Citation Nr: 18152291
Decision Date: 11/21/18	Archive Date: 11/21/18

DOCKET NO. 15-45 467
DATE:	November 21, 2018
ORDER
An effective date of January 10, 2013, but no earlier, for the grant of service connection for right knee arthritis is granted, subject to the laws that govern the payment of monetary benefits.
An effective date of January 10, 2013, but no earlier, for the grant of service connection for left knee arthritis is granted, subject to the laws that govern the payment of monetary benefits.
A disability rating in excess of 50 percent for sleep apnea is denied.
A disability rating in excess of 30 percent for chronic kidney disease is denied.
A disability rating in excess of 20 percent for diabetes mellitus, type II is denied.
A disability in excess of 10 percent for right carpal tunnel syndrome and right upper extremity peripheral neuropathy is denied.
A disability rating in excess of 10 percent for left carpal tunnel syndrome and left upper extremity peripheral neuropathy is denied.
A disability rating in excess of 10 percent prior to April 24, 2014 and in excess of 20 percent thereafter for left lower extremity peripheral neuropathy with alopecia is denied.
A disability rating in excess of 10 percent prior to April 24, 2014 and in excess of 20 percent thereafter for right lower extremity peripheral neuropathy with alopecia is denied.
A disability rating in excess of 10 percent for hypertension is denied.
A disability rating in excess of 10 percent for sinusitis is denied.
A compensable disability rating prior to April 24, 2014 and in excess of 10 percent thereafter for scar, status post cholecystectomy is denied.
A compensable disability rating for diabetic retinopathy is denied.
A compensable disability rating for umbilical hernia is denied.
A compensable disability rating for hemorrhoids is denied.
A compensable disability rating for status post cholecystectomy is denied.
A compensable disability rating for service-connected residuals of lipoma removal is denied.
A compensable disability rating for service-connected erectile dysfunction is denied.
REMANDED
The claim of entitlement to an increased initial evaluation in excess of 10 percent for right knee arthritis is remanded.
The claim of entitlement to an increased initial evaluation in excess of 10 percent for left knee arthritis is remanded.
The claim of entitlement to an increased compensable evaluation for bunions and hallux valgus of the right foot is remanded.
The claim of entitlement to an increased compensable evaluation for service-connected dermatitis and onychomycosis with onychocryplosis (hereinafter skin disability) is remanded.
The claim of entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded.
FINDINGS OF FACT
1.  On January 10, 2013, the RO received correspondence that could be liberally construed as a claim to reopen a previously denied claim for entitlement to service connection for bilateral knee arthritis.
2.  By a December 2015 rating decision, the RO granted service connection for bilateral knee arthritis effective August 20, 2013.  However, the Veteran’s effective date should have been January 10, 2013, the date of the earlier claim to reopen.
3.  Throughout the appeal period, the Veteran’s sleep apnea has been manifested by a condition requiring the use of a continuous positive airway pressure (CPAP) and no showings of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy.
4. Throughout the appeal period, the Veteran’s chronic kidney disease has been manifested by a condition with renal dysfunction and hypertension evaluated at a level of 10 percent disabling under Diagnostic Code (DC) 7101.  There have been no showings of  constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101; or a BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; or regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular.
5. Throughout the appeal period, the Veteran’s type II diabetes mellitus has required insulin use and restricted diet, but has not required regulation of activities.
6. Throughout the appeal period, the Veteran’s bilateral upper extremity peripheral neuropathy and carpal tunnel syndrome has been manifested by mild symptoms shown in the median nerve.
7. Prior to April 24, 2014, the Veteran’s bilateral lower extremity peripheral neuropathy was manifested by mild symptoms, without trophic changes.  After April 24, 2014, the Veteran’s bilateral lower extremity peripheral neuropathy with alopecia has been manifested by moderate symptoms with tropic changes, but no complete paralysis.
8. Throughout the appeal period, the Veteran’s hypertension has result in blood pressure that has to be controlled by the continuous use of medication.  However, his blood pressure readings were not shown to be predominately 110 mmHg or more diastolic pressure or 200 mmHg or more systolic pressure during the appeal period.
9. Throughout the appeal period, the Veteran’s sinusitis has resulted in one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting at most.  There has been no indication of surgery to treat this condition during the period of appeal.
10. Prior to April 24, 2014, the Veteran’s scar, status post cholecystectomy, was manifested by a non-painful and stable scar on the anterior trunk measuring less than 39 square centimeters that is superficial and linear.  Beginning April 24, 2014, the Veteran’s scar, status post cholecystectomy, has been manifested by a painful and stable scar on the anterior trunk measuring less than 39 square centimeters that is superficial and linear.  There has been no showing of more than the single scar associated with status post cholecystectomy nor any indication of disfigurement.
11. Throughout the appeal period, the Veteran’s diabetic retinopathy has not been shown to result in a loss of visual acuity, a loss of visual field, or muscle function; the Veteran’s right eye disability has further not been shown to have caused any incapacitating episodes resulting in doctor ordered bed rest.
12. Throughout the appeal period, the Veteran’s umbilical hernia has been shown to be asymptomatic.
13. Throughout the appeal period, the Veteran’s hemorrhoids have been shown to be asymptomatic.
14. Throughout the appeal period, the Veteran’s status post cholecystectomy has been shown to be asymptomatic.
15. Throughout the period of appeal, the Veteran’s scar, residual of lipoma removal, has been manifested by a non-painful and stable scar on the right clavicle measuring less than 39 square centimeters that is superficial and linear.  
16. Throughout the period of appeal, the Veteran’s erectile dysfunction has been manifested by a loss of erectile power without deformity.
CONCLUSIONS OF LAW
1. The criteria for an effective date of January 10, 2013, but no earlier, for the grant of service connection for bilateral knee arthritis are met.  38 U.S.C. § 5110; 38 C.F.R. §§ 3.159, 3.400(r).
2. The criteria for an evaluation in excess of 50 percent for sleep apnea are not met.  38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code (DC) 6847.
3. The criteria for an evaluation in excess of 30 percent for chronic kidney disease are not met.  38 U.S.C. § 1155; 38 C.F.R. § 4.115a, DC 7502.
4. The criteria for an increased disability rating in excess of 20 percent disabling for type II diabetes mellitus have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.119, DC 7913.
5. The criteria for an increased disability rating in excess of 10 percent each for bilateral upper extremity carpal tunnel syndrome and peripheral neuropathy have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DC 8515.
6. The criteria for an increased disability rating in excess of 10 percent each prior to April 24, 2014 and in excess of 20 percent each thereafter for bilateral lower extremity peripheral neuropathy with alopecia have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DC 8520.
