Citation Nr: 18143009 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 14-25 289A DATE: October 18, 2018 ORDER A 10 percent rating, but no greater, for bilateral plantar fasciitis prior to February 17, 2017 is granted subject to the laws and regulations controlling the disbursement of monetary benefits. A rating in excess of 30 percent as of February 17, 2017 for bilateral plantar fasciitis is denied. An initial rating in excess of 10 percent for glaucoma is denied. A separate 10 percent rating, but no greater, for chronic dry eye syndrome and conjunctivitis is granted subject to the laws and regulations controlling the disbursement of monetary benefits. A rating in excess of 20 percent for benign prostatic hypertrophy prior to September 15, 2016 and a rating in excess of 40 percent thereafter is denied. A rating in excess of 30 percent for xerosis cutis, onychomycosis, and dermatophytosis prior to February 17, 2017 is denied. A 60 percent rating, but no greater, for xerosis cutis, onychomycosis, and dermatophytosis as of February 17, 2017 is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. REMANDED Entitlement to an initial rating in excess of 10 percent for cervical spine strain is remanded. Entitlement to an initial rating in excess of 10 percent for thoracolumbar spine strain with degenerative changes is remanded. FINDINGS OF FACT 1. Prior to February 17, 2017, the Veteran’s left and right foot plantar fasciitis manifested with pain, particularly with weight-bearing, but without any significant physical deformity or swelling. 2. As of February 17, 2017, the Veteran’s left and right foot plantar fasciitis manifests with constant pain, worsened with use and manipulation, but no marked deformity, including no pronation or inward displacement of the tendo achillis. 3. The Veteran’s glaucoma requires continuous medication and has resulted in a remaining visual field of 49 degrees in his right eye and 46 degrees in his left eye. It has not caused any incapacitating episodes. 4. The Veteran’s dry eye syndrome causes dry, itchy, painful eyes but no visual impairment, disfigurement, or incapacitating episodes. 5. Prior to September 15, 2016, the Veteran’s benign prostatic hypertrophy resulted in a daytime voiding interval of one to two hours and nighttime voiding no more than four times per night with no requirement to wear absorbent materials, no catheterization, and no recurrent urinary infections. 6. As of September 15, 2016, the Veteran’s benign prostatic hypertrophy resulted in a daytime voiding interval of less than an hour, voiding no more than four times per night, and wearing absorbent materials that must be changed less than twice a day, but does not require the use of an appliance. 7. Prior to February 17, 2017, the Veteran’s xerosis cutis, onychomycosis, and dermatophytosis did not require systemic therapy and covered between 20 and 40 percent of the Veteran’s body with no evidence of scars or disfigurement. 8. As of February 17, 2017, the Veteran’s xerosis cutis, onychomycosis, and dermatophytosis affected more than 40 percent of his entire body with no evidence of scars or disfigurement. CONCLUSIONS OF LAW 1. The criteria for a rating of 10 percent, but no greater, for bilateral plantar fasciitis have been met prior to February 17, 2017. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5276-5284 (2017). 2. The criteria for a rating in excess of 30 percent for bilateral plantar fasciitis as of February 17, 2017 have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5276-5284 (2017). 3. The criteria for a rating in excess of 10 percent for glaucoma have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.75, 4.76, 4.77, 4.78, 4.79, Diagnostic Code 6013 (2017). 4. The criteria for a separate 10 percent rating for dry eye syndrome have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.75, 4.76, 4.77, 4.78, 4.79, Diagnostic Code 6018 (2017). 5. The criteria for a rating in excess of 20 percent for benign prostatic hypertrophy prior to September 15, 2016 have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.115b, Diagnostic Codes 7527. 6. The criteria for a rating in excess of 40 percent for benign prostatic hypertrophy as of September 15, 2016 have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.115b, Diagnostic Codes 7527. 7. The criteria for a rating in excess of 30 percent for xerosis cutis, onychomycosis, and dermatophytosis prior to February 17, 2017 have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.118, Diagnostic Code 7806. 8. The criteria for a rating of 60 percent, but no greater, for xerosis cutis, onychomycosis, and dermatophytosis as of February 17, 2017 have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In February 2017, the Veteran filed a substantive appeal as to the issue of entitlement to service connection for sleep apnea. As he has requested a hearing before the Board in that matter, it is not being adjudicated at this time. In July 2013, the Veteran indicated he wished to claim service connection for fibromyalgia, gastrointestinal disorder, and undiagnosed illnesses and reopen his claims for service connection for chronic fatigue syndrome, left leg compartment syndrome, arcus senilis, temporal pallor optic disc, myopic astigmatism, and right and left foot peripheral neuropathy. As the issues have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). 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. