Citation Nr: 18143456 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 18-41 019 DATE: October 19, 2018 ORDER Service connection for seborrheic dermatitis, claimed as a skin disability, is denied. A compensable rating for postoperative tonsillitis and pharyngitis is denied. A rating in excess of 20 percent for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion is denied. An initial rating in excess of 20 percent for gastritis is denied. An initial rating in excess of 30 percent for an unspecified anxiety disorder is denied. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran’s seborrheic dermatitis is related to service. 2. The competent and probative medical evidence shows the Veteran’s tonsillitis and pharyngitis are manifested by occasional sore throats and that hoarseness is not shown. 3. The competent and probative medical evidence shows that the Veteran has ankylosis in his metacarpophalangeal and interphalangeal joints in extension, but not in his carpometacarpal joint. 4. The weight of the evidence is against a finding that the Veteran has anemia or weight loss because of his gastritis; recurrent incapacitating episodes have not been shown. 5. Throughout the rating period on appeal, the Veteran’s anxiety has been manifested by occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, due to symptoms such as depressed mood, anxiety, and chronic sleep impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for seborrheic dermatitis, claimed as a skin disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for a compensable rating for postoperative tonsillitis and pharyngitis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code (DC) 6599-6516. 3. The criteria for a rating in excess of 20 percent for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DCs 5010-5224, 5152. 4. The criteria for an initial rating in excess of 20 percent for gastritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7305. 5. The criteria for an initial rating in excess of 30 percent for an unspecified anxiety disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, DC 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from October 1955 to October 1957. This matter is before the Board of Veterans’ Appeals (Board) on appeal from August 2017 and February 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be 1) 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) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57–58 (1990). 1. Entitlement to service connection for seborrheic dermatitis, claimed as a skin disability The Veteran claims service connection for a skin disorder, to include seborrheic dermatitis. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of seborrheic dermatitis, and evidence shows that the Veteran had a separate skin disorder while in service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of seborrheic dermatitis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). VA treatment records show the Veteran was not diagnosed with seborrheic dermatitis until 2008, more than 50 years after his separation from service. While the Veteran is competent to report having to use topical treatment consistently for his skin disability after service, he is not competent to determine that these symptoms were manifestations of rubella, which was documented in service, or were otherwise related to his service. The issue is medically complex and requires expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Furthermore, the January 2018 VA examiner opined that the Veteran’s seborrheic dermatitis is not at least as likely as not related to an in-service injury, event, or disease, including his rubella. The rationale was he was not noted to have seborrheic dermatitis until 2008, and service treatment records did not show seborrheic dermatitis. Therefore, the examiner concluded that his seborrheic dermatitis was less likely than not related to 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). Moreover, the Board notes that there is no competent and probative evidence that shows that the Veteran’s disability is at least as likely as not related to service. After review of the competent and probative evidence, the Board finds that the preponderance of the evidence is against service connection for a seborrheic dermatitis. The Board acknowledges the Veteran’s belief that his skin disability is related to service. However, the competent and probative evidence from the January 2018 VA examination found that the Veteran’s disability was less likely than not related to service. For the above reasons, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). However, a veteran may be entitled to a higher disability evaluation than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes “additional functional loss—i.e., ‘the inability... to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance’—including as due to pain and/or other factors” or “reduction of a joint’s normal excursion of movement in different planes, including changes in the joint’s range of movement, strength, fatigability, or coordination.” Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 2. Entitlement to a compensable rating for postoperative tonsillitis and pharyngitis. The Veteran is rated under diagnostic code 6599-6516 for postoperative tonsillitis and pharyngitis. Under Diagnostic Code 6516 (chronic laryngitis), a 10 percent rating is assigned where there is evidence of hoarseness, with inflammation of cords or mucous membranes. A maximum 30 percent rating is warranted where there is evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97. 