external rotation is from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. Initially, the Board notes that the Veteran is right-handed, as such his left shoulder disability affects the minor joint. The Veteran underwent an examination in October 2010. X-rays revealed mild degenerative changes at the left acromioclavicular joint, and no fracture or dislocation was found. He reported moderate pain, and was taking ibuprofen as needed. He endorsed popping. His shoulder range of motion was flexion to 120 degrees, and abduction to 125 degrees, external rotation to 90 degrees, and internal rotation to 75 degrees. After five repetitions he had flexion to 125, abduction to 125, external rotation to 90, and internal rotation to 75. He had painful motion, but there was no ankylosis. There was no evidence of fatigue, weakness, lack of endurance, or incoordination. There was objective evidence of pain on motion. There were no changes after 5 repetitions. In July 2014 he underwent a VA examination, during which he was diagnosed with degenerative joint disease of the left shoulder. He was treated in the past with physical therapy and Mobic, but has not had treatment since 1996. On range of motion testing he had flexion to 85 degrees, abduction to 80 degrees, and external rotation and internal rotation to 90 degrees. He had difficulty with overhead lifting activities. Following repetitive use testing, there was no change in range of motion. The examiner indicated the Veteran’s decreased range of motion, bilaterally, is secondary to age, inactivity and self-restriction. No range of motion movements were painful on active, passive and or repetitive use testing. There was pain when the joint was used in weight bearing or non-weight bearing, with a note the Veteran has pain with lifting and is limited to a light level of lifting from floor to waist. He had less movement than normal due to pain. Pain, weakness, fatigability or incoordination did not significantly limit functional ability during a flare up or when the joint is used repeatedly. Muscle strength testing was normal, and he had no muscle atrophy. There was no evidence of ankylosis, a shoulder cuff condition, instability, dislocation, or labral pathology. There was no evidence of a humerus condition, a clavicle, scapula, AC joint or sterno clavicular joint condition. He was afforded an examination in February 2017. Treatment records document physical therapy for his left shoulder in 2015. He had cortisone injections in the prior year, which helped for a few months, but the pain returned. He reported that he must sleep on his back because it is painful to sleep on his side. When working, he had to think about his shoulder. Range of motion testing revealed flexion to 120 degrees, abduction to 120 degrees, and external rotation to 90 degrees, and internal rotation to 70 degrees. He had pain on flexion and abduction. There was pain with weight bearing. There was localized tenderness in the deltoid region. He had crepitus. The functional impact of the range of motion was limited overhead activities. He was not able to perform repetitive use testing, and reported he “just can’t.” The examiner concluded the examination was neither medically consistent or inconsistent with the Veteran’s statement describing functional loss with repetitive use over time. Pain, weakness, fatigability or incoordination do not limit functional ability with repeated use over time. There were no reports of flare-ups. There was no evidence of ankylosis. There was a positive Hawkins’ impingement test—meaning pain on internal rotation. There was no evidence of dislocation. There was no evidence of pain and sense of instability on crank apprehension and relocation test. He had tenderness to palpation of the AC joint, and pain during cross-body adduction test. A MRI from November 2015 was reviewed, that revealed moderate AC joint mild supra and infraspinatous tendinosis without tear, small fluid along outer fibers of infraspinatus muscle belly, mild distal subscapularis tendinosis, and chronic superior labral tear, and moderate AC joint arthropathy. The functional impact was identified as he would be limited in a vocation with repetitive overhead activities. There was pain with non-weight bearing. The functional loss was described as decreased range of motion and guarding. He had pain with passive range of motion that did not result in, or cause, functional loss. He had pain with weight bearing, which would limit tasks such as push-ups. Prior to August 14, 2013, the Veteran’s left shoulder disability was rated 10 percent. To warrant the next higher under 5201, there must be limitation of arm motion at the shoulder level or shoulder impairment approximating such level of severity. Here, the restrictions found on examinations fall far short of the limitations required for a 20 percent rating. Notably on examination in October 2010, flexion was to 120 degrees, and abduction to 125 degrees. These limitations show arm movement well above 90 degrees. In short, the evidence does not show, nor does the Veteran allege, that he has, or at any time during the period for consideration has had, limitation of arm motion at the shoulder level—even considering his reported functional impairment. Accordingly, a rating higher than 10 percent under Code 5201 is not warranted prior to August 14, 2013. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any functional loss beyond that considered in the rating currently assigned. 38 C.F.R. §§ 4.10, 4.40, 4.45; DeLuca, 8 Vet. App. at 205. The Veteran reported painful motion; however, such limitation is accounted for by the 10 percent rating currently assigned. There were no further limitations following repetitive use or functional impairment appreciated following a flare-up. From August 14, 2013, the Veteran’s shoulder is rated as 20 percent disabling. To warrant the next higher (under Code 5201) 30 percent schedular rating for disability of the minor shoulder, there must be limitation of arm motion to 25 degrees. Here, the restrictions found on examinations fall far short of the limitations required for a 30 percent rating. Notably on examination on examination in July 2014, range of motion testing revealed flexion to 85 degrees, abduction to 80 degrees, external rotation and internal rotation to 90 degrees. At the February 2017 exam, his range of motion testing revealed flexion to 120 degrees, abduction to 120 degrees, external rotation to 90 degrees, and internal rotation to 70 degrees. There is no indication in these reports that his left arm was limited to 25 degrees from his side. Additionally, the Board notes that the other records where range of motion testing was performed showed normal ranges or did not indicate that his motion was limited to midway between the side and shoulder level. Accordingly, a rating higher than 20 percent under Code 5201 is not warranted. Regarding functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45, the Veteran’s VA records contain reports of left shoulder pain. At the 2014 examination, he had difficulty with overhead lifting activities. Following repetitive use testing, there was no change in range of motion. Pain, weakness, fatigability or incoordination do not significantly limit functional ability during flare up or when the joint is used repeatedly over a period of time. On examination in February 2017, he had pain on flexion, with the functional impact being limited overhead activities. At the 2017 examination, the Veteran reported being unable to perform repetitive testing, and the examiner noted the exam was neither consistent, nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Even taking those factors into consideration, the record does not support a finding that his left arm range of motion was limited to midway between the side and shoulder or to 25 degrees from the side. At the most recent examination, there were no reported flare-ups. As such, an increased rating based on functional loss is not warranted and a rating higher 20 percent for the left shoulder disability is not warranted. See 38 C.F.R. §§ 4.40, 4.45; see also Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Therefore, as the preponderance of the evidence is against the Veteran’s claim for an increased rating higher than 10 percent prior to August 14, 2013, and higher than of 20 percent thereafter, for his left shoulder disability, the benefit of the doubt doctrine does not apply. The claim must be denied. 6. Entitlement to a compensable evaluation for pseudofolliculitis barbae The Veteran asserts that his PFB is more severe than the current noncompensable rating reflects. The Veteran is in receipt of a noncompensable evaluation for pseudofolliculitis barbae. He is evaluated under diagnostic code 7806. After careful review of the medical evidence of record, the Board finds that a compensable rating is not warranted. Under DC 7806, a noncompensable disability rating is warranted for dermatitis or eczema affecting less that 5 percent of the entire body or less than 5 percent of exposed areas, and; no more than topical therapy required during the past 12-month period. A 10 percent disability rating is warranted for dermatitis or eczema affecting 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, or; requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. A 30 percent disability rating is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum schedular 60 percent disability rating is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or; requiring constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Alternatively, the condition is to be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801-05), depending upon the predominant disability. Upon VA examination in July 2014, the Veteran was diagnosed with PFB. During service he developed razor burn from shaving, and he also complained of an episodic rash on his left arm, with no diagnosis or treatment. He had no scarring or disfigurement of the head, face, or neck. He had no systemic manifestations due to any skin disease or skin neoplasms. He was not treated with oral or topical medications in the prior 12 months. He had no debilitating or non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. On physical examination he had dermatitis, with the exposed area (hands, face, and neck), being less than 5 percent affected. Given the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to a compensable disability rating for PFB. To warrant a compensable disability rating under DC 7806, the Veteran’s skin condition would need to affect 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, or; require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. 