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a compensable rating for right and left foot plantar fasciitis prior to February 17, 2017 and a rating in excess of 30 percent for bilateral plantar fasciitis thereafter. The Veteran’s initial noncompensable left and right foot plantar fasciitis was assigned under Diagnostic Code 5284. His increased, 30 percent rating, for bilateral plantar fasciitis was assigned under Diagnostic Code 5276. Diagnostic Codes 5276 through 5283 address specific types of foot injuries or disorders; none of those codes address plantar fasciitis. 38 C.F.R. § 4.71a (2017). The Board finds that diagnostic codes 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), and 5283 (malunion or nonunion of the tarsal or metatarsal bones) do not apply, as the Veteran is service-connected for plantar fasciitis and the symptoms attributable to it do not overlap with these foot disorders. Diagnostic Code 5276 pertains to acquired flat foot (or pes planus) and provides that mild disability of the foot with symptoms that are relieved by built-up shoe or arch support will be assigned a noncompensable rating. Moderate disability, with the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, will be assigned a 10 percent rating. Severe disability, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use of accentuated, indication of swelling on use, characteristic callosities, will be assigned a 20 percent rating where it is unilateral and a 30 percent rating where it is bilateral. Pronounced disability, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, warrants a 30 percent rating where it is unilateral and a 50 percent rating where it is bilateral. 38 C.F.R. § 4.71a (2017). Diagnostic Code 5284, for “other foot injuries” provides for a rating of 10 percent for moderate disability, 20 percent for moderately severe disability, 30 percent for severe disability, and 40 percent for actual loss of use of the foot. See 38 C.F.R. § 4.71a. VA’s General Counsel has stated that this is a more general diagnostic code under which a variety of foot injuries may be rated. See VAOPGCPREC 9-98. Words such as “severe,” “moderate,” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2017). Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 4.2, 4.6 (2017). The Board finds that prior to February 17, 2017, the Veteran’s bilateral plantar fasciitis more closely approximated a moderate disability under Diagnostic Code 5276, thus warranting a 10 percent rating. On VA examination in January 2011 the Veteran reported he wears inserts and does physical therapy for his chronic plantar fasciitis, which is partially effective in relieving his symptoms. He reported pain and stiffness in the medial arch while standing, walking, and at rest. He reported being able to stand 15 to 20 minutes and walk more than a quarter mile but less than a mile. On examination there was evidence of tenderness and abnormal weight bearing and increased pain with stretching of the plantar fascia. Callosities were noted. The examiner found no evidence of painful motion or swelling. VA treatment records reflect he continued to report pain in his feet throughout 2012 despite using orthotics. On examination in February 2012 he was noted to have tenderness on palpation of his feet but his foot pronation was normal. The Board finds that the Veteran’s condition prior to February 17, 2017 does not more closely approximate the criteria for a rating in excess of 10 percent. Under Diagnostic Code 5276, a higher rating for severe disability requires objective evidence of marked deformity, pain on manipulation and use of accentuated, indication of swelling on use, and characteristic callosities. Although the Veteran has reported pain on manipulation and use of his feet and callosities have been noted, the evidence does not reflect that the Veteran has marked deformity or swelling on use. Based on the forgoing, the Board finds that a rating in excess of 10 percent under Diagnostic Code 5276 is not warranted prior to February 17, 2017. The Veteran’s February 17, 2017 VA examination is the first evidence indicating a worsening of the Veteran’s condition such that a higher, 30 percent, rating is warranted under Diagnostic Code 5276. On VA examination in February 2017 the Veteran was noted to have plantar fasciitis, pes planus, and arthritis in his feet. He reported that he has constant pain in his feet and flare-ups of throbbing, aching pain that make it difficult to walk or run. He reported difficulty with prolonged standing, walking, and running. On examination he had pain on use and manipulation of the feet and characteristic calluses. He did not have extreme tenderness of the plantar surfaces of either foot. He was noted to use orthotics, but to still have symptoms. There was no objective evidence of marked deformity, marked pronation, inward bowing of the achilles tendon, or marked inward displacement and severe spasm of the achilles tendon on manipulation. His condition was noted to cause disturbance of locomotion and interference with standing. He had additional functional loss during flare-ups and with repeated use resulting in being unable to walk and stand for a prolonged period of time. While the Board acknowledges the Veteran’s foot pain, the Board finds that his condition overall does not more closely approximate the criteria for a pronounced disability, which under Diagnostic Code 5276 is defined as involving marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. The evidence does not reflect that the Veteran has marked pronation or displacement