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 underwent a VA examination in December 2017 for his tonsillitis and pharyngitis. At the time, he reported occasionally having a sore throat. Objective findings were limited. Another VA examination was performed in January 2018. At this time, the Veteran stated that his condition was unchanged, and that he still had sore throat on occasion. He did not have chronic laryngitis, and had not had a laryngectomy. He acknowledged on and off pharyngitis. The examiner recorded that there was no physical evidence of active pharyngitis, and that the tonsils were absent. After review of the competent and probative evidence, the Board finds that a compensable rating for postoperative tonsillitis and pharyngitis is not warranted. The Veteran has not reported hoarseness. Rather, at both VA examinations, he acknowledged occasional sore throat. At the January 2018 VA examination, the examiner found no evidence of pharyngitis. In light of this, the Board finds that a compensable rating is not warranted. For the above reasons, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to a rating in excess of 20 percent for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion. The Veteran is rated under DC 5010-5224 for residuals of a fracture of the right thumb with traumatic arthritis and limitation of motion. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. DC 5010 provides that traumatic arthritis is rated as for degenerative arthritis. DC 5224, ankylosis of the thumb, provides a 10 percent rating for favorable ankylosis, and a 20 percent rating for unfavorable ankylosis. These ratings are assigned for both the major (dominant) and minor (non-dominant) hand. In classifying the severity of ankylosis of the thumb, the following rules are set forth in 38 C.F.R. § 4.71a: (i) Ankylosis of both the carpometacarpal and interphalangeal joints, with either joint in extension or in full flexion or with rotation or angulation of a bone, is to be rated as amputation at metacarpophalangeal joint or through proximal phalanx; (ii) Ankylosis of both the carpometacarpal and proximal interphalangeal joints, even though each is individually in favorable position, is to be rated as unfavorable ankylosis; (iii) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of more than 2 inches between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as unfavorable ankylosis; and (iv) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of 2 inches or less between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as favorable ankylosis. 38 C.F.R. § 4.71a. For DC 5152, contemplating amputation of the thumb, for the major hand, a 20 percent rating is warranted for amputation of the thumb at the distal joint or through the distal phalanx. A 30 percent rating is warranted for amputation of the thumb at the metacarpophalangeal joint or through the proximal phalanx, and a maximum 40 percent rating is warranted for amputation of the thumb with metacarpal resection. 38 C.F.R. § 4.71a, DC 5152. The Veteran underwent a VA examination for his right thumb disability in June 2017. He is right hand dominant, and he reported flare-ups where he would have difficulty writing or with right hand movements. He also acknowledged functional loss in that he had difficulty with grabbing objects with his right hand. He had limitation of motion in his fingers in that his thumb had maximum flexion and extension of zero degrees. His fingers all had maximum extension and flexion of 10 degrees. He had a gap between the pad of his thumb and fingers of 6.0 centimeters. He had pain that caused functional loss as well as localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion afterwards. While the Veteran was not examined immediately after repetitive use over time, the examiner recorded that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to determine whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. In support, the examiner explained that pain could significantly limit functional ability. Moreover, while the Veteran was not examined during a flare-up, the examiner recorded that the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. The examiner was unable to determine whether pain, weakness, fatigability or incoordination significantly limited functional ability during flare-ups as it would be speculative. The Veteran had reduced muscle strength (2/5) but did not have muscle atrophy. He had ankylosis in his metacarpophalangeal joint and interphalangeal joint in extension. Arthritis was documented in multiple joints of the Veteran’s right hand. The functional impact noted difficulty in pinching and grabbing, as well as the inability to complete a full hand grip. The examiner found there was no evidence of pain on passive range of motion or when used in non-weight bearing of the left hand. The Board observes that the examination report does not include the passive range of motion for the right hand, but does for the left hand. Passive ROM is the amount of motion possible when an examiner moves a body part with no assistance from the individual being evaluated. It is usually greater than active ROM because the integrity of the soft tissue structures does not dictate the limits of movement. Comparisons between passive ROM and active ROM provide information about the amount of motion permitted by the associated joint structures (passive ROM) relative to the individual’s ability to produce motion at a joint (active ROM). Cynthia Norkin & D. Joyce White, Measurement of Joint Motion: A Guide to Goniometry 8-9 (2016). Here, there is no indication that passive ROM in this case would be more limited than active. As such, the Board concludes that the absence of findings related to passive ROM does not render the available evidence inadequate for rating purposes such that a remand for an additional VA examination is warranted, and will evaluate the Veteran’s joint range of motion based on the measurements recorded for active ROM and look at the Veteran’s total right-hand disability picture. Additionally, neither the Veteran nor representative contends that he is prejudiced by this omission, so another VA examination of the joints is not necessary. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). After review of the competent and probative evidence, the Board finds that a rating in excess of 20 percent is not warranted. Under DC 5152, a 30 percent rating is warranted for amputation at the metacarpophalangeal joint for the major hand, which is the Veteran’s right. At the Veteran’s VA examination, it was reported that he had ankylosis in both the MCP and IP joints in extension. Under Note (1), ankylosis of both the carpometacarpal and interphalangeal joints, with either joint in extension, is rated as amputation at the MCP joint. However, as the examiner reported ankylosis in the metacarpophalangeal joint, not in the carpometacarpal joint, a rating of 30 percent for amputation is not warranted. The Board notes that the Veteran is also currently rated at the maximum under DC 5224. Moreover, a higher rating under limitation of motion of individual digits is not warranted. As such, the Board finds that a rating of 30 percent, under DC 5152, is not warranted. Lastly, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations or flare-ups with limitation of motion is more nearly approximated by a higher rating. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current rating already compensates the Veteran for any functional loss due to pain affecting the right thumb, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. In light of the foregoing, the Board finds that an increased rating due to functional impairment would not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. 4. Entitlement to an initial rating in excess of 20 percent for gastritis. The Veteran is rated at 20 percent disabling under DC 7305 for gastritis associated with residuals of a right thumb fracture. The rating criteria for duodenal ulcers provides that a severe duodenal ulcer is manifested by symptomatology including pain that is only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, and is evaluated as 60 percent disabling. A moderately severe duodenal ulcer is manifested by symptomatology that is less than severe, but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year, and is evaluated as 40 percent disabling. A moderate duodenal ulcer has recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations, and merits a 20 percent evaluation. A mild duodenal ulcer with recurring symptoms once or twice a year merits a continuation of the 10 percent evaluation currently in effect. 38 C.F.R. § 4.114, Code 7305. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran underwent a VA examination for his gastritis in June 2017. He reported nausea and heartburn, and that his symptoms worsened when he takes pain medication. He takes continuous medication — Ranitidine 150 mg. He has recurring episodes (four or more) of symptoms that are not severe yearly. He has periodic abdominal pain that is only partially relieved by standard ulcer therapy. He has recurrent nausea, with one episode of nausea per year that lasts less than one day. He denied incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The clinical records, both VA and private, have been reviewed but fail to contain findings referable to the Veteran’s gastritis. After review of the competent and probative evidence, the Board finds that a rating in excess of 20 percent disabling for gastritis is not warranted. Indeed, the Veteran does not have anemia or weight loss because of his gastritis. Nor does he have recurrent incapacitating episodes that average 10 days or more in duration that occur at least four times per year. Rather, the competent and probative evidence reflects that he does not have any incapacitating episodes due to a stomach or duodenum condition. In sum, the Veteran’s gastritis is more nearly approximated by the current rating throughout the period on appeal. 5. Entitlement to an initial rating in excess of 30 percent for an unspecified anxiety disorder. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. “A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442–43 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran’s service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if the disability is productive of 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. 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula, the criteria for a 70 percent rating are: occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. The criteria for a 100 percent rating are: total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. In June 2017, the Veteran had a VA examination. It was reported that he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. He had depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. He had adequate hygiene, and good eye contact. His thought process was coherent and logical. His affect was appropriate and he was oriented. His judgment was good and his insight was adequate. No delusions or hallucinations were reported. While his mood was depressed, he did not have suicidal ideations. He lived with his wife. Clinical records addressing other disorders indicate that the Veteran was generally accompanied by his wife and that he was cooperative. The Board also notes that the Veteran’s medical records show a consistent denial of suicidal and homicidal ideations. After review of the competent and probative evidence, the Board finds the Veteran’s anxiety is most nearly approximated by the criteria for a 30 percent rating for the period on appeal. The examiner noted that he had occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran did not have panic attacks, nor did he have impaired memory or judgment. He did not have suicidal or homicidal ideations. While he had depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood, his thought process was coherent and logical and he had adequate insight. Moreover, he did not have delusions or hallucinations. While the clinical records fail to provide much additional information, they do suggest a positive relationship with his wife, who was noted as being his support system. Overall, the Board finds that the frequency and severity of such symptoms does not more nearly approximate occupational and social impairment with reduced reliability and productivity such as to enable assignment of the next-higher 50 percent evaluation. Accordingly, the claim for increase is denied. ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Morales, Associate Counsel