Citation Nr: 18144141 Decision Date: 10/25/18 Archive Date: 10/23/18 DOCKET NO. 14-35 358 DATE: October 25, 2018 ORDER Entitlement to service connection for lumbar spine degenerative arthritis, as secondary to service-connected sarcoidosis, is granted. Entitlement to service connection for left hip degenerative arthritis, as secondary to service-connected sarcoidosis, is granted. Entitlement to service connection for left leg pain, as secondary to service-connected sarcoidosis, is granted. Entitlement to a rating in excess of 30 percent for sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face is denied. Entitlement to a rating in excess of 30 percent for right eye pseudophakia and anterior uveitis (“right eye disability”), secondary to sarcoidosis, is denied. Entitlement to a 20 percent rating for left hand joint disease, secondary to sarcoidosis, is granted. Entitlement to a 20 percent rating for right hand joint disease, secondary to sarcoidosis, is granted. Entitlement to a compensable rating for sarcoidosis with history of pulmonary involvement is denied. Entitlement to a total disability based on individual unemployability by reason of service-connected disabilities (TDIU) is granted. REMANDED Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a knee condition is remanded. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for an ankle condition is remanded. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for carpal tunnel of the bilateral wrists is remanded. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for headaches is remanded. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include depression, is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of lumbar spine degenerative arthritis, and the evidence is in equipoise on whether it is etiologically related to the service-connected sarcoidosis. 2. The Veteran has a current diagnosis of left hip degenerative arthritis, and the evidence is in equipoise on whether it is etiologically related to the service-connected sarcoidosis. 3. The Veteran has left leg pain, stiffness, and weakness, and the evidence is in equipoise on whether it is etiologically related to the service-connected sarcoidosis. 4. For the entire period of appeal, the Veteran’s sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face covers less than 5 percent of the entire body and less than 5 percent of the exposed body area, without evidence of constant or near-constant systemic therapy. 5. For the entire period of appeal, the Veteran’s right eye disability is assigned a 30 percent rating, which is the maximum rating for visual impairment in one eye where there is not anatomical loss of the eye. 6. For the entire period of appeal, the evidence is in equipoise on whether the Veteran’s left hand joint disease manifests one or two exacerbations a year, without evidence of definite impairment of health, incapacitating exacerbations, or compensable limitation of motion. 7. For the entire period of appeal, the evidence is in equipoise on whether the Veteran’s right hand joint disease manifests one or two exacerbations a year, without evidence of definite impairment of health, incapacitating exacerbations, or compensable limitation of motion. 8. For the entire period of appeal, the Veteran’s sarcoidosis with history of pulmonary involvement manifests post-bronchodilator studies of FEV-1 at least 90 percent predicted and FEV-1/FVC of at least 85 percent predicted, without evidence of pulmonary involvement requiring high dose (therapeutic) corticosteroids for control. 9. The Veteran has three years of college education and worked as a construction laborer. 10. The Veteran’s service-connected disabilities consist of sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face (30 percent from January 6, 1997); right eye disability, secondary to sarcoidosis (30 percent from November 10, 1995); left hand joint disease, secondary to sarcoidosis (10 percent from January 6, 1997, and increased to 20 percent herein); right land joint disease, secondary to sarcoidosis (10 percent from January 6, 1997, and increased to 20 percent herein); sarcoidosis with history of pulmonary involvement (noncompensable from November 10, 1995); lumbar spine degenerative arthritis (granted herein); left hip degenerative arthritis (granted herein); and left leg pain (granted herein). His combined total rating has been 60 percent since January 6, 1997. 11. The evidence is in equipoise on whether the Veteran’s service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his educational and occupational experience. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for lumbar spine degenerative arthritis as secondary to the service-connected sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for left hip degenerative arthritis as secondary to the service-connected sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for left leg pain as secondary to the service-connected sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for a rating in excess of 30 percent for sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.118, Diagnostic Code 7899-7806. 5. The criteria for a rating in excess of 30 percent for the right eye disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.383(a)(1), 4.75, 4.76, 4.76a, 4.77, 4.78, 4.79, Diagnostic Code 6099-6029. 