7. The criteria for an increased disability rating in excess of 10 percent for hypertension have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.104, DC 7101.
8. The criteria for an increased disability rating in excess of 10 percent for sinusitis have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.97, DC 6513.
9. The criteria for an increased compensable disability rating prior to April 24, 2014 and in excess of 10 percent thereafter for scar, status post cholecystectomy, have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7804.
10. The criteria for an increased compensable disability rating for diabetic retinopathy have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.79, DC 6006.
11. The criteria for an increased compensable disability rating for umbilical hernia have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7339.
12. The criteria for an increased compensable disability rating for hemorrhoids have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7339.
13. The criteria for an increased compensable disability rating for status post cholecystectomy have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7318.
14. The criteria for an increased compensable disability rating for residual of lipoma removal have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7805.
15. The criteria for an increased compensable disability rating for erectile dysfunction have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.115b, DC 7522.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran had active military service from January 1965 to May 1965; from May 1968 to August 1969; and from July 1981 to September 2003. 
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2015 and December 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).
At the outset, the Board notes that the Veteran had additionally appealed claims relating to entitlement to service connection for chronic obstructive pulmonary disease (COPD) and a back condition as well as entitlement to an increased evaluation for residuals of a stroke, for which he was provided a statement of the case (SOC) in December 2015.  However, it does not appear from a review of the claims file that the Veteran ever filed a VA Form 9 (Substantive Appeal) or otherwise perfected such appeal within the prescribed time period.  Therefore, the Board finds that these issues are not currently subject to the current appeal and shall not be further adjudicated or discussed.
However, it is noted that the Veteran had also appealed the issue of entitlement to a TDIU in conjunction with the aforementioned claims for which he also did not perfect an appeal.  Nonetheless, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU is part of a rating issue when unemployability is expressly raised by a veteran or reasonably raised by the record.  In this case, despite the fact that the Veteran failed to formally perfect an appeal for his initial TDIU claim, he has continued to submit documentation indicating that the increased rating claims for which he is currently seeking an appeal result in his alleged unemployability.  Therefore, in accordance with Rice, the Board finds that the issue of entitlement to a TDIU is properly before it and has been inferred accordingly as reflected in the additional caption on the title page.
Earlier Effective Date Analysis
The effective date of an award of compensation based on original claim (received beyond one year after service discharge) or a claim reopened after final adjudication (such as the claim in this case) shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application thereof.  38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. 
Effective March 24, 2015, a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by the Secretary.  See 38 U.S.C. § 5101 (a).  However, prior to that date, a “claim” was defined as “a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit.”  38 C.F.R. § 3.1 (p).  An informal claim was “[a]ny communication or action indicating an intent to apply for one or more benefits.”  It must “identify the benefit sought.”  38 C.F.R. § 3.155 (a).  VA was to look to all communications from a claimant that may be interpreted as applications or claims, formal and informal, for benefits and was required to identify and act on informal claims for benefits.  Servello v. Derwinski, 3 Vet. App. 196, 198 (1992).  If VA failed to forward an application form to the claimant after receipt of an informal claim, then the date of the informal claim was accepted as the date of claim for purposes of determining an effective date.  Id. at 200. 
The Veteran contends that an effective date earlier than August 20, 2013, for the grant of service connection for bilateral knee arthritis is warranted.  The Veteran essentially contends that his claim for service connection for a bilateral knee disability was communicated expressly, or reasonably was raised by the record evidence, at the time that he filed his initial claim for such disability.
The Veteran filed an initial claim for a bilateral knee disability in September 2003.  In an August 2004 rating decision, the RO denied the Veteran’s claim on the basis of no showing of a current disability.  He was notified on September 2004.  On October 2004, the Veteran submitted a notice of disagreement.  He was provided with a statement of the case on February 2005.  However, the Veteran thereafter failed to perfect an appeal, as no formal or informal submissions of a VA Form 9 (Substantive Appeal) were submitted within the applicable time limit.  Therefore, the August 2004 rating decision was finalized on September 2005.
The Veteran attempted to reopen his previously denied bilateral knee disability claim in March 2009.  In a September 2009 rating decision, the RO reopened the Veteran’s claim, as he had provided evidence of a current disability, but denied it on the basis for failure to demonstrate a nexus.  The Veteran did not submit a notice of disagreement or any other intent to appeal within a year and that decision was finalized in September 2010. 
Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority.  38 C.F.R. § 3.104 (a).  The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period.  38 U.S.C. §§ 7105 (b) and (c); 38 C.F.R. §§ 3.160 (d), 20.200, 20.201, 20.202, and 20.302(a).
In correspondence received on January 10, 2013, the Veteran listed all of his medical conditions with reference to the duty stations during military service that he was treated.  Significantly, the Veteran wrote that he received a profile for arthritis of the knees in August 1998 and was subsequently treated for arthritis of the knees in July 2012.  
In correspondence received on March 11, 2013, the Veteran wrote that he was given a profile for osteoarthritis of his knees in August 1998 (during his military service) but that, during his separation examination, he was told that there was no evidence of this condition.  The Veteran then stated that four years earlier (approximately 2009), he was again told that he had arthritis of the knees.  
The next correspondence that the RO received from the Veteran regarding a claim for a bilateral knee disability was date-stamped as received by VA on August 20, 2013.  By rating decision dated in March 2014 rating decision, the RO again denied service connection for a bilateral knee disorder, finding no new and material evidence had been submitted to reopen it.  However, in a December 2015 rating decision, the RO reopened and granted service connection for bilateral knee arthritis effective August 20, 2013, the date of the receipt of what the RO considered to be the original claim to reopen.
The Board has reviewed all of the communications in the claims file dated between September 2009 and August 20, 2013.  The Board must read a veteran’s claim and documents in a liberal manner to identify and adjudicate all reasonably raised claims.  A review of the record, when construed liberally, shows that the Veteran expressly raised a claim of service connection for a bilateral knee disability prior to the claim received on August 20, 2013 in his January 10, 2013 correspondence.  Although not specifically indicated, the only reasonable conclusion that can be drawn from the submission of such document in discussing his bilateral knee disability in conjunction with military service and submitting such to the RO was to effectively file a claim to reopen.  Therefore, in accordance with 38 C.F.R. § 3.400, the Board finds that the effective date for the grant of service connection of the Veteran’s bilateral knee disabilities should be January 10, 2013, as such is the earliest manifested intent to reopen such claims. 