4.118, DC 7806. However, the evidence of record, including as discussed above, does not document that the Veteran’s PFB affected an area of at least 5 percent of his entire body or exposed areas, or that the condition required intermittent systemic therapy. As such, a compensable disability rating is not warranted under DC 7806. Additionally, as directed by DC 7806, the Board has also considered whether an increased disability rating is warranted for any period on appeal under DCs 7800-05 regarding disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801-05); however, the evidence of record documents that the Veteran’s predominant skin disability is most closely approximated by the assigned disability rating under DC 7806 for dermatitis or eczema. See 38 C.F.R. 4.118, DCs 7800-06. Moreover, the evidence of record does not document that the Veteran’s service-connected PFB has resulted in disfigurement of the head, face, or neck, or scars which warrant an increased disability rating. The Board has also considered the lay evidence of record, which is probative insofar as it describes observable symptomatology, however, such statements are less probative than the objective evidence of the impact of his skin condition (including the area it covers on his body), and whether he meets the next higher rating under the code. In conclusion, as the preponderance of evidence weighs against the Veteran’s claim of entitlement to a compensable disability rating for PFB, there is no reasonable doubt to be resolved, and the claim is denied. 7. Entitlement to an increased initial rating higher than 10 percent for thyroidectomy with residual scar The Veteran in receipt of a 10 percent rating for thyroidectomy with residual scar, under diagnostic Code 7903. The Veteran contends that an initial disability rating higher than 10 percent is warranted. His thyroidectomy has been rated at 10 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7903. Under DC 7903, a 10 percent disability rating is warranted for fatigability or continuous medication required for control. A 30 percent disability rating is warranted for fatigability, constipation, and mental sluggishness. A 60 percent disability rating is warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent disability rating is warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 heart beats per minute), and sleepiness. VA treatment records document reports of excessive fatigability in June 2007, with a note the Veteran was status-post thyroidectomy. The Veteran underwent an exam in October 2010. He was diagnosed with a multi-goiter thyroid condition, with a note that the condition started in 1994. In 2001 he had a thyroidectomy. The only symptom reported was tiredness. He was taking Synthroid daily, with a good response to the treatment. In July 2014 he was afforded a VA examination. He was taking Synthroid daily. His symptoms included constipation, cold intolerance, and complaints of dehydration. The Veteran had a scar of the neck, related to the thyroid condition. The scar was not painful, elevated or depressed, or adherent to underlying tissue. The scar was less than 13 cm in length, and less than 0.6cm in width. The scar was not hyper or hypopigmented, nor did it have an abnormal texture, or missing tissue. The scar measured 5.5cm x 0.25cm. Based on a careful review of all the subjective and clinical evidence, from June 18, 2010, to July 28, 2014, the Veteran’s thyroidectomy residuals do not warrant an initial rating higher than 10 percent under Diagnostic Code 7903. The Veteran’s medical records demonstrate that throughout this appeal period, he continued to be treated with Synthroid. However, these records do not present any clinical findings establishing that his symptoms warranted consideration of a higher evaluation under the rating criteria. Accordingly, there is no basis upon which to award a higher than 10 percent initial evaluation under Diagnostic Code 7903. Therefore, prior to July 28, 2014, the Veteran’s thyroidectomy residuals are no more than 10 percent disabling. However, from July 28, 2014, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a 30 percent rating is warranted. At the Veteran’s July 2014, examination, the VA examiner noted that the Veteran required continuous medication for control of his thyroid condition, and he complained of constipation, cold intolerance, and dehydration. Throughout the appeal he has complained of fatigability, and though it was not noted on examination in 2014, the medical records support the Veterans consistent contentions of fatigability related to his thyroidectomy residuals. Giving the Veteran the benefit of the doubt, the Board finds that from July 28, 2014, the evidence more closely approximates a 30 percent evaluation under Diagnostic Code 7903. However, the record does not demonstrate that the Veteran’s abnormal thyroid condition presents symptoms consistent with the rating criteria for a 60 percent evaluation. Prior to July 28, 2014, the preponderance of the evidence weighs against finding in favor of an initial rating higher than 10 percent for thyroidectomy residuals. However, resolving all reasonable doubt in favor of the Veteran, a 30 percent evaluation, but no higher, for thyroidectomy residuals is granted, effective July 28, 2014. 