6. Resolving all reasonable doubt in favor of the Veteran, the criteria for a 20 percent rating for left hand joint disease have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5099-5002. 7. Resolving all reasonable doubt in favor of the Veteran, the criteria for a 20 percent rating for right hand joint disease have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5099-5002. 8. The criteria for a compensable rating for sarcoidosis with history of pulmonary involvement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.104, Diagnostic Code 6846. 9. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1984 to April 1985, from October 1986 to September 1988, and from August 1993 to November 1995. The Board notes that the Veteran initiated appeals of service connection for a knee condition, ankle condition, carpal tunnel of the bilateral wrists, headaches, and depression, which were denied in a June 2015 rating decision. A Statement of the Case was issued in October 2016, and the Veteran did not perfect an appeal of the issues by filing a substantive appeal (VA Form 9). As such, these claims are not before the Board. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). 1. Service connection for the lumbar spine, left hip, and left leg. The Veteran has current diagnoses of lumbar spine degenerative arthritis, left hip degenerative arthritis, and left leg pain. With regard to the lumbar spine, in a July 2010 VA examination, x-rays showed degenerative arthritis of the lumbar spine. With regard to the left hip, in an August 2011 examination by the Social Security Administration (SSA), the Veteran was found to have mild degenerative changes of the left hip. With regard to the left leg, VA treatment records indicate that the Veteran reported having left leg pain in September 2009. In April 2010, the Veteran had a VA rheumatology consultation, in which he reported having pain and a limp. X-rays of the left foot were normal. The Veteran was noted to have symptoms of pseudoclaudication and chronic widespread pain. In a July 2010 VA examination, the Veteran reported having left leg stiffness and gait difficulty, which started approximately one year prior. In May 2011, the Veteran’s VA physician indicated that the Veteran had severe left leg weakness. In a March 2013 SSA examination, the Veteran was noted to walk with a brace that extended up to the ankle. The question for the Board is whether the Veteran’s lumbar spine, left hip, and left leg conditions are etiologically related to his service-connected sarcoidosis. The Board finds that the evidence is in equipoise on whether the lumbar spine arthritis, left hip arthritis, and left leg pain are due to the sarcoidosis. In the July 2010 VA examination, the examiner opined that the lumbar spine arthritis was less likely than not secondary to sarcoidosis and was likely related to natural aging, genetics, and intrinsic disc loading (body weight compared to the size of the disc). In a December 2015 VA treatment record, the Veteran was noted to have sarcoidosis that was causing left side paralysis and gait abnormality, and he wore a left foot brace. In October 2016, a private physician, Dr. H.S., reviewed the Veteran’s claims file and interviewed the Veteran. He concluded that the Veteran’s low back, left hip, and left leg conditions were at least as likely as not impairments that were permanently aggravated by the sarcoidosis. Dr. H.S. explained that sarcoidosis is a systemic disease characterized by development of granulomas, and that while it most commonly involves the lungs, any organ system can be affected and patients could present with any number of rheumatologic, musculoskeletal, and/or neurological symptoms. The doctor pointed to the Veteran’s service-connected bilateral hand joint disease as compatible with sarcoidosis impairments. He also noted that epithelial lesions of sarcoidosis are known to affect the musculoskeletal system, which would account for the symmetrical degenerative changes noted. The Board finds the VA examiner’s and Dr. H.S.’s opinions to be of limited probative value. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board). Both opinions were offered after a review of all available records. However, the VA examiner did not provide sufficient explanation for the opinion that the lumbar spine arthritis was not caused or aggravated by the sarcoidosis, and Dr. H.S. did not discuss any of the potentially conflicting medical evidence. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claims. Specifically, another medical opinion could be obtained that specifically accounted for and discussed all the evidence. However, under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that there is “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter.” As such, this is a situation where the benefit of the doubt rule applies. In resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for lumbar spine degenerative arthritis, left hip arthritis, and left leg pain, as secondary to sarcoidosis, is warranted. Increased Ratings 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. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 2. Increased rating for sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face. The Veteran’s sarcoidosis with skin plaque including the bilateral legs and face is currently rated as 30 percent disabling under Diagnostic Code 7899-7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. Here, the hyphenated diagnostic code indicates that the Veteran’s sarcoidosis is rated as analogous to a disease of the skin (Diagnostic Code 7899) under the criteria for dermatitis or eczema (Diagnostic Code 7806). See 38 C.F.R. § 4.118. Under Diagnostic Code 7806, a 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; if systemic therapy such as corticosteroids or other immune-suppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past twelve-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. In Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017), the Federal Circuit found that some applications of topical corticosteroids may constitute systemic therapy under Diagnostic Code 7806. The Federal Circuit made clear that this determination should be made based on the facts of each individual case. The Court also clarified that in applying the old regulations, the Board must determine whether a given treatment is “like” a corticosteroid or other immunosuppressive drug in determining whether the treatment constituted a systemic therapy to warrant a higher rating. Id. Burton v. Wilkie, 2018 U.S. App. Vet. Claims LEXIS 1314, *20, The Court further explained that “nothing in Warren requires a certain order in which the Board must determine if a treatment is a systemic therapy or like a corticosteroid or immunosuppressive drug. Both elements must be present to justify a higher rating under DC 7806, but the order in which they are addressed is of no import.” Burton v. Wilkie, 2018 U.S. App. Vet. Claims LEXIS 1314, *20. On July 13, 2018, VA issued a final rule amending its regulations covering skin disabilities. The effective date of this final rule is August 13, 2018. Under the final rule, claims pending prior to the effective date of this final rule will be considered under both old and new rating criteria. The new General Rating Formula for Skin for Diagnostic Codes 7809, 7813-7816, 7820-7822, and 7824, notes that a 30 percent rating is warranted for characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or for systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118. Under the new 38 C.F.R. § 4.118, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018) (to be codified at 38 C.F.R. pt. 4). Under both versions of Diagnostic Code 7806, “exposed areas” are defined as the head, neck, and hands. Here, the Board finds that a rating in excess of 30 percent is not warranted at any point during the period of appeal. VA treatment records that in September 2009, the Veteran was prescribed triamcinolone acetonide cream, which he was to apply a small amount topically twice per day or as needed, for his sarcoidosis. In a November 2009 VA skin examination, the Veteran reported that the sarcoidosis had spread to his face and left leg, in addition to the right hand and leg, since May 2009. He indicated that he was using the same cream (triamcinolone cream) to treat his skin, and he did not see a dermatologist. His symptoms included itching, without pain or systemic symptoms. Upon examination, the Veteran had black hyperpigmented plaque-like lesions over the right hip of his nose measuring 0.6 centimeters (cm) in length and 0.6 cm in width. There were also lesions on his right nostril, left upper lip, chin, back of the right elbow, left leg, and right leg. There was no edema, inflammation, disfigurement, or significant scarring. The examiner indicated that the lesions covered 5 percent of the exposed body areas and less than 5 percent of the entire body. In a July 2010 VA examination of the joints, the Veteran’s skin lesions due to sarcoidosis were noted to be not progressive and the Veteran reported that his dermatologist had stopped the medication last week. The examiner noted that the Veteran’s skin did not cause any functional limitations or disfigurement. In November 2010, the Veteran’s skin was noted to be normal, without lesions. The Veteran had another VA skin examination in July 2011. He reported that he continued to have plaques on his bilaterally upper extremities, face, and left leg. He indicated that he had been taken off all medication, but he continued to apply some previously-prescribed medication to plaques. The Veteran indicated that his only symptom was occasional itching, and he denied having ever used light therapy. On examination, the Veteran’s skin was noted to be warm, dry, with good color, and normal turgor. There was no ecchymosis, breakdown, or jaundice. He had a hyperpigmented macular area on his chin that was 2 by 2 cm, circular and smooth. He also had hyperpigmented areas on his left arm, right arm, right leg, and left leg. The examiner indicated that there was “minimal skin plaque involvement.” The total body area affected was 0.05 percent and exposed body area was 0.03 percent. In March 2012 and July 2013, the Veteran’s skin was noted to be normal, without lesions. He continued to be prescribed fluocinonide, to be applied topically to the affected area of skin twice per day. In May 2014, the Veteran had a third VA skin examination. He reported having skin lesions that came “in crops” and were usually worse on his lower legs. He also got spots/plaques on his upper back, chest, and face. He treated them with a steroid cream; without the cream, they would dry, crack, and itch. The examiner indicated that the Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck, and he did not have any skin neoplasms. The Veteran used betamethasone, a topical corticosteroid for six weeks