The record, however, does not show that the Veteran submitted any earlier correspondence or intention to appeal prior to January 10, 2013.  Nor does the record indicate a claim that could be reasonably construed as a service connection claim for a bilateral knee disability prior to January 10, 2013.  Although the record clearly reflects that the Veteran had been treated for bilateral knee arthritis for many years after service, it does not contain medical evidence relating this disability to service.  As such, prior to January 10, 2013, the record contained no evidence indicating that the Veteran had a well-supported claim of service connection for a bilateral knee disability.  The Board reasonable concludes that the Veteran's January 10, 2013 claim was the first attempt to notify VA that he was seeking to reopen a claim for service connection for a bilateral knee disability.  See Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010).  In summary, the Board concludes that an earlier effective date than January 10, 2013, for a grant of service connection for bilateral knee arthritis is not warranted.
Increased Ratings Analysis
Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4.  The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service.  The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.
In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991).  Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern.  Francisco v. Brown, 7 Vet. App. 55 (1994).
The Board notes, however, that where, as in the case of the Veteran’s alopecia of the feet extending up the calf and chronic kidney disease, the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence ‘used to decide whether an original rating on appeal was erroneous.’  Fenderson v. West, 12 Vet. App. 119, 126 (1999).  If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, ‘staged’ ratings may be assigned for separate periods of time.  Fenderson, 12 Vet. App. at 126.  When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim.  Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009).
A veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).   The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods.
Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.
In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1377 (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”).
The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107 (a).  See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009).  The Board shall consider all information and lay and medical evidence of record.  38 U.S.C. § 5107 (b).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
1. Sleep Apnea
The Veteran’s sleep apnea has been rated as 50 percent throughout the appeal period.  38 C.F.R. § 4.97, DC 6847.  A 50 percent evaluation is warranted for use of breathing assistance device such as a CPAP machine.  Id.  A 100 percent evaluation is warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy.
The Veteran claims that his sleep apnea is worse than reflected by his current evaluation of 50 percent.  In this regard, the Veteran has reported increased daytime sleepiness.
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for sleep apnea throughout appeal period.  Treatment included the use of CPAP machine.  There were no indications of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy.
The Veteran was provided with a VA sleep apnea examination in July 2013.  At this examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with sleep apnea.  Treatment included the use of CPAP machine.  There were no indications of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy.  The examiner also opined that the Veteran’s separate use of oxygen therapy in addition to the CPAP was exclusively due to the Veteran’s chronic obstructive pulmonary disease (COPD) and not his sleep apnea.
The Veteran was provided with another VA sleep apnea examination in April 2015.  At this examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with sleep apnea.  Treatment included the use of CPAP machine.  There were no indications of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy.  It was further noted that the Veteran’s sleep apnea does not impact his ability to work.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s sleep apnea more nearly approximates an evaluation of 50 percent.  The evidence of record shows that the Veteran’s sleep apnea is of such severity that it has required CPAP to control it.  Thus, in accordance with the Rating Schedule, a 50 percent evaluation is warranted.
However, the Board finds that the Veteran’s sleep apnea does not warrant an evaluation of 100 percent.  In order to warrant such, the Veteran’s sleep apnea would need to show indications of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy.  No such findings have been shown in the medical evidence of record.
In conclusion, the evidence of record does not warrant a rating in excess of 50 percent for the Veteran’s sleep apnea at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
2. Chronic Kidney Disease
The Veteran’s service-connected chronic kidney disease is rated as 30 percent disabling.  38 C.F.R. § 4.115a, DC 7502.  The Rating Schedule directs that such disability is to be rated as renal dysfunction.  Id.  A 30 percent evaluation is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under DC 7101.  Id.  A 60 percent evaluation is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101.  Id.  An 80 percent evaluation is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion.  Id.  A 100 percent evaluation is warranted for requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular.  Id.
The Veteran claims that his chronic kidney disease is worse than reflected by his current evaluation of 30 percent. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for chronic kidney disease since August 2007 which has been found to be the result of his service-connected hypertension.  There were no showings of  constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101; or a BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; or regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular.
The Veteran was provided with a VA examination in April 2013.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with chronic kidney disease.  It was determined that the Veteran had hypertension and renal dysfunction, with showings of near constant proteinuria, hematuria, or GFR less than 60 cc/min/1.73m2.  There were no showings of  constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101; or a BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; or regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular.
The Veteran was provided with an additional VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with chronic kidney disease.  The examiner found that the Veteran no longer showed signs of renal dysfunction.  All other findings were within normal limits, including BUN of 25mg% and creatinine of 1.10mg%.  It was noted that the Veteran’s disability does not impact his ability to work.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s chronic kidney disease more nearly approximates an evaluation of 30 percent.  The evidence of record shows that the Veteran’s chronic kidney disease is such a severity that it resulted from hypertension rated 10 percent compensable under DC 7101.  Thus, in accordance with the Rating Schedule, a 30 percent evaluation is warranted.
However, the Board finds that the Veteran’s chronic kidney disease does not warrant an evaluation higher than 30 percent throughout the appeal period.  In order to warrant such, the Veteran’s chronic kidney disease would need to show indications of constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101; or a BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; or regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular.  No such findings have been shown in the medical evidence of record.
In conclusion, the evidence of record does not warrant a rating in excess of 30 percent for the Veteran’s chronic kidney disease at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
3. Diabetes Mellitus Type II
The Veteran’s service-connected diabetes is rated as 20 percent disabling in accordance with the General Rating Formula for the Endocrine System.  38 C.F.R. § 4.97, DC 7913.  Pursuant to DC 7913, a 20 percent rating is warranted for diabetes requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet.  Id.  A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities.  Id.  A 60 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated.  Id.  A 100 percent rating is warranted for diabetes requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated.  Id.
The Veteran claims that his diabetes mellitus type II is worse than reflected by his current evaluation of 20 percent. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for diabetes mellitus type II throughout the appeal period.  Treatment has included regulation of diet and insulin.  There were no showings of the requirement for regulation of activities, episodes of ketoacidosis, or hypoglycemic reactions.
The Veteran was provided with a VA diabetes examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with diabetes mellitus type II.  It was noted that the Veteran’s condition required the injection of daily insulin to treat.  There was no requirement for restriction of activities.  There were no episodes of ketoacidosis or hypoglycemic reactions.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s diabetes mellitus type II more nearly approximates an evaluation of 20 percent.  The evidence of record shows that the Veteran’s diabetes mellitus type II is of such severity that it requires dietary restriction and the provision of daily insulin.  Thus, in accordance with the Rating Schedule, a 20 percent evaluation is warranted.
However, the Board finds that the Veteran’s diabetes mellitus type II does not warrant an evaluation higher than 20 percent.  In order to warrant such, the Veteran’s diabetes mellitus type II would need to show the requirement of a regulation of activities or the presence of ketoacidosis or hypoglycemic episodes.  No such findings have been shown in the medical evidence of record.