and severe spasm of the tendo achillies. The Board finds that the pain he has described and the functional limitation of difficulty with prolonged walking and standing is contemplated by the criteria for a severe disability under Diagnostic Code 5276. The Board notes that higher ratings are potentially available under Diagnostic Code 5284 for other foot injuries. However, the Veteran’s symptoms of pain and tenderness on manipulation and use are specifically noted in the rating criteria for Diagnostic Code 5276. Plantar fasciitis is defined as “inflammation involving the plantar fascia especially in the area of its attachment to the calcaneus and causing pain under the heel in walking and running.” Hoag v. Brown, 4 Vet. App. 209, 211 (1993). Plantar fasciitis is inflammation of the sole of the foot, associated with eosinophilia, edema, and swelling. Fenderson v. West, 12 Vet. App. 119, 122 (citing DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 609-10, 1300 (28th ed.1994)). Symptoms of pain and tenderness of the plantar surface of the feet are encompassed under and contemplated in the rating criteria for Diagnostic Code 5276. The intent of Diagnostic Code 5284 is to encompass disabilities not contemplated by the other diagnostic codes of the foot, as evidenced by its title of “Foot injuries, other.” The Board reads this to mean that it applies to disabilities of the feet which are not otherwise listed in 38 C.F.R. § 4.71a. The Board is cognizant of the VAOPGCPREC 9-98 for authority that Diagnostic Code 5284 is a more general diagnostic code under which a variety of foot injuries may be rated. However, the Board does not read this as mandating application of Diagnostic Code 5284 instead of Diagnostic Code 5276 for service-connected plantar fasciitis. Diagnostic Code 5284 may be applied to foot disorders other than those which are specifically listed in the Rating Schedule. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015) (when a condition is specifically listed in the Schedule, it may not be rated by analogy under Diagnostic Code 5284). Thus, in conclusion, the Board finds that Diagnostic Code 5276 is the most appropriate code under which to rate the Veteran’s bilateral plantar fasciitis. Under that code, the Veteran is entitled to a 10 percent rating, but no greater, for bilateral plantar fasciitis prior to February 17, 2017. He is not entitled to a rating in excess of 30 percent as of February 17, 2017. 2. Entitlement to an initial rating in excess of 10 percent for glaucoma, conjunctivitis, and chromic dry eye syndrome. The Veteran has a 10 percent rating for glaucoma, conjunctivitis, and chronic dry eye syndrome under Diagnostic Code 6013 for open-angle glaucoma. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Both the former and revised criteria indicate that a minimum 10 percent rating is warranted under Diagnostic Code 6013 if continuous medication is required. Under the former criteria, DC 6013 instructed to evaluate pursuant to visual impairment due to open-angle glaucoma. Under the revised criteria, DC 6013 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye. The General Rating Formula for Diseases of the Eye instructs to evaluate a condition based on visual impairment or its rating criteria for incapacitating episodes. Thus, the primary difference between the former and revised criteria is consideration of incapacitating episodes. With regard to visual impairment, the amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. Id. § 4.75(b). Examinations of visual field or muscle function will be conducted only when medically indicated. Id. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). When the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, the visual acuity of the poorer eye will be evaluated using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. 38 C.F.R. § 4.76(b)(1). Provided that the claimant customarily wears contact lenses, evaluate the visual acuity of any individual affected by a corneal disorder that results in severe irregular astigmatism that can be improved more by contact lenses than by eye glasses, as corrected by contact lenses. 38 C.F.R. § 4.76(b)(2). In any case where an examiner reports that there is a difference equal to two or more scheduled steps between near and distance corrected vision, with the near vision being worse, the examination report must include at least two recordings of near and distance corrected vision and an explanation of the reason for the difference. In these cases, evaluation will be based on corrected distance vision adjusted to one step poorer than measured. 38 C.F.R. § 4.76(b)(3). Evaluation of visual field is based on the remaining field of vision in each eye. The examiner must record the remaining visual field of at least 16 meridians 22½ degrees apart for each eye, even though only the visual field at eight principal meridians 45 degrees apart will be used for rating purposes. Id. The table of Ratings for Impairment of Visual Fields provides ratings for visual field loss. The first half of the table provides ratings based on loss of an entire half of field of vision in an eye. The second half of the table provides ratings based on the average concentric contraction of the visual field of each eye. To calculate average concentric contraction, the rater should add the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart and divide the sum by eight. 38 C.F.R. § 4.77(b). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, separately evaluate the visual acuity and visual field defect (expressed as a level of visual acuity), and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77(c). Evaluations of visual impairment of muscle function is based on the degree of diplopia. The examiner must record test results for the four major quadrants (upward, downward, and right and left lateral) and the central field (20 degrees or less). 38 C.F.R. § 4.78(a). On VA examination in both April 2011 and May 2016 the Veteran was noted not to have diplopia. In April 2011 the Veteran’s corrected distance vision was measured to be 20/30+ in the right eye and 20/25+ in the left eye. In May 2016 the Veteran’s corrected distance vision was measured to be 20/40 or better in both eyes. On neither examination was he found to have a difference equal to two or more scheduled steps or lines of visual acuity between near and distance corrected vision for either eye. At the Veteran’s April 2011 VA examination, the examiner noted that the Veteran had full visual field on testing in December 2010. On VA examination in May 2016 the examiner noted that the Veteran had contraction, but not loss, of a visual field. The Board has reviewed the Veteran’s visual field testing and finds that it shows the Veteran has a remaining visual field of 49 degrees in his right eye and 46 degrees in his left eye. Under Diagnostic Code 6080, with a remaining visual field of 46 to 60 degrees a 10 percent rating is warranted where the condition is bilateral or unilateral. Or each affected eye may be evaluated as 20/50. Under Diagnostic Code 6066 for impairment of visual acuity, a 10 percent rating is warranted where vision is 20/50 in each eye. Based on the forgoing, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent based on impairment of muscle function, impairment of visual acuity, or visual field loss. Under the revised criteria, glaucoma may also be rated based on incapacitating episodes. Although the Veteran has not undergone a VA examination since the new criteria took effect, the Board notes that at his most recent May 2016 VA examination the Veteran was not noted to have had incapacitating episodes due to his eye conditions. The Veteran reported he treats his eye conditions with daily drops. The General Rating Formal for Diseases of the Eye defines as incapacitating episode for purposes of evaluation under 38 C.F.R. § 4.79 to be eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. For a rating in excess of 10 percent at least three documented treatment visits for an eye condition during the past 12 months are required. Note (2) to 38 C.F.R. § 4.79 indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. There is no indication in the record that since the revised criteria went into effect May 13, 2018 that the Veteran has had such incapacitating episodes. Based on the forgoing, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s service-connected glaucoma. However, the Board finds that the Veteran is entitled to a separate rating for dry eye syndrome. The condition is separate from the Veteran’s glaucoma and causes separate symptomatology. Specifically, the Veteran has reported having dry, itchy, painful eyes as a result of the dry eye syndrome. Records indicate he treats the condition with daily eye drops. The Veteran’s glaucoma also requires daily medication, separate from the Veteran’s dry eye syndrome, and is the sole cause of his visual field impairment, for which he has a 10 percent rating. Dry eye syndrome is not a listed condition in the rating schedule. Given its location and symptomatology, the Board finds that it is best rated by analogy under Diagnostic Code 6018. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board’s choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Diagnostic Code 6018 applies to chronic conjunctivitis. Under the criteria in effect prior to May 13, 2018, an active disease process (with objective findings, such as red, thick conjunctivae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (DC 7800). The Board finds that the Veteran’s symptomatology of dry, itchy, painful eyes equates to active chronic conjunctivitis. Accordingly, the Board finds that the criteria for a 10 percent rating under Diagnostic Code 6018 have been met. 38 C.F.R. § 4.79. As the condition has not caused incapacitating episodes or resulted in visual impairment or disfigurement, a higher rating is not warranted. The Board notes that although the Veteran is also service connected for conjunctivitis, a separate or higher rating is not warranted with respect to that condition. On VA examination in 2016 the Veteran reported that he had not had any conjunctivitis symptoms or treatment for some time, and his medical records do not indicate differently. 3. Entitlement to a rating in excess of 20 percent for benign prostatic hypertrophy prior to September 15, 2016 and a rating in excess of 40 percent thereafter. The Veteran’s benign prostatic hypertrophy is rated under Diagnostic Code 7527, which evaluates prostate gland injuries, infections, hypertrophy and postoperative residuals, and directs that they are evaluated as voiding dysfunction or urinary tract infection, whichever is dominant. 