or more in the past 12 months, but not constantly. He had not had any other treatments in the past 12 months, nor had he experienced any debilitating or non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examiner indicated that the sarcoidosis covered less than 5 percent of the Veteran’s total body area and none of the exposed body area. The Veteran had no other pertinent physical findings, complications, conditions, signs, and/or symptoms of the sarcoidosis. In VA appointments in December 2015; May, July, August, and November 2016; and February, August 2017, the Veteran was noted to have no rash, ulcers, or lesions of the skin, and there were no changes in his skin color. He was prescribed urea cream, which was to be applied to the affected area every day. In sum, the Veteran’s sarcoidosis was consistently noted in November 2009, July 2011, and May 2014 VA examinations to cover less than 5 percent of the entire body and less than 5 percent of the exposed body area. It was never noted to cover more than 40 percent of the entire body or more than 40 percent of exposed areas affected, which is required for an increased 60 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7806 (prior to August 13, 2018, and from August 13, 2018). In addition, the evidence does not show that the Veteran has required constant or near-constant use of systemic therapy at any point during the period of appeal. The Veteran was prescribed a topical corticosteroid (fluocinonide and betamethasone) prior to December 2015; however, it is not clear that those creams constitute “systemic therapy” under Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). Even assuming that the fluocinonide and/or betamethasone did constitute systemic therapy, the evidence does not show that the Veteran required constant or near-constant use of either of them to warrant a 60 percent rating under Diagnostic Code 7806. Rather, in the July 2010 and July 2011 VA examinations, he reported that he had been taken off all medication for the sarcoidosis, and in the May 2014 VA examination, he was noted to use a topical corticosteroid for six weeks or more in the past 12 months, but not constantly. Finally, the Board notes that no higher or alternative rating under a different diagnostic code can be applied, as the Veteran does not have scarring, lupus, skin neoplasms, or other manifestations of sarcoidosis to warrant consideration under any other diagnostic codes for skin disabilities. 3. Increased rating for the right eye disability. The Veteran’s left eye disability is rated under Diagnostic Code 6099-6029, indicating that the Veteran’s right eye disability is rated as analogous to a disease of the eye (Diagnostic Code 6099) under the criteria for aphakia or dislocation of the crystalline lens (Diagnostic Code 6029). See 38 C.F.R. § 4.79. Under Diagnostic Code 6029 aphakia or dislocation of the crystalline lens is evaluated based on visual impairment, and elevate the resulting level of visual impairment one step. A minimum 30 percent rating is assigned for unilateral or bilateral symptoms. When only one eye is service-connected, as is the case here, and subject to the provisions of 38 C.F.R. § 3.383(a), the visual acuity of the nonservice-connected eye will be considered to be 20/40 for the purposes of rating the service-connected visual impairment. 38 C.F.R. § 4.75(c). The maximum rating for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. The rating for visual impairment may be combined with ratings for other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under Diagnostic Code 7800). 38 C.F.R. § 4.75(d). Under 38 C.F.R. § 3.383(a), compensation is payable for the certain combinations of service-connected and non-service-connected disabilities, as if both disabilities were service-connected, provided the nonservice-connected disability is not the result of the veteran’s own willful misconduct. With respect to the eyes, this applies when there is impairment of vision in one eye as a result of service-connected disability, and impairment of vision in the other eye as a result of nonservice-connected disability, and the impairment of vision in each eye is rated at a visual acuity of 20/200 or less; or the peripheral field of vision for each eye is 20 degrees or less. 38 C.F.R. § 3.383(a)(1). In this case, the Veteran is not service-connected for a left eye disability, and the Board finds that his nonservice-connected left eye does not meet the criteria under 38 C.F.R. § 3.383(a)(1) for consideration in rating the service-connected right eye disability. Specifically, the medical treatment records do not show that the Veteran’s left eye has had a corrected distance visual acuity of 20/200 or less or a peripheral field of vision of 20 degrees or less at any time during the period on appeal. In a February 2016 VA optometry appointment, the Veteran’s left eye corrected visual acuity was 20/20-, and there is no indication that the left eye peripheral field of vision was 20 degrees or less. Accordingly, the Veteran’s nonservice-connected left eye is not for consideration in rating the service-connected right eye disability. As noted above, the minimum and maximum rating for the Veteran’s right eye disability is 30 percent unless there is anatomical loss of the eye. 38 C.F.R. § 4.75(d). Because the Veteran does not have anatomical loss of the right eye and is only service-connected for visual impairment in the right eye, 30 percent is both the minimum and the maximum rating available for his disability and, thus, he has been in receipt of the maximum rating allowed for his right eye disability throughout the entire rating period. As the Veteran has been assigned the maximum rating for his right eye disability for the entirety of the appeal period, there is no legal basis upon which to award a higher rating and the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). 