In conclusion, the evidence of record does not warrant a rating in excess of 20 percent for the Veteran’s diabetes mellitus type II at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
4.  Carpal Tunnel Syndrome and Peripheral Neuropathy Upper Extremities
The Veteran’s service-connected carpal tunnel syndrome and peripheral neuropathy of the bilateral upper extremities is rated as 10 percent disabling each in accordance with the General Rating Formula for the Nervous System.  38 C.F.R. § 4.124a, DC 8515.  A 10 percent rating is warranted for incomplete paralysis of both extremities of the median nerve that is mild.  Id.  A 20 percent rating is warranted for incomplete paralysis of the minor median nerve that is moderate.  Id.  A 30 percent rating is warranted for incomplete paralysis of the major median nerve that is moderate.  Id.  A 40 percent rating is warranted for incomplete paralysis of the minor median nerve that is severe.  Id.  A 50 percent rating is warranted for incomplete paralysis of the major median nerve that is severe.  Id.  A 60 percent rating is warranted for complete paralysis of the minor median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances.  Id.  A 70 percent rating is warranted for complete paralysis of the major median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances.  Id.
The term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration.  38 C.F.R. § 4.124a, Note.  When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id.  The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor.  Id. 
The Veteran claims that his upper extremity neuropathies are worse than reflected by his current evaluations of 10 percent each. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for bilateral upper extremity carpal tunnel syndrome and peripheral neuropathy.  Symptoms have presented as wholly sensory numbness and tingling without muscular atrophy or trophic changes.
The Veteran was provided with a VA peripheral nerve examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with peripheral neuropathy of the bilateral upper extremities.  It was noted that this condition resulted in the incomplete paralysis of the median nerve for both upper extremity.  The impairment was noted to be wholly sensory and mild.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s upper extremity neuropathies more nearly approximate an evaluation of 10 percent for each extremity.  The evidence of record shows that the Veteran’s neuropathies are manifested by wholly sensory mild impairment.  Thus, in accordance with the Rating Schedule, a 10 percent evaluation for each extremity is warranted.
However, the Board finds that the Veteran’s neuropathies do not warrant an evaluation higher than 10 percent each throughout the appeal period.  In order to warrant such, the Veteran’s condition would need to show at least moderate or greater impairment, manifested primarily by more than mere wholly sensory presentation and mild pain.  No such findings have been shown in the medical evidence of record.
In conclusion, the evidence of record does not warrant ratings in excess of 10 percent for the Veteran’s bilateral upper extremity neuropathies at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
5. Peripheral Neuropathy Lower Extremities
At the outset, the Board notes that the Veteran initially filed his claim for an increased evaluation for these disabilities on April 24, 2014, at which time the Veteran was already rated at 10 percent for each extremity.  The RO initially denied the claim, but then over the course of the appeal, increased the Veteran’s disabilities to 20 percent each, effective April 24, 2014, the date of claim.  However, the entire claims period for an increased rating also includes the one-year lookback period; in this case April 24, 2013.   In this regard, the Board notes that applicable law mandates that when an appellant seeks an increased rating, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded.  See A.B. v. Brown, 6 Vet. App. 35 (1993).  As there are higher evaluations available for the service-connected peripheral neuropathy and the increased evaluations do not cover the entire periods of appeal, the Veteran’s claims are still in controversy and shall continue to be adjudicated by the Board.
The Veteran’s service-connected peripheral neuropathy of the bilateral lower extremities is rated as 10 percent disabling each prior to April 24, 2014 and 20 percent disabling each in accordance with the General Rating Formula for the Nervous System.  38 C.F.R. § 4.124a, DC 8520.  A 10 percent rating is warranted for incomplete paralysis of the sciatic nerve that is mild.  Id.  A 20 percent rating is warranted for incomplete paralysis of the sciatic nerve that is moderate.  Id.  A 40 percent rating is warranted for incomplete paralysis of the sciatic nerve that is moderately severe.  Id.  A 60 percent rating is warranted for incomplete paralysis of the sciatic nerve that is severe with marked muscular atrophy.  Id.  An 80 percent rating is warranted for complete paralysis of the sciatic nerve that results in the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost.  Id.
As above, the term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration.  38 C.F.R. § 4.124a, Note.  When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id.  The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor.  Id. 
The Veteran claims that his lower extremity neuropathies are worse than reflected by his current evaluations of 10 percent each prior to April 24, 2014 and 20 percent each thereafter. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for bilateral lower extremity sciatic peripheral neuropathy throughout the appeal period.  Symptoms prior to April 24, 2014 have presented as wholly sensory numbness and tingling without muscular atrophy or trophic changes.
The Veteran was provided with a VA peripheral nerves examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with peripheral neuropathy of the bilateral upper extremities.  It was noted that this condition resulted in the incomplete paralysis of the sciatic nerve for both upper extremity.  The impairment was noted to be wholly sensory and mild.  However, the examiner also noted that the condition resulted in trophic changes as alopecia on the lower extremities.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s upper extremity neuropathies more nearly approximates an evaluation of 10 percent for each extremity prior to April 24, 2014 and 20 percent for each extremity thereafter for the entire period of appeal.  The evidence of record shows that the Veteran’s neuropathies were only manifested by wholly sensory mild impairment throughout the period prior to April 24, 2014.  Thus, in accordance with the Rating Schedule, a 10 percent evaluation for each extremity is warranted prior to that time.  From April 24, 2014, via complaints at the time of the Veteran’s claim coupled with the findings of trophic changes at the April 2015 VA examination, the Veteran’s condition was shown to warrant 20 percent evaluations each.
However, the Board finds that the Veteran’s neuropathies do not warrant an evaluation higher than 10 percent each prior to April 24, 2014 because his condition was wholly sensory with only showings of mild pain and no muscular involvement or trophic changes.  The evidence of record does not mention any trophic changes until the April 2015 VA examination, so therefore such symptoms are not attributable to the year before the Veteran filed his claim for increased symptoms.  The Veteran’s neuropathies from April 24, 2014 also do not warrant evaluations higher than 20 percent each because, even though he has shown the presence of trophic changes, the only other impairment has been shown to be mild pain.  For higher evaluations the Veteran would need to show evidence of more severe pain or impairment, including muscular involvement or complete paralysis.
The Board notes that the Veteran’s bilateral alopecia is rated with the Veteran’s bilateral lower extremity peripheral neuropathy as such allows for the greater benefit to the Veteran.  If these conditions were to be rated separately, the Veteran’s bilateral alopecia would be noncompensable in accordance with 38 C.F.R. § 4.118, DCs 7830 and 7831, as the alopecia does not affect the head, face, or neck and does not result in complete hair loss of the entire body or any scarring.  Additionally, as discussed above, without the inclusion of the trophic changes, the Veteran’ bilateral lower extremity peripheral neuropathy would only be evaluated at 10 percent each.  Therefore, the combined rating of these disabilities is more favorable. 