38 U.S.C. 5107(b); 38 C.F.R. 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In considering whether a separate evaluation is warranted for the Veteran’s thyroidectomy scar, the Board notes his scar was not painful, unstable or larger than 9 centimeters. A separate compensable evaluation for the surgical scar is not warranted unless there are scars that superficial and nonlinear in an area or areas of 144 square inches (929 sq.cm.) or greater, or one or two scars that are unstable or painful, or if it is deep and nonlinear in an area that is at least 6 square inches (30 sq.cm.), but less than 12 square inches (77sq.cm). As such, a separate compensable evaluation is not warranted. 38 C.F.R. § 4.118. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include as secondary to service connected status-post thyroidectomy, is remanded. 2. Entitlement to service connection for hypertension, to include as secondary to service connected status-post thyroidectomy, is remanded. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service connected status-post thyroidectomy, is remanded. 4. Entitlement to service connection for diabetes mellitus, also claimed as hyperglycemia, to include as secondary to service connected status-post thyroidectomy, is remanded. May 2010 medical records from Dr. Ravin indicate the Veteran was seen and treated for diabetes, hypertension, and erectile dysfunction. A February 2012, statement from Dr. Ravin, reports that after the removal of the thyroid, the Veteran manifested significant metabolic abnormalities. These metabolic abnormalities created hypertension, hyperglycemia, and later diabetes mellitus. He then developed erectile dysfunction, which is likely related to his antihypertensives and diabetes mellitus. He also suffered from sleep apnea, which was produced by his thyroid disease. This statement did not include an adequate rationale for the opinions provided. In May 2013, the Veteran underwent a VA examination. The examiner reviewed the file, and concluded the Veteran’s hypertension and erectile dysfunction preceded his diabetes diagnosis by many years. The examiner stated that his goiter was recognized in 1993, and he was euthyroid. In 2002, he saw his primary care provider as the goiter was pressing uncomfortably on his trachea when he was supine in bed. The examiner indicated there are no abnormal labs available to substantiate the significant metabolic abnormalities. The Veteran was treated effectively with thyroid replacement hormone since his surgery. His mildly elevated blood pressure readings have been documented since 1998, prior to the thyroidectomy. As such, the examiner concluded, it is less likely than not that his hypertension is secondary to his goiter or thyroidectomy. With regard to hyperglycemia and diabetes, the examiner indicated hyperglycemia has been associated with hyperthyroidism, however the Veteran has not had hyperthyroidism. There is no connection between post-operative hypothyroidism and hyperglycemia. The examiner concluded it is less likely than not that his goiter and thyroidectomy caused his hyperglycemia. About erectile dysfunction, the Veteran was noted as having been diagnosed with erectile dysfunction in 1998. The examiner concluded his erectile dysfunction is less likely than not proximately due to or the result of a service connected condition. There is no opinion on the likelihood of direct service connection, or of aggravation. As such, the claim must be remanded for an addendum opinion addressing whether the conditions were aggravated by the status-post thyroidectomy, or otherwise are directly related to the Veteran’s service. The matters are REMANDED for the following action: 1. Appropriate efforts should be made to obtain and associate with the case file any further medical records (private and/or VA) identified and authorized for release by the Veteran. 2. Obtain an addendum opinion regarding the claimed sleep apnea, hypertension, erectile dysfunction, and diabetes mellitus. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. The examiner should answer the following questions: (a.) Is it at least as likely as not that: sleep apnea, hypertension, erectile dysfunction, and diabetes mellitus, was caused OR aggravated (worsened beyond its natural progression) by the service-connected status post thyroidectomy? The examiner is asked to provide an opinion as to both causation and aggravation. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of the sleep apnea, hypertension, erectile dysfunction, or diabetes mellitus, disability, by the service-connected disability. (b.) If not, is it at least as likely as not that the Veteran’s sleep apnea, hypertension, erectile dysfunction, or diabetes mellitus, is otherwise related to an event, injury, or disease in active duty? The examiner should provide a rationale for all opinions reached. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Skiouris, Associate Counsel