4. Increased ratings for bilateral hand joint disease. The Veteran’s joint disease of the bilateral hands are currently each rated as 10 percent disabling under Diagnostic Code 5099-5002, indicating that they are rated as analogous to a disease of the musculoskeletal system (Diagnostic Code 5099) under the criteria for rheumatoid arthritis (atropic), as an active process (Diagnostic Code 5002). See 38 C.F.R. § 4.71a. Under this code, rheumatoid arthritis as an active process is to be rated 20 percent for one or two exacerbations a year in a well-established diagnosis; 40 percent for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year; 60 percent for symptoms that are less than the criteria for a 100 percent rating, but with weight loss and anemia, that are productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods; and a 100 percent rating for constitutional manifestations associated with active joint involvement that is totally incapacitating. For chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, the disability is rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, 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 Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The Note to Diagnostic Code 5002 instructs that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. The higher rating should be assigned. Here, the Board finds that 20 percent ratings are warranted for the bilateral hand joint disease. (The Board notes that the Veteran has a diagnosis of bilateral carpal tunnel syndrome, for which he uses bilateral wrist splints. However, service connection was denied for bilateral carpal tunnel syndrome, and the issue is not on appeal.) In a July 2010 VA examination, the Veteran reported that for the last five months, he had pain in the bilateral wrists and fingertips, which was constant and sharp. He also had pain in the finger joints with swelling, stiffness, and sometimes locking. The Veteran reported that the right hand was worse than the left. He had right wrist swelling, stiffness, and constant pain. He had right hand flare-ups at night, which included an increase in pain that lasted for a couple of hours. Both hands felt weak. Upon examination, the Veteran was noted to be right hand dominant. Neither hand was found to have swelling or tenderness. The fingers on both hand did not show swelling or tenderness. Active range of motion after three repetitions included metacarpophalangeal joint to 90 degrees, proximal interphalangeal joint to 110 degrees, and distal interphalangeal joint to 60 degrees, without pain on motion. The Veteran was noted to have good grip in the right hand for twisting, pushing, and pulling. There was minimal weakness for holding and gripping in the right hand. Both hands had a zero-cm gap. X-rays showed a healed fracture of the right fifth metacarpal and a healed fracture of the radial side of the thumb IP joint, and a left hand remote injury/mild deformity in the distal end of the proximal phalanx of the third finger and mild volar spurring on the base of the proximal phalanx of the left thumb. VA treatment records dated in November 2010, January 2011 indicate that the Veteran denied having joint pain or stiffness. In a July 2011 VA examination, after three repetitions of movement, the Veteran could flex his bilateral thumbs metacarpophalangeal joints to 90 degrees. The right metacarpophalangeal joint flexed to 110 degrees and the left to 100 degrees. The bilateral second third, fourth, and fifth fingers metacarpophalangeal joints flexed to 90 degrees, proximal interphalangeal joints to 100 degrees, and distal interphalangeal joints to 70 degrees. The Veteran could perform thumb/finger intact opposition without difficulty and he could fist to the transverse crease without difficulty bilaterally. There was no deformity, malalignment, drainage, edema, redness, heat, spasms, abnormal movement, guarding of movement, fatigue, lack of endurance, weakness, atrophy, incoordination, or instability noted in either hand. The Veteran was noted to have joint disease of both hands with minimal functional limitations. In a May 2014 VA hand and finger examination, the Veteran was noted to use bilateral wrist splints for carpal tunnel syndrome, for which he was not service-connected. The Veteran complained of bilateral hand pain, which was worse in the mornings and at the end of the day. He also reported bilateral hand cramping and stiffness first thing in the morning that improved during the day. He was able to open jars and doors and use keys. The Veteran reported that he was right-handed and that he had flare-ups in which his hands “will swell and be fat.” Upon examination, there was no limitation of motion or evidence of painful motion for any fingers or thumb. After repetitive-use testing with three repetitions, there was no additional limitation of motion. There was also no gap between the thumb pad and fingers, nor was there