In conclusion, the evidence of record does not warrant a rating in excess of those assigned for the Veteran’s bilateral lower extremity neuropathies with alopecia at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
6. Hypertension
The Veteran’s service-connected hypertension is rated as 10 percent disabling.  38 C.F.R. § 4.104, DC 7101.  A 10 percent evaluation is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control.  Id.  A 20 percent evaluation is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more.  Id.  A 40 percent evaluation is warranted for diastolic pressure predominantly 120 or more.  Id.  A 60 percent evaluation is warranted for Diastolic pressure predominantly 130 or more.  Id.
Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days.  38 C.F.R. § 4.104, DC 7101, Note 1.  For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90 mmHg or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mmHg or greater with a diastolic blood pressure of less than 90 mmHg.  Id.
The Veteran claims that his hypertension is worse than reflected by his current evaluation of 10 percent. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for hypertension throughout the period on appeal.  The Veteran’s blood pressure has been well-controlled with use of medication.  At an April 2015 doctor’s appointment, the Veteran had a sitting blood pressure of 138/66 mmHg.
The Veteran was provided with a VA hypertension examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with hypertension.  It was noted that this condition requires the use of continuous medication and that the Veteran’s hypertension is well-controlled.  Blood pressure readings were 114/68 mmHg, 153/74 mmHg, and 131/59 mmHg.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s hypertension more nearly approximates an evaluation of 10 percent for the entire period of appeal.  The evidence of record shows that the Veteran’s hypertension is manifested by well controlled blood pressure readings predominately under 90/160 mmHg.  Thus, in accordance with the Rating Schedule, the Veteran would not even qualify for a diagnosis of hypertension for VA purposes with his current readings.  However, because the Veteran is required to take continuous medication to control his blood pressure, it is presumed that such uncontrolled readings would at least be predominately 100/160 mmHg and, therefore, warrant a 10 percent evaluation.  
In this regard, the Board further notes that United States Court of Appeals for Veterans Claims (Court) has held that VA may not deny a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria.  Jones v. Shinseki, 26 Vet. App. 56, 61.  The rating criteria for DC 7101 do not contemplate the effects of medication on hypertension, other than to note the requirement of continuous medication, and so the Board must consider his symptoms without medication.  Even considering such, however, the Board finds that the Veteran’s blood pressure would most likely not reach the level of a 20 percent evaluation without his medication, as currently the readings were so well-controlled that they did not even manifest in a diagnosis of hypertension for VA purposes in and of themselves.  If the Veteran’s blood pressure readings were at the level of a 10 percent evaluation, even with his medication, then such may actually warrant a 20 percent evaluation.  However, such is not shown by the medical evidence of record.  For higher evaluations the Veteran would need to show evidence of such higher blood pressure readings.
In conclusion, the evidence of record does not warrant a rating in excess of 10 percent for the Veteran’s hypertension at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
7. Sinusitis
The Veteran’s service-connected sinusitis is rated as 10 percent disabling.  38 C.F.R. § 4.97, DC 6513.  A 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  Id.  A 30 percent evaluation is warranted for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  Id.  A 50 percent evaluation is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries.  Id.
The Veteran claims that his sinusitis is worse than reflected by his current evaluation of 10 percent. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for sinusitis throughout the appeal period.  The Veteran’s condition has actually shown improvement during the appeal period, though not sustained, as there are periods where he has had less than two incapacitating episodes per year of sinusitis or three to six non-incapacitating episodes per year of sinusitis.  There has been no indication of more than two incapacitating episodes per year of sinusitis or three to six non-incapacitating episodes per year of sinusitis.  There has also been no indication of any surgery performed to treat the Veteran’s sinusitis.
The Veteran was provided with a VA sinuses examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with chronic sinusitis.  It was noted that this condition only results in periodic episodes of sinusitis.  There were no incapacitating episodes or non-incapacitating episodes requiring the use of antibiotics in the previous year, nor where there any showings of surgeries.  The Veteran was provided with x-rays which revealed the Veteran’s condition to be within normal limits.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s sinusitis more nearly approximates an evaluation of 10 percent.  The evidence of record shows that the Veteran’s sinusitis is manifested by periodic episodes of sinusitis that are not incapacitating or have required the use of antibiotics.  Thus, in accordance with the Rating Schedule, the Veteran would not even qualify for an evaluation of 10 percent, much less any higher evaluations.  However, because the Veteran has not shown sustained improvement, his evaluation of 10 percent shall not be disturbed.  
In order to warrant higher evaluations, the Veteran’s sinusitis must show increased incapacitating episodes, episodes requiring the use of antibiotics, or the provision of surgery.  As the medical evidence of record has not shown such manifestations during the period of appeal, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a rating in excess of 10 percent for the Veteran’s sinusitis at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
8. Scar
At the outset, the Board notes that the Veteran initially filed his claim for an increased evaluation for this disability on April 24, 2014, at which time the Veteran was already rated at noncompensably disabling.  The RO increased the Veteran’s disability to 10 percent, effective April 24, 2014, the date of claim.  However, the entire claims period for an increased rating also includes the one-year lookback period; in this case April 24, 2013.   In this regard, the Board notes that applicable law mandates that when an appellant seeks an increased rating, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded.  See A.B., 6 Vet. App. at 35.  As there are higher evaluations available for the service-connected scar and the increased evaluations do not cover the entire periods of appeal, the Veteran’s claim is still in controversy and shall continue to be adjudicated by the Board.
The Veteran’s service-connected scar is rated as noncompensably disabling prior to April 24, 2014 and 10 percent disabling thereafter.  38 C.F.R. § 4.118, DC 7804.  A 10 percent evaluation is warranted for one or two scars that are unstable or painful.  Id.  A 20 percent evaluation is warranted for three or four scars that are unstable or painful.  Id.  A 30 percent evaluation is warranted for five or more scars that are unstable or painful.  Id.
An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.  Id. at Note 1.  If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.  Id. at Note 2.  Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC, when applicable.  Id. at Note 3.
The Board notes that DC 7800 would not be applicable to the Veteran’s scar as it does not involve the head, face, or neck; DC 7801 would not be applicable to the Veteran’s scar as it is neither deep nor nonlinear; DC 7802 would not be applicable to the Veteran’s scar as it is not nonlinear; and DC 7805 would not be applicable to the Veteran’s scar as it has not been shown to involve any other disabling effects not provided in the aforementioned DCs.