38 C.F.R. § 4.115b, Diagnostic Code 7527. Voiding dysfunction may be rated as urine leakage, frequency, or obstructive voiding. A 20 percent rating is warranted for urine leakage where the disorder requires the wearing of absorbent materials which must be changed less than twice a day. A 40 percent rating requires the wearing of absorbent materials which must be changed two to four times per day. A 60 percent rating requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a. The criteria for urinary frequency provide for a 20 percent waking for a daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 40 percent rating is warranted when there is a daytime voiding interval of less than one hour, or; awakening to void five times per night. Id. A 30 percent rating for obstructed voiding requires urinary retention requiring intermittent or continuous catheterization. Id. When there are recurrent symptomatic urinary infections requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management, a 30 percent rating is assigned. Id. The Board finds that a rating in excess of 20 percent is not warranted prior to September 15, 2016. On VA examination in January 2011 the Veteran reported a one to two hour daytime voiding interval and waking to void three times per night. A January 2012 VA treatment record reflects that the Veteran reported waking up to void two to three times per night and an August 2013 VA treatment record reflects that the Veteran reported waking up to void three to four times per night. A higher, 40 percent rating, for urinary frequency requires a daytime voiding interval of less than one hour or awakening to void five times per night. The record does not reflect the Veteran experienced such urinary frequency prior to September 15, 2016. Further, the 2011 VA examination specifically states that the Veteran did not require wearing of absorbent materials and no VA treatment records indicate the wearing of absorbent materials. There is further no evidence of requires urinary retention requiring intermittent or continuous catheterization or recurrent symptomatic urinary infections. Therefore, the Board finds that a preponderance of the evidence is against a rating in excess of 20 percent based on voiding dysfunction or urinary tract infection. The earliest evidence suggesting a worsening of the Veteran’s condition such that a higher rating is warranted is the VA examination of September 15, 2016. On that examination the Veteran reported a daytime voiding interval of less than an hour, voiding three to four times per night, and wearing absorbent materials that must be changed less than twice a day. The examination specifically notes that voiding dysfunction does not require the use of an appliance. A 60 percent rating for urine leakage is the only rating in excess of 40 percent available under Diagnostic Code 7527. The rating requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. Neither applies to the Veteran. Therefore, a rating in excess of 40 percent as of September 15, 2016 is denied. 4. Entitlement to an initial rating in excess of 30 percent for xerosis cutis, onychomycosis, and dermatophytosis. The Veteran is currently assigned a 30 percent rating for xerosis cutis, onychomycosis, and dermatophytosis under Diagnostic Code 7806. Notably, during the appeal period, changes were made to 38 C.F.R. § 4.118, Diagnostic Code 7806. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32592 (July 13, 2018). Under both the pre-August 2018 rating criteria and the post-August 2018 rating criteria, Diagnostic Code 7806 provides for a 30 percent rating when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or, where systemic therapy, such as corticosteroids or other immunosuppressive drugs, are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or, when constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, is required during the past 12-month period. The post-August 2018 rating criteria clarify that systemic therapy includes, but is not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, and other immunosuppressive drugs. Or the skin condition may be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. In Johnson v. Shulkin, the Federal Circuit distinguished between “systemic” therapy versus “topical” therapy, holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied. 862 F.3d 1351 (Fed. Cir. 2017). In considering whether a treatment is systemic, the Board must also consider whether the treatment affects the body as a whole and whether the given treatment is like or similar to a corticosteroid or other immunosuppressive drug. see Burton v. Wilkie, No. 16-2037, 2018 U.S. App. Vet. Claims LEXIS 1314 *20 (September 2018). There is no evidence of scars or disfigurement resulting from the Veteran’s xerosis cutis, onychomycosis, and dermatophytosis at any time pertinent to the appeal. At his January 2011 VA examination, the Veteran was noted to use a topical lotion daily that was neither a corticosteroid or immunosuppressive. The examiner stated that 20 to 40 percent of the Veteran’s entire body is affected by his xerosis cutis, described as diffuse dry skin more noticeable on his trunk, including less than 5 percent of his exposed areas. His onychomycosis, described as thickening and discoloration of multiple toenails, was noted to affect none of his exposed areas and less than 5 percent of his total body. On VA examination on February 17, 2017 the Veteran was noted to use constant or near-constant topical skin moisturizers. On examination, less than 5 percent of his total body area was noted to be affected by skin infection, described as nail thickening and discoloration, and none of his exposed areas. His xerosis cutis was noted to affect 40 percent of his total body area and 5 percent of his exposed areas. The examiner specifically noted that the condition affects the Veteran’s anterior and posterior torso and upper and lower extremities. The Veteran himself described his condition as worsening over the years and currently involving dryness of skin over his entire body except the face, head, and neck, and fungal infection of all of his toes on both feet. The Board finds that giving the Veteran the benefit of the doubt, he is entitled to a 60 percent rating as of February 17, 2017, but no earlier. The February 17, 2017 VA examiner opined that 40 percent of the Veteran’s total body area, specifically the skin of his torso and extremities, was affected by his xerosis cutis, and less than 5 percent of his total body area, specifically his nails, was affected by a skin infection. Although the examiner did not specify a combined total area affected, the evidence reflects that the xerosis affects his skin and the onychomycosis his nails; therefore, the Board concludes that the total area is at least as likely as not greater than 40 percent as 40 plus any additional amount would be greater than 40. In addition, the Veteran has reported that only his entire body from below the neck is affected by dry, itchy skin, a symptom readily observable to a lay person. A 60 percent disability rating is warranted when more than 40 percent of the entire body is affected. A 60 percent rating is the highest schedular rating available under Diagnostic Code 7806. Prior to February 17, 2017, the only estimate in the record of the total area of the Veteran’s body affected by his skin conditions is the January 2011 VA examination. The examiner opined that 20 to 40 percent of the Veteran’s body was affected by his xerosis cutis and less than 5 percent was affected by his onychomycosis. The examiner did not provide an opinion as the combined total area affected. However, to find that greater than 40 percent of the Veteran’s entire body was affected would require that the total area affected by his xerosis cutis to fall at the very top of the range given by the VA examiner. However, as the VA examiner described only diffuse dry skin more noticeable on the trunk whereas by 2017 the Veteran described the condition as having worsened and involving his entire body below the neck, the evidence suggests that significantly less than 40 percent of his body must have been affected at the time of his 2011 VA examination. A 60 percent rating under either the prior or new criteria based on area affected requires more than 40 percent of the entire body or more than 40 percent of exposed areas be affected. The Board finds that a preponderance of the evidence is against finding that more than 40 percent of the Veteran’s body was affected prior to February 17, 2017. A 60 percent rating is also available when constant or near-constant systemic therapy is required. However, here only topical lotion, which is not a systemic therapy, is noted to be used. Furthermore, the topical treatment was a lotion and was not described as affecting the whole body or being like a corticosteroid or immunosuppressive drug. Therefore, the Board finds that a rating in excess of 30 percent is not warranted prior to February 17, 2017. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for cervical spine strain and in excess of 10 percent for thoracolumbar spine strain with degenerative changes are remanded. The Veteran underwent examination of his cervical and thoracolumbar spine in January 2011 and again in February 2017. Although the 2017 VA examiner noted objective evidence of pain on passive range of motion and nonweight-bearing testing of the neck and back, the examiner did not provide measurements in degrees for the ranges of motion of the Veteran’s cervical or thoracolumbar spine in active motion, passive motion, weight-bearing, and non-weight-bearing. All of these measurements provided in degrees are necessary for the examination to be considered adequate under the new case law of Correia v. McDonald, 28 Vet. App. 158 (2016). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination of his cervical spine strain and thoracolumbar spine strain with degenerative changes. The examination report must include ranges of motion of the cervical and thoracolumbar spine in active motion, passive motion, weight-bearing, and nonweight-bearing, with notations as to the degree of motion at which the Veteran experiences pain. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner also should express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups of the cervical or thoracolumbar spine. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. In particular, with respect to flare-ups and repeated use over time, the examiner should identify any functional loss caused by flare-ups and repeated use over time, to include the amount of range of motion loss, if any, that is present during flare-ups and repetitive motion. If the examination is not taking place during a flare-up or repeated use over time, the examiner should elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups and repeated use over time, and estimate range of motion loss, in terms of degrees. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. (Continued on the next page)   A complete rationale must be provided for any opinions expressed. 2. Thereafter, readjudicate the Veteran’s pending claims in light of any additional evidence added to the record. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board for appellate review. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Christensen