a bap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test. There was no limitation of extension for the index finger or long finger post-test, and the Veteran did not have any functional loss or functional impairment of any of the fingers or thumbs on either hand. The Veteran did not have tenderness or pain to palpation in either hand, including the fingers and thumbs. Grip strength was normal (5/5) in the right hand and there was active movement against some resistance (4/5) in the left hand. There was no ankylosis of the thumb or fingers, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the bilateral hand condition. In a December 2015 appointment to establish care at the Shreveport VAMC, the Veteran indicated that he had bilateral hand pain. In August 2017, the Veteran was noted to have “unchanged general arthritis pain.” In sum, the evidence is in equipoise on whether the bilateral hand joint disease manifests one or two exacerbations a year. Diagnostic Code 5002 does not specifically list what symptoms are considered to constitute an exacerbation of arthritis. The Veteran has claimed to experience flare-ups of swelling and stiffness in both hands. The Board finds that it is within the ability of a lay person to attest to acute symptom such as swelling and stiffness, as the Veteran has noted throughout the claim. Layno v. Brown, 6 Vet. App. 465 (1994). Resolving all reasonable doubt in favor of the Veteran, the Board considers his report of flare-ups to be exacerbations. As such, 20 percent ratings are warranted under Diagnostic Code 5002. Higher or alternative ratings are not warranted. The next higher rating of 40 percent under Diagnostic Code 5002 requires that the Veteran’s left and right hand joint disease approximate symptom combinations productive of definite impairment of health, objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. There is no evidence here, nor does the Veteran contend, that his bilateral hand disabilities cause incapacitating episodes three or more times per year. Moreover, the evidence does not show that a compensable rating is available based on limitation of motion, as the highest schedular rating available for limitation of motion of individual fingers is 20 percent and the Note to Diagnostic Code 5002 instructs that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. 5. Increased rating for sarcoidosis with history of pulmonary involvement. The Veteran’s sarcoidosis with history of pulmonary involvement is currently rated as noncompensable (zero percent) under Diagnostic Code 6846, indicating that it is rated as sarcoidosis. See 38 C.F.R. § 4.97. Under Diagnostic Code 6846, sarcoidosis is rated under either the rating criteria of Diagnostic Code 6846, the active disease or residuals of chronic bronchitis as set forth in Diagnostic Code 6600, or as extra-pulmonary involvement under the specific body system involved. Under the specific criteria of Diagnostic Code 6846, a noncompensable rating is assigned when the evidence of record shows sarcoidosis with chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment. A 30 percent rating is assigned upon a showing of sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. A 60 percent rating is assigned when the evidence of record shows sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. A 100 percent rating is assigned when the evidence of record shows sarcoidosis with cor pulmonale or cardiac involvement with congestive heart failure, or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. Sarcoidosis may alternatively be rated as chronic bronchitis under Diagnostic Code 6600. Evaluations under Diagnostic Code 6600 fall within service-connected disabilities related to the Trachea and Bronchi and utilize different Pulmonary Function Tests in evaluating disabilities. 38 C.F.R. § 4.97. These tests include Forced Expiratory Volume in one second (FEV-1), Forced Vital Capacity (FEV-1/FVC) and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)). Under Diagnostic Code 6600, a 10 percent rating is assigned for an FEV-1 of 71 to 80 percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO (SB) of 66 to 80 percent predicted. A 30 percent rating is assigned for an FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56 to 65 percent predicted. A 60 percent rating is assigned for an FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is assigned for an FEV-1 less than 40 percent of predicted value; or the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or the requirement for outpatient oxygen therapy. The above regulatory criteria related to Diagnostic Code 6600 call for the use of Pulmonary Function Test results produced after optimum therapy, such as post-bronchodilator. It also requires Pulmonary Function Tests to rate respiratory conditions except in certain situations, such as when the Pulmonary Function Tests are inconsistent with the other clinical evidence of record and the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. In addition, the criteria direct that post-bronchodilator Pulmonary Function Tests studies should be used except when the results of pre-bronchodilator tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. The criteria also provide that when evaluating a disability based on Pulmonary Function Tests, post-bronchodilator results should be used unless such results are poorer than the pre-bronchodilator results, in which