The Veteran claims that his scar is worse than reflected by his current evaluations of 0 percent prior to April 24, 2014 and 10 percent thereafter. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his scar throughout the appeal period.  The Veteran has been shown to report pain and tenderness intermittently associated with his scar since the filing of his claim in April 2014, but not prior.
The Veteran was provided with a VA skin examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with a scar of the anterior trunk that was associated with his status post cholecystectomy.  It was noted that the anterior scar was linear and measured .5 centimeter by l centimeter.  The examiner noted that the scar was painful.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s scar more nearly approximates a noncompensable evaluation prior to April 24, 2014 and 10 percent thereafter for the entire period of appeal.  The evidence of record shows that the Veteran’s scar was only manifested a linear, superficial, and nonpainful scar prior to April 24, 2014 and a single linear, superficial, and painful scar thereafter.  Thus, in accordance with the Rating Schedule, the Veteran’s scar would only warrant a noncompensable evaluation prior to April 24, 2014 and 10 percent thereafter.  
In order to warrant higher evaluations, the Veteran’s scar must show evidence that  it was painful, deep, nonlinear, unstable, or consists of more than 2 scars prior to April 24, 2014 or deep, nonlinear, unstable, or consists of more than 2 scars thereafter.  As the medical evidence of record has not shown such manifestations during the appeal period, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a rating in excess of those assigned for the Veteran’s scar at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
9. Diabetic Retinopathy
The Veteran’s service-connected diabetic retinopathy is rated as noncompensably disabling.  38 C.F.R. § 4.79, DC 6006.  Pursuant to DC 6006, retinopathy is to be evaluated on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation.  A 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the past 12 months.  Id.  A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months.  Id.  A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months.  Id.  A 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.  Id.  
Visual impairment is rated based on the consideration of three factors: 1) impairment of visual acuity (excluding developmental errors of refraction), 2) visual field, and 3) muscle function.  38 C.F.R. § 4.75 (a).  However, examinations of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function.  38 C.F.R. § 4.75 (b).
Central visual acuity is to be evaluated on the basis of corrected distance vision with central fixation, even if a central scotoma is present.  However, 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 is to be evaluated using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity.  38 C.F.R. § 4.76 (b). 
When both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the evaluation is determined by separately evaluating the visual acuity and visual field defect (expressed as a level of visual acuity) and combined under the provisions of 38 C.F.R. § 4.25.  38 C.F.R. § 4.77(c).
The basis for rating visual acuity takes into account the best distance vision obtainable after best correction by glasses.  38 C.F.R. § 4.75.  A compensable rating for loss of visual acuity requires that corrected vision be 20/40 in one eye and 20/50 in the other.  38 C.F.R. § 4.79, DC 6066.
The regulations indicate that the extent of visual field contraction in each eye is determined by recording the extent of the remaining visual field in each of the eight 45 degree principal meridians.  The number of degrees lost is determined at each meridian by subtracting the remaining degrees from the normal visual fields given in Table III.  The degrees lost are then added together to determine the total degrees lost.  This is subtracted from 500.  The difference represents the total remaining degrees of visual field.  The difference divided by 8 represents the average contraction for rating purposes.  38 C.F.R. §4.77(b).
A 10 percent rating is warranted for concentric contraction of visual field with a remaining field of 46 to 60 degrees unilaterally or bilaterally, 31 to 45 degrees unilaterally, or 16 to 30 degrees unilaterally; a 20 percent rating is warranted for concentric contraction of visual field with a remaining field of 6 to 15 degrees unilaterally; a 30 percent rating is warranted for concentric contraction of visual field with a remaining field of 31 to 45 degrees bilaterally or 5 degrees unilaterally; a 50 percent rating is warranted for concentric contraction of visual field with a remaining field of 16 to 30 degrees bilaterally; a 70 percent rating is warranted for concentric contraction of visual field with a remaining field of 6 to 15 degrees bilaterally; and a 100 percent rating is warranted for concentric contraction of visual field with a remaining field of 5 degrees bilaterally.  A 10 percent rating is also rated for a unilateral eye disability with visual defect with loss of superior half of visual field, loss of inferior half of visual field, loss of nasal half of visual field, or loss of temporal half of visual field.  Higher ratings are assigned only for bilateral loss of visual field.  38 C.F.R. § 4.79, DC 6080.
As there has been no previous medical findings of diplopia, DC 6090 is not applicable as it relates to impairment of muscle function and is not for application.
The Veteran claims that his diabetic retinopathy is worse than reflected by his current noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for diabetic retinopathy.  The Veteran’s condition has not shown any impairment of visual field, visual acuity, or muscle function during the period of appeal.  Additionally, there have not been any showings of incapacitating episodes requiring doctor-ordered bedrest at any point during the appeal period.
The Veteran was provided with a VA eye examination in May 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with age-related macular degeneration of the bilateral eyes.  It was noted that this condition is unrelated to diabetes.  Visual acuity testing revealed uncorrected right distance of 20/200 and left distance of 20/50 corrected to 20/40 bilaterally.  Near visual acuity was 10/200 bilaterally corrected to 20/40 bilaterally.  There was no diplopia or astigmatism.  There was no visual field defect.  Maculopathy was noted without any accompanying visual impairment.  There were no incidents of incapacitating episodes requiring doctor-ordered bedrest.  No other pertinent findings were noted.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s diabetic retinopathy more nearly approximates a noncompensable disability rating.  The evidence of record shows that the Veteran’s disability is manifested by maculopathy without any noted impairment or symptoms, as corrected distance visual acuity, visual fields, and muscular function were all normal.  Thus, in accordance with the Rating Schedule, the Veteran’s disability without any medical evidence of visual impairment or incapacitating episodes only warrants a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s diabetic retinopathy must show worsened visual impairment or incapacitating episodes.  As the medical evidence of record has not shown such manifestations during the appeal period, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s diabetic retinopathy at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
10. Umbilical Hernia
The Veteran’s service-connected hernia is rated as noncompensably disabling.  38 C.F.R. § 4.114, DC 7339.  A noncompensable evaluation is warranted for wounds, postoperative, healed, no disability, belt not indicated.  Id.  A 10 percent evaluation is warranted for a hernia that is small, not well supported by belt under ordinary conditions, or healed ventral hernia or postoperative wounds with weakening of abdominal wall and indication for a supporting belt.  Id.  A 40 percent evaluation is warranted for a hernia that is large, not well supported by belt under ordinary conditions.  Id.  A 100 percent evaluation is warranted for a hernia that is massive, persistent, severe diastasis of recti muscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable.  Id.
The Veteran claims that his hernia is worse than reflected by his current noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his hernia throughout the appeal period.  The Veteran’s condition has only shown a healed hernia without current symptoms.
The Veteran was provided with a VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with an umbilical hernia.  It was noted that this condition has been previously surgically repaired with no residual symptoms.  The examiner found that the Veteran’s disability had no effect on his employment.