case the latter should be applied. See 38 C.F.R. § 4.96(d). Here, the Board finds that a compensable rating is not warranted at any point during the period of appeal. VA treatment records indicate that in September 2009, the Veteran was prescribed an albuterol inhaler, which he reported he used before he mowed the grass. In June 2010, the Veteran had an echocardiogram to evaluate his sarcoidosis. Results showed mild pulmonary regurgitation and trivial pericardial effusion that was not clinically significant. The Veteran then had a Cardiolite stress test, which did not show any significant side effects or significant EKG changes. In a July 2011 VA respiratory examination, the Veteran denied having any pulmonary symptoms. He also denied taking any medication. He stated that he had not had any specific tests, hospitalizations, or surgeries related to the sarcoidosis with history of pulmonary involvement, and he denied having any fever, night sweats, weight changes, hemoptysis, or daytime hypersomnolence other than occasional naps. Upon examination, the Veteran’s respirations were bilaterally symmetrical, regular, and rhythmic. The lungs were clear and there were no wheezes or crackles. The examiner indicated that pulmonary function studies were normal and there were no functional limitations. Results of a September 2011 PFT study indicate that FEV-1 was normal and FEV-1/FVC was normal. In a May 2014 VA examination, the Veteran complained of rare episodes of shortness of breath. He was not currently being treated for any respiratory or pulmonary problems, and he denied having a cough, hemoptysis, fever, night sweats, or weight loss. He could walk 100 yards, and did not use corticosteroids, inhaled medication, oral bronchodilator, antibiotics, or outpatient oxygen therapy. The examiner indicated that the Veteran had stage 1 bilateral hilar lymphadenopathy, and no ophthalmologic, renal, cardiac, neurologic, or other organ system involvement due to sarcoidosis. Post-bronchodilator showed FEV-1 of 90 percent predicted, FEV-1/FVC of 85 percent, and DLCO (SB) percentage was not noted. The examiner indicated the FEV-1 test most accurately reflected the Veteran’s level of disability. The Veteran had an appointment to establish care at the Shreveport VAMC in December 2015. An albuterol inhaler and PFT were ordered for him. Results of the PFT showed a “minimal decrease in vital capacity.” In April 2016, he was noted to be stable on the albuterol inhaler, which he used as needed. In August 2017, the Veteran denied having shortness of breath or wheezing. In sum, the Board finds that a compensable rating for the Veteran’s sarcoidosis with history of pulmonary involvement is not warranted at any point during the period of appeal. For a 10 percent rating results of a PFT must show FEV-1 of 71 to 80 percent predicted, FEV-1/FVC of 71 to 80 percent, or DLCO (SB) of 66 to 80 percent predicted (using the criteria of Diagnostic Code 6600). Here, however, PFT studies have shown post-bronchodilator results of no worse than FEV-1 of 90 percent predicted and FEV-1/FVC of 85 percent. As such a 10 percent rating under Diagnostic Code 6600 is not warranted. Under Diagnostic Code 6846, a 30 percent rating is warranted upon a showing of sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. However, the Veteran is already in receipt of a 30 percent rating for sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face based on the use of corticosteroids. As such, a 30 percent rating under Diagnostic Code 6846 would constitute impermissible pyramiding. 38 C.F.R. § 4.14. A higher 60 percent rating is also not warranted under Diagnostic Code 6846, as there is no evidence that the Veteran requires systemic high dose (therapeutic) corticosteroids for control. Finally, the Board notes that alternative rating under a different diagnostic code can be applied, as the sarcoidosis has not been found to involve any other body systems, aside from the skin, joint, and eye disabilities for which the Veteran is already service-connected, to warrant consideration under any other diagnostic codes. 6. Entitlement to a TDIU. Total disability meriting a 100 percent schedular rating exists “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. Where the schedular disability rating is less than 100 percent, a total rating due to individual unemployability may nonetheless be assigned if a veteran is rendered unemployable as a result of service-connected disabilities, provided that certain regulatory requirements are satisfied. See 38 C.F.R. §§ 3.341(a), 4.16(a). Total disability ratings for compensation may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular- renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16. “Marginal employment,” for example, as a self-employed worker or at odd jobs or while employed at less than half of the usual remuneration, shall not be considered “substantially gainful employment.” 