On the Veteran’s April 2015 VA scars Examination, it was noted that there was a scar from the Veteran’s surgical repair of his umbilical hernia.  It was noted as a linear stable scar on the abdomen measuring .5 centimeter by 1 centimeter.  The scar was not found to be painful.  Therefore, in accordance with 38 C.F.R. § 4.118, DCs 7800-7805, the Veteran’s scar would not be separately compensable, as it is not painful, unstable, or nonlinear.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s hernia more nearly approximates a noncompensable for the entire period of appeal.  The evidence of record shows that the Veteran’s hernia was only manifested by a well-healed stable linear and nonpainful scar, with no other residuals.  Thus, in accordance with the Rating Schedule, the Veteran’s condition only warrants a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s hernia must show increased symptoms in either active symptoms of the hernia or worsened scar symptoms, such as a nonlinear, painful, or unstable scar.  As the medical evidence of record has not shown such manifestations during the period of appeal, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s hernia at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
11. Hemorrhoids
The Veteran’s service-connected hemorrhoids are rated as noncompensably disabling.  38 C.F.R. § 4.114, DC 7336.  A noncompensable evaluation is warranted for hemorrhoids that are mild or moderate.  Id.  A 10 percent evaluation is warranted for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences.  Id.  A 20 percent evaluation is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures.  Id.
The Veteran claims that his hemorrhoids are worse than reflected by his current noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his hemorrhoids throughout the appeal period.  The Veteran’s condition has only shown the presence of mild, intermittent hemorrhoids.
The Veteran was provided with a VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with hemorrhoids.  It was noted that the Veteran’s hemorrhoids were either small or moderate.  The Veteran was shown to use creams and suppositories to treat his hemorrhoids.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s hemorrhoids more nearly approximates a noncompensable evaluation.  The evidence of record shows that the Veteran’s hemorrhoids were only manifested by mild to moderate manifestations.  Thus, in accordance with the Rating Schedule, the Veteran’s condition only warrants a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s hemorrhoids must show increased symptoms of large and/or thrombotic hemorrhoids.  As the medical evidence of record has not shown such manifestations during the period of appeal, higher evaluations are, thus, not warranted.
In regard to the fact that the Veteran is shown to take medication for this condition, the Board notes that the Court has held that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria.  Jones, 26 Vet. App. at 61.  The rating criteria for DC 7336 do not contemplate the effects of medication on hemorrhoids and so the Board must consider the Veteran’s symptoms without medication.  However, even disregarding the ameliorative effects of treatment, there is simply no objective medical evidence of hemorrhoids that are large, thrombosed, or otherwise meet the criteria for an increased rating, even prior to the period of time when the Veteran began medication.  Therefore, it is reasonable to presume that, even without the medication, the Veteran’s hemorrhoids would not currently manifest in large or thrombotic occurences.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s hemorrhoids at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
12. Cholecystectomy
The Veteran’s service-connected cholecystectomy is rated as noncompensably disabling.  38 C.F.R. § 4.114, DC 7318.  A noncompensable evaluation is warranted for a condition that is nonsymptomatic.  Id.  A 10 percent evaluation is warranted for a condition with mild symptoms.  Id.  A 30 percent evaluation is warranted for a condition with severe symptoms.  Id.
The Veteran claims that his cholecystectomy is worse than reflected by his current noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his cholecystectomy residuals throughout the appeal period.  The Veteran’s condition has only shown a well healed scar that has been painful since April 24, 2014 and is separately compensable, without any other current symptoms.
The Veteran was provided with a VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with status post cholecystectomy.  It was noted that this condition has no current symptoms, notwithstanding the scar that has been previously addressed as separately compensable.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s cholecystectomy more nearly approximates a noncompensable evaluation.  The evidence of record shows that the Veteran’s cholecystectomy was only manifested by a well-healed stable linear and nonpainful scar prior to April 24, 2014 and a well-healed stable linear and painful scar thereafter, with no other residuals.  Thus, in accordance with the Rating Schedule, the Veteran’s condition only warrants a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s hernia must show increased active symptoms of the cholecystectomy that are either mild or severe.  As the medical evidence of record has not shown such manifestations during the period of appeal, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s cholecystectomy at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
 
13. Lipoma Removal
The Veteran’s service-connected residuals of lipoma removal is rated as noncompensably disabling.  38 C.F.R. § 4.118, DC 7805.  Under that DC, a scar that has other disabling effects not provided in DCs 7800 to 7804 are to be evaluated under any other appropriate DC.
The Board notes that DC 7800 would not be applicable to the Veteran’s scar as it does not involve the head, face, or neck; DC 7801 would not be applicable to the Veteran’s scar as it is neither deep nor nonlinear; DC 7802 would not be applicable to the Veteran’s scar as it is not nonlinear; and DC 7804 would not be applicable to the Veteran’s scar as it is nonpainful.
The Veteran claims that his lipoma residual is worse than reflected by his current noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his lipoma residual throughout the appeal period.  Results have shown that his residual scar is superficial, linear, stable, and nonpainful.
The Veteran was provided with a VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with a scar of the right clavicle that was associated with his status post lipoma.  It was noted that the scar was linear and measured.5 centimeter by l centimeter.  The examiner noted that the scar was nonpainful and stable.  The examiner found that the Veteran’s disability had no effect on his employment.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s lipoma residual more nearly approximates an evaluation of noncompensably disabling for the entire period of appeal.  The evidence of record shows that the Veteran’s lipoma residual was only manifested a stable, linear, superficial, and nonpainful scar prior.  Thus, in accordance with the Rating Schedule, the Veteran’s scar would only warrant a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s lipoma residual must show evidence that it is painful, deep, nonlinear, unstable.  As the medical evidence of record has not shown such manifestations during the appeal period, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s lipoma residual at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
14. Erectile Dysfunction
The Veteran’s service-connected erectile dysfunction is rated as noncompensably disabling.  38 C.F.R. § 4.115b, DC 7522.  A noncompensable evaluation is warranted for a condition that results in loss of erectile power with no deformity or other symptoms.
The Veteran claims that his erectile dysfunction is worse than reflected by his noncompensable evaluation. 
A review of the Veteran’s outpatient treatment records shows that he has been continuously treated for his erectile dysfunction as a result of his diabetes mellitus type II throughout the appeal period.  The Veteran’s condition has only shown loss of erectile power without deformity or other symptoms.
The Veteran was provided with a VA examination in April 2015.  At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with erectile dysfunction.  It was noted that this condition results in loss of erectile power without deformity or other symptoms.  The examiner found that the Veteran’s disability had no effect on his employment.
Although the April 2015 VA examiner found that the Veteran also had a voiding dysfunction, in a June 2015 addendum opinion, it was indicated that such condition was unrelated to the erectile dysfunction or any other service-connected disability.
After having carefully reviewed the evidence of record, the Board finds that the Veteran’s erectile dysfunction more nearly approximates a noncompensable evaluation.  The evidence of record shows that the Veteran’s erectile dysfunction was only manifested by loss of erectile power without deformity or other symptoms.  Thus, in accordance with the Rating Schedule, the Veteran’s condition only warrants a noncompensable evaluation.  
In order to warrant higher evaluations, the Veteran’s erectile dysfunction must show penile deformity or other associated compensable symptoms.  As the medical evidence of record has not shown such manifestations during the period of appeal, higher evaluations are, thus, not warranted.
In conclusion, the evidence of record does not warrant a compensable disability rating for the Veteran’s erectile dysfunction at any time during the period pertinent to this appeal.  38 U.S.C. § 5110.
REASONS FOR REMAND
1. Bilateral Knees
For Veteran’s bilateral knee arthritis, the Board observes that a recent precedential opinion that may impact this case was issued by the Court.  In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities.  The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.”  The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59.
In this case, the examination forms used in the administration of the Veteran’s prior VA examinations appears to have used a format that did not contain any discussion of these presentations as appear to have been contemplated by the holding in Correia.  Accordingly, the Veteran should be afforded a new VA examination for the bilateral knees to comply with this case.
Additionally, this remand will also afford the RO the opportunity to ask the clinician who conducts the VA examination requested above to apply a decision issued by the Court, Sharp v. Shulkin, 29 Vet. App. 26 (2017).  In Sharp, the Court noted that the VA’s Clinician’s Guide specifically advises examiners to try to procure information necessary to render an opinion regarding flares from Veterans.  The Court in Sharp found that the examination in question in that case to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of his conditions, failed to ascertain adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means.  Id.  The prior VA examinations discussed above did not reflect the considerations required by Sharp, and the instructions to the examiner below will request such consideration.
2. Right Foot Hallux Valgus and Bunions
The Veteran was provided with a VA examination for his right foot hallux valgus and bunions on April 2015.  However, the examination did not show that he was diagnosed with hallux valgus of the right foot.  Rather he was diagnosed with hallux valgus of the left foot only.  The Veteran is not currently service connected for a left foot disability.  The Veteran’s bilateral feet, however, showed diagnoses of pes planus and metatarsalgia.  Symptoms that the examiner noted included pain in both feet subjectively and on manipulation, including discomfort wearing shoes and walking.  The Veteran had characteristic calluses on both feet.
The examiner did not discuss whether these symptoms or calluses were the result of the Veteran’s previously diagnosed right foot hallux valgus and or bunions.  In this regard, the Board finds that the Veteran’s claims file should be returned to the examiner for an addendum opinion in order to clarify the attribution of such symptoms, whether it be the Veteran’s service-connected right foot hallux valgus and bunions, or one of the non service-connected disabilities, such as the pes planus, metatarsalgia, or left foot hallux valgus.  A complete rationale for any opinions must be provided.
3. Skin Disability
The Veteran’s April 2015 VA examination indicated that he treats his skin disability with topical corticosteroids.  However, it is not indicated if such treatment is tantamount to systemic therapy, such as corticosteroids or other immunosuppressive drugs, as contemplated in the pre-August 13, 2018 version of 38 C.F.R. § 4.118, DC 7806 (2017).  See Burton v. Wilkie, ___Vet. App. ___, No. 16-2037, (September 28, 2018).  Because this claim was filed before August 13, 2018, the old version of the Rating Schedule applies and, thus, the issue of topical treatment in the Veteran’s case must be resolved.
The Veteran’s claims file should be returned to the April 2015 VA examiner so that an opinion may be provided that indicates whether the topical treatment operates by affecting the body as a whole in treating a veteran’s skin condition and whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.  A complete rationale for any opinions must be provided.
4. TDIU
As to the issue of entitlement to a TDIU, the increased rating claims being remanded herein are inextricably intertwined with the Veteran’s claim for a TDIU.  See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered).  The issues on remand must be addressed by the agency of original jurisdiction before the Board renders a decision on the TDIU, as such outcome will affect whether the Veteran’s entitlement is thus warranted.
Last, as this case must be remanded for the foregoing reasons, any recent treatment records, including VA records, should also be obtained. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992).
The matters are REMANDED for the following action:
1. Obtain and associate updated VA treatment records.
2. Thereafter, schedule the Veteran for a VA examination to determine the nature, severity, and extent of his current pathology associated with her service-connected bilateral knee arthritis. The record, to include a copy of the claims file, should be made available to the examiner. Any required testing should be performed and recorded.
The examiner should take into account the Veteran’s lay statements regard the worsening of his condition.
The examiner should conduct range of motion testing of the bilateral knees (expressed in degrees) in active motion, passive motion, weight-bearing and nonweight-bearing. The examiner should note the point at which pain begins in the range of motion. 
The examiner should also render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with the bilateral knees. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss of the bilateral knees due to pain and/or any of the other symptoms noted above during repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. 
The examiner should also describe the functional limitations resulting from the bilateral knees, to include during flare-ups. If flare-ups are not shown during the examination, the examiner should conduct efforts to obtain adequate information regarding the impairment resulting from flare-ups by alternative means, to include statements as to any such impairment by the Veteran himself.
A complete rationale for any opinions rendered must be provided.
3. Return the Veteran’s claims file to the VA examiner who conducted the April 2015 VA examination for the Veteran’s feet.  If that examiner is no longer available, provide the Veteran’s claims file to an examiner of like skill and qualification.  The claims file must be reviewed.  Any testing deemed necessary should be conducted.
The examiner should address whether the symptoms noted in the April 2015 VA foot examination, to include pain and characteristic calluses are attributable to the Veteran’s previously diagnosed right foot hallux valgus and/or bunions or whether they are attributable to one of the non service-connected disabilities, such as the pes planus, metatarsalgia, or left foot hallux valgus.
A complete rationale for any opinions rendered must be provided.
4. Return the Veteran’s claims file to the April 2015 VA skin examiner.  If that examiner is no longer available, provide the Veteran’s claims file to an examiner of like skill and qualification.  The claims file must be reviewed.  Any testing deemed necessary should be conducted.
The examiner must opine with regard to the following:
i. Whether the topical treatment operates by affecting the body as a whole in treating a veteran’s skin condition; and 
ii. Whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.  
A complete rationale for any opinions rendered must be provided.
(Continued on the next page)
 
5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated.  If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review.
 
APRIL MADDOX
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	R. Dodd, Counsel