38 C.F.R. § 4.16(a). The Veteran’s service-connected disabilities consist of sarcoidosis with extensive skin plaque and involvement to include bilateral legs and face (30 percent from January 6, 1997); right eye disability, secondary to sarcoidosis (30 percent from November 10, 1995); left hand joint disease, secondary to sarcoidosis (10 percent from January 6, 1997, and increased to 20 percent herein); right land joint disease, secondary to sarcoidosis (10 percent from January 6, 1997, and increased to 20 percent herein); sarcoidosis with history of pulmonary involvement (noncompensable from November 10, 1995); lumbar spine degenerative arthritis (granted herein); left hip degenerative arthritis (granted herein); and left leg pain (granted herein). His combined total rating has been at least 60 percent since January 6, 1997. Thus, the percentage requirements of § 4.16(a) are met. The remaining issue is whether the service-connected disabilities preclude the Veteran from engaging in substantial gainful employment (i.e., work that is more than marginal, which permits the individual to earn a “living wage”). See Moore v. Derwinski, 1 Vet. App. 356 (1991). Regarding the Veteran’s education and employment history, the Veteran indicated on a May 2011 Application for Increased Compensation Based on Unemployability that his education consisted of three years of college and no other education or training. He worked as a construction laborer from 1998 to August 2008. The Board finds that the evidence is in equipoise on whether the Veteran’s service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his educational and work background. In November 2009, the Veteran’s VA physician, Dr. R.P., noted that the Veteran reported that his back, left hip, and left rendered him unable to work as a highway painter. The July 2010 VA examiner opined that the Veteran’s left hand joint disease caused mild functional limitations with holding and gripping, the left hip caused mild functional limitations with long standing and walking, and the lumbar spine caused moderate functional limitations with prolonged standing and walking. In January 2011, the Veteran’s VA physician, Dr. W.S. indicated that the Veteran was “totally disabled in any employment.” He did not specify which disabilities caused the unemployability. In a July 2011 VA examination, the examiner indicated that the Veteran’s bilateral hand disability caused minimal functional limitations and the sarcoidosis caused no functional limitations. The examiner opined that the Veteran could perform gainful sedentary or light duty employment. In a July 2011 VA eye examination, the examiner opined that the Veteran’s service-connected right eye did not affect his ability to work. The Veteran had an SSA examination in March 2013. The examining doctor concluded that the Veteran would have difficulty in occupations that required prolonged standing or climbing because of the Veteran’s dependence on his left lower extremity brace, which extended from his knee to the ankle. The Veteran was determined by SSA to be disabled effective September 2012 due to “unspecified arthropathies.” In a series of VA examinations in May 2014, the examiner indicated that the Veteran’s sarcoidosis, including respiratory effects, and bilateral hand condition did not impact his ability to work. Dr. H.S. opined in October 2016 that the Veteran’s lumbar spine, left hip, and left leg conditions, in tandem with his other service-connected disabilities rendered him unable to maintain gainful work in any employment base, and that the Veteran was totally and permanently disabled due to these disabilities. The Board finds at all the medical opinions have some probative value. The VA examiners and Dr. H.S.’s opinions were rendered after a review of all available records and an interview of the Veteran. The VA physician opinions (Dr. R.P. and Dr. W.S.) were rendered based on treatment of the Veteran for his service-connected disabilities. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Accordingly, the Board finds that the evidence is in equipoise on whether the Veteran’s service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment. Under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). Thus, on this record, affording the Veteran the benefit of the doubt, the Board finds that the Veteran’s service-connected disabilities are shown to prevent him from engaging in any substantially gainful employment, and entitlement to a TDIU by reason of service-connected disabilities is warranted. REASONS FOR REMAND 1. Whether new and material evidence has been received to reopen claims for service connection for a knee condition, ankle condition, carpal tunnel of the bilateral wrists, headaches, and an acquired psychiatric disorder are remanded. The RO found that new and material evidence had not been received to reopen previously denied claims of entitlement to service connection for a knee condition, ankle condition, carpal tunnel of the bilateral wrists, headaches, and depression in an October 2017 rating decision. In January 2018, the Veteran submitted a timely notice of disagreement. A Statement of the Case (SOC) has not been issued. As such, the Board is required to remand the issues for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: Issue an SOC to the Veteran and his representative addressing the issues of whether new and material evidence has been received to reopen claims for service connection for a knee condition, ankle condition, carpal tunnel of the bilateral wrists, headaches, and an acquired psychiatric disorder to include depression. The Veteran should be advised of the time limit in which to file a Substantive Appeal. Then, if an appeal is timely perfected, the issues should be returned to the Board for further appellate consideration, if otherwise in order. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel