Citation Nr: 18154309
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 15-08 944A
DATE:	November 29, 2018
ORDER
Service connection for chronic obstructive pulmonary disorder (COPD) is granted.
For the entire period on appeal, an initial rating of 70 percent, but no higher, for generalized anxiety disorder and bipolar disorder (an acquired psychiatric disability) is granted, subject to the laws and regulations governing payment of monetary benefits.
An initial rating in excess of 20 percent for a right shoulder disability is denied.
An initial rating in excess of 20 percent for a left shoulder disability is denied.
An initial rating in excess of 10 percent for a low back disability is denied.
Prior to December 12, 2013, an initial rating of 10 percent, but no higher, for bilateral plantar fasciitis is granted, subject to the laws and regulations governing payment of monetary benefits.
From December 12, 2013 to May 21, 2018, a compensable rating for bilateral plantar fasciitis is denied.
From May 22, 2018, forward, a 20 percent rating, but no higher, for bilateral plantar fasciitis is granted, subject to the laws and regulations governing payment of monetary benefits.
Prior to December 12, 2013, a compensable initial rating for paroxysmal tachycardia status post ablation (a heart disability) is denied.
From December 12, 2013, forward, a rating in excess of 10 percent for a heart disability is denied.
Prior to May 22, 2018, an initial rating of 10 percent for stomach and back scars is granted, subject to the laws and regulations governing payment of monetary benefits.
From May 22, 2018, forward, a compensable rating for stomach and back scars is denied.
An initial rating in excess of 10 percent for sinusitis is denied.
A separate compensable rating for headaches, secondary to service-connected sinusitis, is denied.
A compensable initial rating for chronic fatigue syndrome (CFS) is denied for the period prior to November 1, 2015.
A compensable initial rating for condyloma is denied.
REMANDED
Entitlement to service connection for a deviated nasal septum is remanded.
Entitlement to service connection for a jaw disability, including temporomandibular joint (TMJ) syndrome and bruxism, is remanded.
Entitlement to an initial compensable rating for rhinitis is remanded.
Entitlement to an initial compensable rating for right elbow tendonitis is remanded.
Entitlement to an initial compensable rating for status post removal of left great toenail is remanded.
Entitlement to an effective date prior to May 24, 2011 for the award of service connection for rhinitis is remanded.
Entitlement to an effective date prior to May 24, 2011 for the award of service connection for right elbow tendonitis is remanded.
Entitlement to an effective date prior to May 24, 2011 for the award of service connection for status post removal of left great toenail is remanded.
FINDINGS OF FACT
1. The Veteran’s COPD was initially diagnosed during service and is etiologically related to service.
2. For the entire appeal period, the Veteran’s acquired psychiatric disability more nearly approximated occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment.
3. The Veteran is right hand dominant.
4. For the entire period on appeal, the Veteran’s right and left shoulder disabilities were characterized by painful motion and more nearly approximated limitation of motion to shoulder level, but not midway between the side and shoulder level. 
5. For the entire period on appeal, the Veteran’s low back disability was not characterized by forward flexion 60 degrees or less, combined range of motion 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis, or incapacitating episodes.  
6. For the initial rating period prior to December 12, 2013, the Veteran’s bilateral plantar fasciitis manifested in moderate impairment, but not moderately severe or severe impairment, or loss of actual use of a foot.
7. From December 12, 2013 to May 21, 2018, the Veteran’s bilateral plantar fasciitis did not manifest in at least moderate impairment.
8. From May 22, 2018, forward, the Veteran’s bilateral plantar fasciitis manifested in moderately severe impairment, but not severe impairment or actual loss of use of a foot.
9. Prior to December 12, 2013, the Veteran’s heart disability was not characterized by permanent atrial fibrillation, at least one episode per year of paroxysmal atrial fibrillation, or other supraventricular tachycardia (SVT) documented by ECG or Holter monitor.
10. From December 12, 2013, forward, the Veteran’s heart disability was not characterized by paroxysmal atrial fibrillation or other SVT, with more than four episodes per year documented by ECG or Holter monitor.
11. For the initial rating period prior to May 22, 2018, the Veteran’s stomach and back scars were painful, but not unstable, more than six square inches in area, or productive of limitation of function of any affected part.
12. From May 22, 2018, the Veteran’s scars are not shown to be painful, unstable, more than six square inches in area, or productive of limitation of function of any affected part.
13. For the entire period on appeal, the Veteran’s sinusitis did not manifest in incapacitating episodes or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  The Veteran had not undergone surgery for the sinusitis.
14. For the entire period on appeal, the Veteran’s sinus headaches did not manifest in characteristic prostrating attacks or very frequent completely prostrating and prolonged attacks.
15. For the entire period on appeal, the Veteran did not exhibit CFS symptoms that wax and wane, are nearly constant, or are controlled by medication.
16. For the entire period on appeal, the Veteran’s condyloma did not manifest in a characteristic of disfigurement of the head, face, or neck; gross distortion or asymmetry of the head, face, or neck; visible or palpable tissue loss; or involvement of at least five percent of the Veteran’s total body area or exposed areas.
CONCLUSIONS OF LAW
1. The criteria for service connection for COPD have been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303 (2017).
2. The criteria for initial rating of 70 percent, but no higher, for an acquired psychiatric disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. 
§§ 4.7, 4.130, Diagnostic Code (DC) 9413 (2017).
3. The criteria for an initial rating in excess of 20 percent for a right shoulder disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, DC 5201 (2017).
4. The criteria for an initial rating in excess of 20 percent for a left shoulder disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5201 (2017).
5. The criteria for an initial rating in excess of 10 percent for a low back disability are not met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5237 (2017).
6. Prior to December 12, 2013, the criteria for an initial rating of 10 percent, but no higher, for bilateral plantar fasciitis have been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5284 (2017).
7. From December 12, 2013 to May 21, 2018, the criteria for a compensable rating for bilateral plantar fasciitis have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5284 (2017).
8. From May 22, 2018, forward, the criteria for a rating of 20 percent, but no higher, for bilateral plantar fasciitis have been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5284 (2017).
9. Prior to December 12, 2013, the criteria for a compensable initial rating for a heart disability have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. 
§§ 4.7, 4.104, DCs 7099-7010 (2017).
10. From December 12, 2013, forward, the criteria for a rating in excess of 10 percent for a heart disability have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.104, DCs 7099-7010 (2017).
11. Prior to May 22, 2018, the criteria for an initial rating of 10 percent, but no higher, for stomach and back scars have been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DCs 7800-7805 (2017).
12. From May 22, 2018, forward, the criteria for a compensable rating for stomach and back scars are not met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DCs 7800-7805 (2017).
13. The criteria for an initial rating in excess of 10 percent for sinusitis have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.97, DC 6512 (2017).
14. The criteria for a separate compensable rating for headaches, secondary to service-connected sinusitis, have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, DC 8100 (2017).
15. The criteria for an initial compensable rating for CFS prior to November 1, 2015, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.14, 4.89, DC 6354.
16. The criteria for an initial compensable rating for condyloma have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DCs 7899-7820, 7800, 7806 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran, who is the appellant in this case, served on active duty from June 1986 to June 1991, from August 2004 to January 2005, and from September 2007 to May 2011.  She also had over 8 years of inactive service, including with the Colorado Army National Guard.  
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado.
In a November 2012 rating decision, the RO denied entitlement to service connection for a lung condition claimed as a result of asbestos exposure; a bladder condition, secondary to the service-connected low back disability; a deviated nasal septum; and TMJ syndrome.  The RO also granted service connection for the following conditions, all effective May 24, 2011: acquired psychiatric conditions (rated 30 percent disabling); a right shoulder disability (rated 10 percent disabling); a left shoulder disability (rated 10 percent disabling); a low back disability (rated 10 percent disabling); bilateral plantar fasciitis (rated 0 percent disabling); tachycardia (rated 0 percent disabling); and residual scars of the stomach and back (rated 0 percent disabling).
In a February 2013 rating decision, the RO awarded service connection for chronic sinusitis with headaches (rated 10 percent disabling from May 24, 2011); condyloma (rated 0 percent disabling from May 24, 2011); and CFS (rated 0 percent disabling from May 24, 2011).
In a March 2015 rating decision, the RO, in pertinent part, increased from 30 percent to 50 percent the rating assigned for the Veteran’s acquired psychiatric disorders, effective December 16, 2013.  The RO also increased from 0 percent to 10 percent the rating assigned for tachycardia, effective December 12, 2013.  As less than the maximum available benefits for a schedular rating were awarded and the separate ratings were not awarded for the entirety of the claims period, the claims remain before the Board.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993).  
In an August 2015 rating decision, the RO severed service connection for CFS, effective November 1, 2015.  The Veteran did not appeal this decision and it became final.  Therefore, the Board will only consider the period prior to November 1, 2015 in determining whether an increased rating for CFS is warranted.
In a June 2018 rating decision, the RO increased the ratings for right and left shoulder disabilities from 10 percent to 20 percent, effective May 24, 2011.  The RO also increased the rating for the Veteran’s acquired psychiatric disorders from 50 percent to 70 percent, effective May 2, 2018.  As less than the maximum available benefits for a schedular rating were awarded and the separate ratings were not awarded for the entirety of the claims period, the claims remain before the Board.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993).
After reviewing the contentions and evidence of record, the Board finds that the issues are more accurately stated as listed above.  The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant makes a claim, he or she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled.  See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing symptoms of the disability); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record).  Specifically, Veteran claimed service connection for asbestosis, which the Board has recharacterized as a claim of service connection for a lung condition.
The Board also considered whether an inferred request for a total disability rating based on individual unemployability (TDIU) has been raised under Rice v. Shinseki, 22 Vet. App. 447 (2009).  Here, the record reflects that the Veteran has been either working or in school throughout the period on appeal, and neither the Veteran nor the evidence raise the issue that she is unemployable on account of her service-connected disabilities.  Accordingly, a TDIU request has not been inferred.  See Roberson v. Principi, 251 F.3d 1378, 1384 (2001).  See also Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009) (requiring cogent evidence of unemployability).
The Veteran has another appeal before the Board.  Because that appeal involves an issue dependent on different law and facts, it is the subject of a separate decision. 
The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016).
1. Entitlement to service connection for a lung disability, claimed as asbestosis.
The Veteran seeks service connection for a lung disability, claimed as asbestosis.  
Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.  Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d). 
Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).
In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 
A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994).  Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation.  Barr v. Nicholson, 21 Vet. App. 303 (2007).  
Under 38 C.F.R. § 3.300(a), for claims received by VA after June 9, 1998, a disability will not be considered service-connected on the basis that it resulted from injury or disease attributable to the Veteran’s use of tobacco products during service.  38 C.F.R. § 3.300(a).  However, where a disease related to smoking is diagnosed during service, service connection may be established.  See 38 C.F.R. § 3.300(b).
When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.
As an initial matter, the Board notes that the Veteran claimed service connection for asbestosis, which the Board has recharacterized as a claim of service connection for a lung condition.  The Board notes that there is no evidence of record indicating a diagnosis of asbestosis.  See October 2011 VA examination report.  Furthermore, the Veteran is not competent to diagnose that she has asbestosis through her own lay assertions due to the medical complexity of the matter.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n.4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the disability where the disability is simple, for example a broken leg, and sometimes not, for example, a form of cancer”).  As such, the Board has recharacterized the claim to include any lung condition.
On review, the Board finds that service connection for a lung condition, including COPD, is warranted.  There is no evidence of a lung disability prior to the Veteran’s entrance into her last period of active service.  During a period of active service, she was diagnosed with COPD.  See November 2007 service treatment record.  The Board notes that the Veteran filed this claim for service connection within one month of her separation from active service.  
For these reasons, and resolving any reasonable doubt in her favor, the Board finds the Veteran’s COPD was diagnosed during a period of active service and is etiologically related to her miliary service.  Service connection is therefore granted.
Increased Ratings
Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities.  The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes.  38 U.S.C. § 1155; 38 C.F.R. § 4.1. 
The Veteran’s entire history is to be considered when making disability evaluations.  See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).  Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings.  Fenderson v. West, 12 Vet. App. 119, 126 (1999).
Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran.  38 C.F.R. § 4.3. 
When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing.  38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement.  See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011).  Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate.  See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). 
The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record.  Burton v. Shinseki, 25 Vet. App. 1 (2011).
Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran’s service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).
When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.
2. Entitlement to an initial rating in excess of 30 percent for an acquired psychiatric disability prior to December 16, 2013, in excess of 50 percent from December 16, 2013 to May 1, 2018, and in excess of 70 percent thereafter.
The Veteran is currently in receipt of a 30 percent initial rating for an acquired psychiatric disorder prior to December 16, 2013, a 50 percent rating from December 16, 2013 to May 2, 2018, and a 70 percent rating thereafter.  The acquired psychiatric disorder is rated under 38 C.F.R. § 4.130, DC 9411. The Veteran contends that higher ratings are warranted throughout the initial rating period on appeal.
All psychiatric disabilities are evaluated under a general rating formula for mental disorders.  A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as de-pressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events).
A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships.
A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships.
A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (ADLs) (including maintenance of mental and personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name.
In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability.  See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so).
Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5).  See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014.  Id.  VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014.  See 80 Fed. Reg. 53, 14308 (March 19, 2015). 
Here, the RO certified the Veteran’s appeal to the Board after August 4, 2014; therefore, the claim is governed by DSM-5 and the Global Assessment of Functioning scores are not to be used to assign a rating.   Golden v. Shulkin, 29 Vet. App. 221, 225 (2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where DSM-5 applies). 
When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran’s symptoms affecting his level of occupational and social impairment.  See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002).  The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation, but are not meant to be exhaustive.  Id. 
Turning to the evidence, a July 2008 service treatment record indicated that the Veteran had a history of phobia for driving in the highway.  
A February 2011 treatment record indicated that the Veteran had been very dysfunctional and was unable to cope with her work and life in general.  She was very anxious, sleepy all the time, tired, apathetic, depressed, lethargic, and having death wishes without suicidality.  She had been feeling overwhelmingly sad, fearful with poor focusing and poor concentration, very distractible, having some memory problems, excessively sleeping 12 to 13 hours per day, decreased appetite, loss of interest in her usual activities, and poor motivation.  She had been isolative, hopeless and helpless, anxious, having panic attacks with palpitations, shortness of breath, paresthesias, and inability to focus.  She left meetings when she was expected to remain seated and was often restless and fidgety.  She had difficulty unwinding and relaxing, and felt compelled to do things.  She had difficulty waiting her turn and she had problems with interrupting others when they speak.  
A May 2011 private treatment record indicated that the Veteran had symptoms of anxiety, including frequent worry about multiple things and panic attacks.  She was sleeping too much and felt like she was barely going through the motions with her job.  In retrospect, the Veteran thought she might have had a psychotic component because she recalled seeing shadows out of the corner of her eyes.  She had thoughts that she might be better off dead and had brief thoughts of driving her government vehicle into a train.  Residual signs and symptoms included persistent worry and anxiety, lack of enjoyment of life, and poor sleep.  She described mostly doing well, but every four to five months “hitting a blue spot.”
The Veteran was afforded a VA examination in October 2011.  Diagnoses of generalized anxiety disorder rand mood disorder not otherwise specified (NOS) were noted.  The examiner opined that it was not possible to differentiate what symptoms are attributable to each diagnosis, because the symptoms overlap and are comorbid.  The examiner opined that the Veteran’s acquired psychiatric disorders resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation.  The Veteran was working on a bachelor’s degree in business management, and had a degree in paralegal studies.  She lived alone with her dog, but her son visited often.  She was married once for almost 10 years and divorced in 1996.  She claimed that she and her ex-husband were still very close.  She had worked for the same company for 10 years, and in her current field for 18 years.  She denied any problems on the job, despite periods when the job was quite stressful.  She had developed significant avoidance behaviors due to anxiety.  She would not drive on highways due to a history of panic attacks when driving in busy places.  She avoided crowded busy areas, such as grocery stores. She avoided going on public transportation because it made her feel trapped and like she needed an easy way out.  She tried to park in discrete areas in order to make a quick exit from places. She had an avoidance for places where she felt boxed in. She had a history of some difficulty with her temper. She could be quite verbal and abrasive with others and was aware of this. Sometimes she was caught rolling her eyes or making faces at other people and this could interfere with her work relationships.  She was easily upset if she was criticized and felt herself become verbally defensive.  She would then attack someone before they attack her again.  She denied physical violence.  She described significant sadness and loneliness.  She recalled the most severe period of depression in January 2011 when she began to neglect her hygiene and stayed in bed for days at a time.  She started having thoughts of hurting herself when she would see a stray knife in the kitchen or when she was driving.  She could not recall when she was last seriously suicidal.  She denied any history of hallucinations, but reported having some peripheral visual illusions prior to her current medication regimen.  She reported that during this period of severe depression she was sleeping 14 to 16 hours per day and lost weight.
A January 2012 VA treatment note indicated that the Veteran reported being inclined to becoming hypomanic, with lots of energy, racing thoughts, pressured speech, and occasional irritable mood. Twice a year, from March to April and October to November, the Veteran crashed into a depressive mode that lasted from two weeks to a month.  She reported having sleep disturbance (sleeping too much), low energy, and a lack of motivation in taking care of herself.  She had to force herself to get up, brush her teeth, and take a shower so she could go to work.  When feeling depressed, the Veteran noted that she also “sees shadows from the sides of my eyes.”  
A June 2012 VA treatment note indicated that the Veteran had symptoms of irritability, “poor filter,” hypersexuality, racing thoughts, pressured speech, insomnia, and grandiosity.  She had two down periods every year from March to April and November to December.  During those periods, she is depressed, had decreased energy, sleeping more, suicidal thoughts, poor motivation, and lack of enjoyment.  She would have trouble doing basic activities of daily living.
The Veteran was afforded a VA examination in December 2012.  Symptoms of anxiety, chronic worry, irritability, intermittent insomnia, fatigue, and variable mood states with current low energy, interest and motivation levels were noted.  The examiner opined that the Veteran’s acquired psychiatric disorders resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to function. The Veteran was living with her adult son and reported that they got along very well.  She also lived with her pet dog.  She was still in touch with her ex-husband who sometimes visited.  She had gotten burned out with her job and decided to quit.  She was having trouble with a younger co-worker who she felt was disrespectful.  When one of the managers took leave, she had problems with communication with this younger co-worker who was somewhat inappropriate with her, so she decided that she did not want to do the work anymore.  She had returned to school and was enjoying studying sports events and production management.  She woke early in the morning and would walk her dog, do some house cleaning, and sometimes help a friend do some photography errands.  She often napped in the middle of the day for an hour or so.  She had school classes two days per week and went to the gym about three days per week.  Her appetite was poor.  She had applied for six different jobs since starting classes and wanted to find a part-time job while she was taking classes.  She reported ongoing problems with both anxiety and mood issues.  She did not have sleep issues.  She had three small panic attacks in recent months.  She stated that she had no intention of harming herself, but sometimes these images would cross her mind and upset her.  She had a tendency to multitask and be busy, but would then felt exhausted.  She reported that she usually felt most tired in the mid-afternoon.  A depression screening indicated that she had moderate to severe depression at the time of the examination.  She described significant irritability, difficulty with confrontations, a tendency to be verbally aggressive, and a tendency to overspend.  She had a history of some sexual acting out.  Her moods fluctuated throughout the year, such that she tended to be more depressed both in the winter and late spring.  On examination, her speech was somewhat pressured and her overall mood was anxious.  She presented as somewhat irritable, particularly when relating frustrations with the VA system and having to navigate it.  Her overall affect was slightly pressured and showed some psychomotor tension with restlessness.  She denied suicidal or homicidal ideation, intent, or plan, as well as auditory or visual hallucinations. 
A January 2013 VA treatment note indicated that the Veteran had difficulty with her “filter” and some irritability.
A May 2013 VA treatment note indicated that the Veteran made the Dean’s list in college and really liked her classes.  She liked working in study groups and was excited about her life.  She had a year left to finish her bachelor’s degree and was thinking about doing a master’s degree.
In December 2013, the Veteran was afforded a VA examination.  The examiner opined that her acquired psychiatric disorders resulted in occupational and social impairment with reduced reliability and productivity.  The Veteran lived with her adult son.  She maintained contact with her ex-husband.  She was working part-time at a job she had obtained in September 2013.  She was a member of the United States Army Reserves and undergoing a medical board.  She was taking classes.  She tried to stay busy “tearing up pallets and making furniture,” and was painting her recently purchased home.  She tried to stay physically busy, including doing laundry and sometimes lifting weights.  She usually napped for about an hour or so per day and would set her alarm so that she did not nap too long.  She described ongoing problems with anxiety and mood.  She had recently been diagnosed with bipolar disorder.  She tended to worry about things in her life that she could not control.  She had intermittent feelings of panic.  She visited the emergency room in May 2013 because she felt that she was “losing control.”  She recalled being upset, angry, and full of rage towards the “system” due to prolonged medical board process and her perceived lack of control in influencing it.  She described physical aggression if she were drinking in past, but this had not occurred in many years since being sober.  She reported feeling in May 2013 that maybe she would be better off dead.  On examination, her mood was mildly dysphoric.  Her symptoms included depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, and disturbances of motivation and mood.  
A January 2014 VA treatment record indicated that the Veteran reported having increased panic attacks for one month, with at least two a week.  She reported that her panic attacks were coming more often and with more intensity over the last 30 days.  She reported not being able to take a walk due to irrational fears and anxiety.  She denied any work-related issues.
A September 2014 VA treatment note indicated that the Veteran spent the weekend volunteering for an art project in the community.  She continued full-time classes in sports management and was planning a trip with her son to visit her ex-husband.
A January 2015 VA treatment note indicated that the Veteran reported recently having episodes of panic attack with increased heart rate.
A June 2015 VA treatment note indicated that the Veteran had completed her third bachelor’s degree and was doing a three-month internship.  She reported some increase in anxiety and feeling more energized over the past few months.  She attributed this to the internship and putting pressure on herself to do an excellent job.  
A July 2015 VA treatment note indicated that the Veteran was taken to the emergency department after calling the crisis hotline that morning with increasing panic attacks.  She reported relationship issues, ongoing depression, and trouble coping.
In May 2018, the Veteran was afforded a VA examination.  She reported having a driving phobia, such that she avoided driving on the highway.  She was anxious about being in open spaces and feared having panic attacks.  She was hypervigilant and avoided situations that would lead to anxiety.  She was agitated, challenged people, and did not always get along with people at work.  She continued to have hypomanic episodes.  She talked rapidly and was irritable.  Her last depressive episode was six months prior.  She had poor judgment.  She asked a coworker to live with her, which did not go well due to poor boundaries.  She was impulsive in her relationships at work and home and had poor frustration tolerance.  The examiner opined that the Veteran’s acquired psychiatric disorder symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.  Since October 2015, she had worked at a call center.  She completed a master’s degree in 2016 in Business Administration.  She had poor boundaries, poor frustration tolerance, and poor impulse control.  She was easily agitated at work.  She had difficulty with the lack of structure at work, became overwhelmed, and had been counseled about her inappropriate behavior at work.  She had symptoms of depressed mood, anxiety, suspiciousness, panic attack smore than once a week, near continuous panic or depression affecting her ability to function, chronic sleep impairment, mild memory loss, speech intermittently illogical, obscure, or irrelevant, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to stablish and maintain effective relationships, and suicidal ideation.  
Based on this body of evidence, the Board finds that for the entirety of the initial rating period on appeal, the Veteran’s acquired psychiatric disorder more nearly approximates the criteria for a 70 percent rating.  her symptoms include intermittent depression; anxiety with panic attacks a few times a week affecting the ability to function appropriately and effectively; sleep impairment; hypervigilance, suicidal ideation; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively;  speech intermittently illogical, obscure, or irrelevant; impaired impulse control (wanting to punch people); some memory impairment; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships.  The evidence clearly shows her difficulties getting along with others in the work setting.  Her anger and irritability affect her at work, despite her success in academic environments.   Although the Veteran’s symptoms fluctuated in severity throughout the period on appeal, the Board finds that the Veteran’s overall disability picture has been consistent with the criteria for a 70 percent rating.  Resolving all reasonable doubt in the Veteran’s favor, the Board concludes that her acquired psychiatric disorder symptoms result in occupational and social impairment with deficiencies in most areas, warranting a 70 percent rating. 
A higher rating of 100 percent is not warranted.  The Board notes that total occupational and social impairment generally requires symptoms severe enough to severely distort the individual’s perception of reality, which is not shown by the record.  She has continuously appeared oriented and generally cooperative, albeit angry, during her examinations and outpatient visits.  She has not displayed gross impairment in thought processes or communication; persistent delusions or hallucinations; or grossly inappropriate behavior.  Moreover, although she reports memory loss, she is not shown to have had memory loss for names of close relatives, own occupation, or own name.  Although she has reported some visual hallucinations and periods of being unable to perform activities of daily living, these have been very infrequent and acute in nature.  While she is socially impaired, she is nonetheless capable of maintaining relationships with her family members, indicating that impairment is not total.  Lastly, she has been found capable of managing her own financial affairs and is currently employed. Thus, total occupational and social impairment is not demonstrated.
3. Entitlement to an initial rating in excess of 20 percent for a right shoulder disability.
The Veteran is in receipt of a 20 percent initial rating for a right shoulder disability.  She contends that a higher rating is warranted.  
The Veteran’s right shoulder disability is rated under 38 C.F.R. § 4.71a, DC 5201, applicable to limitation of motion of the arm.  
As a foundational matter, ratings based on function impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major.  38 C.F.R. § 4.69.  The medical evidence in this case reflects that the Veteran is right-hand dominant.  See October 2011 VA examination report.  Therefore, her right upper extremity will be considered the major extremity. 
In terms of the pertinent rating criteria, DCs 5200 through 5203 address disability ratings for the shoulder and arm.
DC 5200 provides for the evaluation of a shoulder or arm disability if there is ankylosis of the scapulohumeral articulation.  As there is no evidence that the Veteran has ankylosis of the right shoulder, DC 5200 is not for application.
DC 5201 provides for a 20 percent rating for limitation of major arm motion at the shoulder level, a 30 percent rating for limitation of the major arm to midway between the side and shoulder level, and a maximum, 40 percent rating for limitation of the major arm to 25 degrees from the side.  38 C.F.R. § 4.71a. 
DC 5202 is applicable to impairment of the humerus.  As there is no evidence that the Veteran has impairment of the humerus of the right shoulder, DC 5202 is not for application.
DC 5203 provides for a 10 percent rating for malunion of the clavicle or scapula or nonunion of the clavicle or scapula without loose movement.  A 20 percent rating is warranted for nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula.  DC 5203 provides that the shoulder disability may alternatively be rated on impairment of function of the contiguous joint.  As there is no evidence that the Veteran has impairment of the clavicle or scapula of the right shoulder, DC 5203 is not for application.
Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees.  38 C.F.R. § 4.71, Plate I.  In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction.  See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003).
Turning to the evidence, a March 2011 service treatment record indicated that the Veteran had right shoulder pain with push-up activities, but her x-rays were normal.
A March 2011 service treatment record indicated that the Veteran had right shoulder pain with locking, popping, grating, and impingement.  She also had numbness of the limbs.
The Veteran was afforded a VA examination in October 2011.  She reported symptoms of stiffness, giving way, lack of endurance, locking and pain.  She had flare-ups as often as twice a day and each time lasted for two weeks.  Flare-ups manifested as pain when sleeping and limitation of motion, such that she could not move her arm while sleeping.  She also experienced locking in place after doing push-ups.  On examination, there were no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, or drainage.  There was no subluxation or ankylosis.  Flexion was to 180 degrees with pain at 170 degrees.  Abduction was to 180 degrees with pain at 140 degrees.  Internal and external rotation were to 90 degrees with pain at 90 degrees.  There was no additional loss of range of motion or joint function after repetitive use.  
In May 2018, the Veteran was afforded a VA examination.  She reported that “it is an effort” to take off her shirt.  She had shoulder pain.  The pain discouraged pointing and lifting, especially lifting above the shoulders.  On examination, flexion was 180 degrees, abduction was 180 degrees, external rotation was 90 degrees and internal rotation was 75 degrees.  The range of motion itself did not contribute to a functional loss.  Pain was noted on all ranges of motion.  There was objective evidence of modest tenderness to palpation of the right anterior shoulder.  There was objective evidence of crepitus.  There was evidence of pain with weight bearing.  There was no additional loss of function or range of motion after three repetitions.  The Veteran was not examined immediately after repetitive use over time, and the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.  Pain, fatigue, and lack of endurance significantly limited functional ability with repeated use over a period of time, such that flexion was 160 degrees, abduction was 160 degrees, external rotation was 80 degrees, and internal rotation was 65 degrees.  The Veteran was not examined during a flare-up and did not report experiencing flare-ups.  Additional contributing factors of disability included less movement than normal and pain with reaching, pointing, lifting, carrying, pushing, and pulling.  She experienced pain when driving a car.  Muscle strength testing was normal and there was no muscle atrophy.  There was no ankylosis.  A rotator cuff condition was not suspected.  A Hawkins impingement test was positive.  Shoulder instability, dislocation or labral pathology was not suspected.  There was no history of mechanical symptoms or recurrent dislocation.  A clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition was not suspected.  The Veteran did not have a condition or impairment of the humerus.  The Veteran stated that she had pain with elevation of the shoulder, with reaching or pointing.  It was difficult to lift her arm above shoulder level.  
Based on a review of the evidence, both lay and medical, the Board finds that a rating in excess of 20 percent under DC 5201 is not warranted, as the evidence reflects that Veteran’s right shoulder adduction and flexion were consistently greater than 25 degrees to the side. In addition, the Veteran’s right shoulder disability pain has been intermittent, and the evidence reflects that any loss of range of motion or functional impairment has not met or approximated the criteria for a rating in excess of 20 percent.  Thus, the Board finds that the current 20 percent rating contemplates the Veteran’s functional impairment of painful motion, and less movement than normal.
For these reasons, the Board finds the preponderance of evidence supports a finding that a rating in excess of 20 percent for a right shoulder disability is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.
4. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability.
The Veteran is in receipt of a 20 percent initial ratings for right and left shoulder disabilities.  She contends that higher ratings are warranted.  
The Veteran’s left shoulder disability is rated under 38 C.F.R. § 4.71a, DC 5201, applicable to limitation of motion of the arm.  
As a foundational matter, ratings based on function impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major.  38 C.F.R. § 4.69.  The medical evidence in this case reflects that the Veteran is right-hand dominant.  See October 2011 VA examination report.  Therefore, her left upper extremity will be considered the minor extremity.
In terms of the pertinent rating criteria, DCs 5200 through 5203 address disability ratings for the shoulder and arm.
DC 5200 provides for the evaluation of a shoulder or arm disability if there is ankylosis of the scapulohumeral articulation.  As there is no evidence that the Veteran has ankylosis of the left shoulder, DC 5200 is not for application.
DC 5201 provides for a 20 percent rating for limitation of minor arm motion at the shoulder level, a 20 percent rating for limitation of the minor arm to midway between the side and shoulder level, and a maximum, 30 percent rating for limitation of the minor arm to 25 degrees from the side.  38 C.F.R. § 4.71a. 
DC 5202 is applicable to impairment of the humerus.  As there is no evidence that the Veteran has impairment of the humerus of the left shoulder, DC 5202 is not for application.
DC 5203 provides for a 10 percent rating for malunion of the clavicle or scapula or nonunion of the clavicle or scapula without loose movement.  A 20 percent rating is warranted for nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula.  DC 5203 provides that the shoulder disability may alternatively be rated on impairment of function of the contiguous joint.  As there is no evidence that the Veteran has impairment of the clavicle or scapula of the left shoulder, DC 5203 is not for application.
Turning to the evidence, the Veteran was afforded a VA examination in October 2011.  The left shoulder showed signs of tenderness.  There were no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, or drainage.  There was no subluxation or ankylosis.  On examination, flexion was 180 degrees with pain at that point.  Abduction was 180 degrees with pain at 170 degrees.  Internal and external rotation were both 90 degrees, with pain at that point.  There was no additional loss of range of motion or joint function after repetitive use.
In May 2018, the Veteran was afforded a VA examination.  She reported that “it is an effort” to take off her shirt.  She had shoulder pain.  The pain discouraged pointing and lifting, especially lifting above the shoulders.  On examination, flexion was 180 degrees, abduction was 180 degrees, external rotation was 90 degrees and internal rotation was 75 degrees.  The range of motion itself did not contribute to a functional loss.  Pain was noted on all ranges of motion.  There was objective evidence of modest tenderness to palpation of the right anterior shoulder.  There was objective evidence of crepitus.  There was evidence of pain with weight bearing.  There was no additional loss of function or range of motion after three repetitions.  The Veteran was not examined immediately after repetitive use over time, and the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.  Pain, fatigue, and lack of endurance significantly limited functional ability with repeated use over a period of time, such that flexion was 160 degrees, abduction was 160 degrees, external rotation was 80 degrees, and internal rotation was 65 degrees.  The Veteran was not examined during a flare-up and did not report experiencing flare-ups.  Additional contributing factors of disability included less movement than normal and pain with reaching, pointing, lifting, carrying, pushing, and pulling.  She experienced pain when driving a car.  Muscle strength testing was normal and there was no muscle atrophy.  There was no ankylosis.  A rotator cuff condition was not suspected.  A Hawkins impingement test was positive.  Shoulder instability, dislocation or labral pathology was not suspected.  There was no history of mechanical symptoms or recurrent dislocation.  A clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition was not suspected.  The Veteran did not have a condition or impairment of the humerus.  The Veteran stated that she had pain with elevation of the shoulder, with reaching or pointing.  It was difficult to lift her arm above shoulder level.  
Based on a review of the evidence, both lay and medical, the Board finds that a rating in excess of 20 percent under DC 5201 is not warranted, as the evidence reflects that Veteran’s left shoulder adduction and flexion were consistently greater than 25 degrees to the side. In addition, the Veteran’s left shoulder disability pain has been intermittent, and the evidence reflects that any loss of range of motion or functional impairment has not met or approximated the criteria for a rating in excess of 20 percent.  Thus, the Board finds that the current 20 percent rating contemplates the Veteran’s functional impairment of painful motion, and less movement than normal.
For these reasons, the Board finds the preponderance of evidence supports a finding that a rating in excess of 20 percent for a left shoulder disability is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.
5. Entitlement to an initial rating in excess of 10 percent for a low back disability. 
The Veteran is also in receipt of an initial 10 percent rating for a low back disability, and she contends that a higher rating is warranted.  
The Veteran’s low back disability is rated under 38 C.F.R. § 4.71a, DC 5237, which is applicable to lumbosacral strain.
Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (“General Formula”), or as intervertebral disc syndrome (IVDS) under the Formula for Rating IVDS Based on Incapacitating Episodes (“IVDS Formula”).  Ratings under the General Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.
The General Formula provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm or guarding not severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or, vertebral body fracture with loss of 50 percent or more of the height.  A 20 percent disability rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine.  A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine.  A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine.  Any associated objective neurologic abnormalities are to be evaluated separately under an appropriate diagnostic code.  38 C.F.R. § 4.71a.
As indicated, IVDS can alternatively be rated under the IVDS Formula.  Under the IVDS Formula, a rating of 20 percent is warranted for incapacitating episodes with a total duration of at least two weeks but less than four weeks during the past 12 months.  A rating of 40 percent is warranted for incapacitating episodes with a total duration of at least four weeks but less than six weeks during the past 12 months.  A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least six weeks during the past 12 months.  38 C.F.R. § 4.71a, DC 5243.  For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  Id. at Note (1).
Turning to the evidence, an October 2009 radiology report indicated that the Veteran had levoscoliosis or spasm of the lumbar spine.
A December 2010 service treatment record indicated that the Veteran complained of mid and lower back pains and stiffness, with occasional muscle spasms.  The pain was non-radiating.
A March 2011 service treatment record indicated that the Veteran’s mid and lower back pain remained the same, and the pain was non-radiating.  The pain was aggravated by running and prolonged sitting of greater than 30 minutes.  Range of motion was within normal limits, except for 20 percent end range extension limitation and mild axial L2-L5 pain at the end range of flexion.
A September 2011 private treatment note indicated that the Veteran was experiencing intermittent low back pain.  Aggravating factors were bending to lift, sitting, playing tennis and golf, and getting out of bed first thing in the morning.  She had full range of motion, but with pain.
The Veteran was afforded a VA examination in October 2011.  She reported limitation in her walking because of her spine condition and numbness in her legs.  She stated that, on average, she could walk two miles in 30 minutes.  She reported symptoms of stiffness, spasms, decreased motion and numbness.  She also reported symptoms of weakness of the spine, leg, and foot.  She had no bowel problems.  She urinated five times per day, approximately every hour.  She did not urinate during the night.  Urinary incontinence was reported.  She had moderate low back pain during flare-ups, with difficulty bending and twisting.  She did not report any incapacitating episodes.  The Veteran was unable to sit for long periods, could not exercise, and experienced pain when sleeping.  She was unable to vacuum, climb stairs, take out the trash, perform gardening activities, and push a lawn mower due to pain and difficulty twisting and bending.  On examination, the Veteran’s gait was normal.  Forward flexion was 90 degrees with no pain.  Extension was 30 degrees with pain at 20 degrees. Right and left lateral flexion were 30 degrees, with pain at 25 degrees.  Right rotation was 30 degrees with pain at that point.  Left rotation was 30 degrees with pain at 25 degrees.  There was no additional loss of range of motion or joint function after repetitive use.  There was no abnormal spinal curvature.
A June 2013 VA treatment note indicated that the Veteran complained of low back pain.  The symptoms were aggravated by sitting, lifting weights, squats, lunges, and twisting as in playing golf.  Physical therapy had helped.
The Veteran was afforded a VA examination in December 2013.  She reported feeling stiff and achy all the time.  There was no radiation of pain.  Forward flexion was 90 degrees, with no objective evidence of painful motion.  Extension was 30 degrees or greater, with objective evidence of painful motion at the endpoint.  Right and left lateral flexion were both 30 degrees or greater, with objective evidence of painful motion at the endpoints.  Right and left lateral rotation were both 30 degrees or greater, with objective evidence of painful motion at the endpoints.  There was no additional loss of range of motion after repetitive use testing.  However, there was pain on movement after repetitive use.  The Veteran had localized tenderness of the lumbar paraspinous muscles.  There were no muscle spasms or guarding of the low back.  Muscle strength testing was normal and there was no muscle atrophy.  Reflex and sensory examinations were normal.  The straight leg raising test was negative bilaterally.  The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy.  There was no ankylosis of the spine.  The Veteran did not have any other neurological abnormalities or findings related to a thoracolumbar spine condition, such a bowel or bladder issues.  The Veteran did not have IVDS of the thoracolumbar spine.  She did not use any assistive devices as a normal mode of locomotion.  The examiner opined that the Veteran’s low back disability did not impact her ability to work.  In addition, the examiner opined that, based on history and examination findings, no additional functional loss and/or range of motion loss was expected due to flares or pain/weakness/fatigability with repeated use.
A December 2014 VA treatment note indicated that the Veteran was not experiencing bowel or bladder incontinence, to include dribbling, and did not need to wear a continence containment garment.
In May 2018, the Veteran was afforded a VA examination.  She reported having daily low back pain.  On examination, forward flexion was 90 degrees, extension was 20 degrees, lateral flexion was 20 degrees bilaterally, and lateral rotation was 30 degrees bilaterally.  The range of motion contributed to a functional loss, specifically that it impacts her ability to bend, lift and carry, or push or pull.  Pain was noted for all ranges of motion on examination and caused functional loss. There was objective evidence of mild tenderness to palpation of the bilateral lumbar spine paraspinals.  There was evidence of pain with weight bearing.  There was no additional loss of function or range of motion after three repetitions.  The Veteran was not examined immediately after repetitive use over time and the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.  The examiner opined that pain, fatigue, and lack of endurance significantly limit functional ability with repeated use over a period of time.  The examiner described this limitation in terms of range of motion, with forward flexion of 80 degrees, extension of 15 degrees, lateral flexion of 15 degrees bilaterally, and lateral rotation of 25 degrees bilaterally.  The examination was not conducted during a flare-up and the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-up.  Pain, weakness, and incoordination did not significantly limit functional ability with flare-ups, since there were no flare-ups.  The Veteran did not have guarding or muscle spasm of the thoracolumbar spine.  She had additional contributing factors of disability, including less movement than normal, disturbance of locomotion, interference with sitting, and interference with standing.  Her low back disability impacted her ability to lift, carry, push, pull, and bend.  Muscle strength testing was normal and there was no muscle atrophy.  Reflex and sensory examinations were normal.  The straight leg raising test was negative bilaterally.  She did not have radicular pain or any other signs or symptoms due to radiculopathy.  There was no ankylosis of the spine.  She did not have any other neurologic abnormalities or findings related to the low back disability.  She did not have IVDS of the thoracolumbar spine.  Her low back disability impacted her ability to work.  She would have to stand at stretch at work and would require an ergonomic chair.  If sitting a lot, she would rise every hour to stretch.  She could stand in one place for 15 minutes.  She walked her dogs, but only for less than one mile.  If she ran on the treadmill, she would have a lot of pain at 200 meters, but would run through it.  She could not lift 50 pounds.  She would even avoid lifting 25 pounds.  She would have difficulty if she had to stand, ambulate, lift, or carry at work.  
Based on the above, the lay and medical evidence of record supports a finding that a rating in excess of 10 percent is not warranted for the low back disability at any point during the initial rating period on appeal.  At no point during the period on appeal has the Veteran’s forward flexion of the thoracolumbar spine been 60 degrees or less, including during flare-ups and after repetitive use, and the combined range of motion of the lumbar spine has been greater than 120 degrees at all times. In addition, the evidence indicates that the Veteran has not had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. There is no evidence of ankylosis. For these reasons, an initial rating in excess of 10 percent for a low back disability is not warranted.
The Board has also considered the Veteran’s reported impairment of spine function, including limitation of motion, disturbance of locomotion, interference with sitting and standing, pain, stiffness, decreased motion, weakness, difficulty twisting and bending, and numbness, and has also considered additional limitations of motion due to pain and repetitive use.  Even considering additional limitation of motion or function of the thoracolumbar spine due to pain or other symptoms such as stiffness, weakness, disturbance of locomotion, and interference with sitting and standing (see 38 C.F.R. §§ 4.40, 4.45, 4.59), the evidence does not show that the low back disability more nearly approximates the criteria for a higher rating for any period on appeal.  To the extent that the Veteran has reported experiencing functional impairment, this impairment is contemplated by the 10 percent rating assigned herein and is not of such severity that it could be characterized as ankylosis or flexion of 60 degrees or less, as is required for the next-higher rating.  As such, a higher rating based on pain and functional loss is not warranted.
The Board further finds that a higher disability rating is not warranted under the IVDS Formula.  38 C.F.R. § 4.71a, DC 5243.  The Veteran has not reported having any incapacitating episodes of her low back disability in the prior year or physician-prescribed bed rest.  The Veteran’s VA and private treatment records do not reflect any physician-prescribed bed rest for incapacitating episodes due to the low back disability.  For these reasons, the Board finds that a rating in excess of 10 percent based on incapacitating episodes is not warranted.  38 C.F.R. §§ 4.3, 4.7.
In addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code.  See 38 C.F.R. § 4.71a, General Rating Formula, Note (1).  The Veteran has not reported symptoms of radiculopathy.  While she has reported symptoms of bladder impairment, these symptoms appear to have been intermittent and of limited duration, as they were only noted in the October 2011 VA examination report.  Moreover, as the December 2013 and May 2018 VA examination reports indicate that the Veteran had no neurological manifestations of the low back disability, including radiculopathy and bladder impairment, and there is no evidence to the contrary, the Board finds that no further discussion of separate evaluations of the low back disability as manifested neurologically is warranted. 
For these reasons, the Board finds the preponderance of evidence supports a finding that a rating in excess of 10 percent for a low back disability is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.
6.  Entitlement to an initial compensable rating for bilateral plantar fasciitis.
The Veteran is currently in receipt of a noncompensable initial rating for bilateral plantar fasciitis under 38 C.F.R. § 4.71a, DC 5284, applicable to other foot injuries. She contends that a higher rating is warranted for the entire period on appeal.
Under DC 5284, a 10 percent rating is warranted for moderate impairment.  A 20 percent rating is warranted for moderately severe impairment.  A 30 percent rating is warranted for severe impairment.  A Note under DC 5284 provides that a 40 percent rating is warranted for actual loss of use of the foot.
Alternative and additional Diagnostic Codes for the feet are available under 38 C.F.R. § 4.71a are available for acquired pes planus, bilateral weak foot, acquired pes cavus, metatarsalgia, hallux valgus, hallux rigidus, hammer toes, and nonunion or malunion of the tarsal or metatarsal bones.  As the evidence does not indicate the presence of such manifestations, these Diagnostic Codes are not for application.
Turning to the evidence, a March 2009 service treatment record indicated that the Veteran had fallen arches on both feet.  Palpation of the foot revealed no abnormalities.  Foot motion was normal, with no pain.
The Veteran was afforded a VA examination in October 2011.  She reported experiencing localized pain that was aching and sharp.  She had no symptoms at rest.  She had weakness while standing or walking, and was unable to exercise.  Examination of the Veteran’s feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern.  The examiner characterized the Veteran’s bilateral plantar fasciitis as mild.  Examination of the feet revealed bilateral tenderness, but no painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness, or instability.  Alignment of the achilles tendon was normal bilaterally with weight-bearing.  There was no evidence of pes planus, pes cavus, hammer toes, Morton’s metatarsalgia, hallux valgus, or hallux rigidus.  The Veteran did not have any limitation with standing and walking, and did not require any type of support with her shoes.
The Veteran was afforded a VA examination in December 2013.  The VA examiner opined that the Veteran’s bilateral plantar fasciitis had resolved with no residuals.  She did not have any current symptoms of plantar fasciitis.  
In May 2018, the Veteran was afforded a VA examination.  She reported that she still had problems with her feet.  She reported having pain every day, but it was not necessarily worse in the morning upon arising.  She stated that the pain was “more like a burning sensation” and more on the sole at the forefoot than at the heel.  She had pain on use of her feet and the pain was accentuated on use.  She had pain on manipulation of the feet and the pain was accentuated on manipulation.  Arch supports were used and alleviated the symptoms.  She did not have extreme tenderness of the plantar surfaces of either foot.  The examiner stated that the Veteran’s bilateral foot pain on examination contributed to a functional loss, specifically pain on weight-bearing, disturbance of locomotion, and interference with standing.  The examiner stated that the Veteran had plantar fasciitis causing pain with standing, walking and weight-bearing bilaterally.  She had pain that significantly limited functional ability when the foot was used repeatedly over time, specifically that she tried to get off her feet at the end of the day because of pain.  The examiner noted that the Veteran would have trouble with a job that involved much standing or walking, but that her current job involved working at a desk.  She had foot pain when walking her dogs.
Based on review of the evidence, lay and medical, the Board finds that a 10 percent initial rating, but no higher. is warranted for the Veteran’s bilateral plantar fasciitis for the period prior to December 12, 2013.  This is based on her symptoms of localized pain and weakness while standing and walking.  See October 2011 VA examination report.  However, a rating in excess of 10 percent is not warranted for the period prior to December 12, 2013, as the October 2011 VA examination report indicated that the Veteran’s bilateral plantar fasciitis was mild in severity, did not result in any limitation with standing and walking, and did not require any type of support with her shoes.  
For the period from December 12, 2013 to May 21, 2018, the Board finds that a 0 percent rating is warranted under DC 5284 for the Veteran’s bilateral plantar fasciitis.  This is based on the December 2013 VA examination report indicating that the Veteran’s bilateral plantar fasciitis had resolved with no residuals and the Veteran did not have any current symptoms.  
For the period from May 22, 2018, forward, the Board finds that a rating of 20 percent, but no higher, is warranted for the Veteran’s bilateral plantar fasciitis under DC 5284.  This is based on the May 2018 VA examination report indicating that the Veteran had current symptoms of bilateral plantar fasciitis, including daily pain with standing, walking, and weight-bearing, resulting in significantly limited functional ability with repeated use over time.   However, a rating in excess of 20 percent is not warranted because the Veteran’s functional impairment was no more than moderate, as she was still able to walk her dogs and function during the day.   
7. Entitlement to an initial compensable rating for a heart disability prior to December 12, 2013, and a rating in excess of 10 percent thereafter.
The Veteran is currently in receipt of a noncompensable initial rating for a heart condition under 38 C.F.R. § 4.104, DC 7099-7010, applicable to supraventricular arrhythmias.  She contends that a higher rating is warranted for the entire period on appeal.
Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  38 C.F.R. § 4.27.  When an unlisted condition is encountered, as with paroxysmal tachycardia status-post ablation, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  38 C.F.R. § 4.20.  According to the policy in the Rating Schedule, when a disability is not specifically listed, the Diagnostic Code will be “built up,” meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be “99.”  38 C.F.R. § 4.27.
Under DC 7010, a 10 percent rating is warranted for permanent atrial fibrillation (lone atrial fibrillation), or one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A 30 percent rating is assigned for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor.  Given that the Veteran’s heart condition is a type of intermittent tachycardia, the Board finds DC 7010 to be the most appropriate diagnostic code for rating this disability.
Turning to the evidence, a March 2011 service treatment record indicated that the Veteran had a history of SVT status post slow pathway ablation in 2010.  She also had a heart catherization done in 2010 with normal results.  There were no recurrent tachypalpitations, no syncope, and no chest pain.  Since the ablation, the Veteran had not had any recurrent symptoms.  She was released for full duty, with no restrictions.
The Veteran was afforded a VA examination in October 2011.  She reported no symptoms of angina, shortness of breath, fatigue, dizziness, or syncope attacks.  She reported no congestive heart failure.  She had a heart ablation in May 2010 and had been asymptomatic since September 2010.
The Veteran was afforded a VA examination in December 2013.  The Veteran had a history of SVT with intermittent frequency and no episodes in the past 12 months.  The VA examiner stated that this disability was in stable condition since ablation without recurrence.
In May 2018, the Veteran was afforded a VA examination.  The VA examiner noted the Veteran’s history of heart symptoms and treatment, but stated that she had not had any issues since 2010 and had no current SVT symptoms.  
Based on a review of the evidence, lay and medical, the Board finds that an initial compensable rating is not warranted for the Veteran’s heart condition for the period prior to December 12, 2013.  The evidence consistently indicated that the Veteran has not had any heart condition symptoms since September 2010, prior to her discharge from service.  As such, an initial compensable rating is not warranted for the period prior to December 12, 2013, as there was no current disability or functional impairment during that period.
In addition, the Board finds that a rating in excess of 10 percent is not warranted for the period from December 12, 2013, forward.  Throughout this period, the evidence does not indicate that the Veteran had paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor.  As such, a rating in excess of 10 percent is not warranted for the period from December 12, 2013, forward.  
For these reasons, the Board finds the preponderance of evidence supports a finding that an initial compensable rating for a heart condition is not warranted, for the initial rating period prior to December 12, 2013, and a rating is excess of 10 percent is not warranted for the period from December 12, 2013, forward. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.
8. Entitlement to an initial compensable rating for scars.
The Veteran is in receipt of a noncompensable initial rating for scars of the stomach and back under 38 C.F.R. § 4.118, DC 7805.  She contends that a higher rating is warranted. 
DC 7805 provides that other scars (not otherwise considered under the DCs 7800-7804) are to be rated according to their disabling effects under an appropriate diagnostic code.  See 38 C.F.R. § 4.118, DC 7805.
DC 7800 rates scars of the head, face, or neck based upon disfigurement, and does not apply in this case as the stomach and back scars are not located on the head, face, or neck.  38 C.F.R. § 4.118. 
Under DC 7801, scars other than on the head, face, or neck that are deep or cause limited motion are rated as 10 percent disabling for areas exceeding 6 square inches (39 square centimeters), 20 percent disabling for areas exceeding 12 square inches (77 square centimeters), 30 percent disabling for areas exceeding 72 square inches (465 square centimeters), and 40 percent disabling for areas exceeding 144 square inches (929 square centimeters).  Note (2) under DC 7801 provides that a deep scar is defined as one associated with underlying soft tissue damage.  Id.
DC 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent evaluation. 10 percent is the only rating assignable under DC 7802.  A superficial scar is one not associated with underlying soft tissue damage.  Note (2) under that code provides that if multiple qualifying scars are present, a separate evaluation is assigned for each affected extremity based on the total area of the qualifying scars that affect that extremity.  Id.
Under DC 7804, a 10 percent rating is warranted for 1 or 2 scars that are unstable or painful.  A 20 percent rating is warranted for 3 to 4 scars that are unstable or painful.  A 30 percent disability rating is warranted for 5 or more scars that are unstable or painful.  Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.  Note (2) provides that 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.
Based on a review of the evidence, both lay and medical, the Board finds that a 10 percent initial rating under DC 7804 for the scars of the stomach and back is warranted for the period prior to May 22, 2018.  This is based on the October 2011 VA examination report indicating that the two scars were painful.  While the Veteran reported skin breakdown as often as four times per week, the Board does not find that such breakdown is necessarily indicative of frequent loss of covering of skin.  The examiner found no objective evidence of tissue damage, pain, inflammation, edema, keloid formation, disfigurement, or skin breakdown.  For these reasons, and because there were only two painful scars, a rating in excess of 10 percent is not warranted under DC 7804.
The Board however finds that a rating in excess of 10 percent for the stomach and back scars is not warranted for any part of the initial rating period prior to May 22, 2018. The October 2011 VA examination report indicates that the scars are not of the face or neck; therefore, a compensable rating is also not warranted under DCs 7801 and 7802. Finally, the evidence of record, including the October 2011 VA examination report, does not indicate the scars are productive of limitation of function; therefore, a compensable rating is not warranted under DC 7805.
For the period from May 22, 2018, forward, the Board finds that a noncompensable rating is warranted under DC 7804 for the Veteran’s stomach and back scars.  This is based on the May 2018 VA examination report indicating that the Veteran’s stomach and back scars were no longer painful or unstable.  In addition, the Board finds that a compensable rating for the Veteran’s stomach and back scars is not warranted from May 22, 2018, forward, under DCs 7801, 7802, and 7805, as the evidence of record, including the May 2018 VA examination report, indicates that the scars are not more than 144 square inches in area, deep, or productive of limitation of function.
In summary, the Board finds that a 10 percent rating is warranted for the period prior to May 22, 2018, for the Veteran’s painful scars.  The Board further finds that the weight of the evidence does not support a rating in excess of 10 percent prior to May 22, 2018, or a compensable rating thereafter, for the scars of the stomach and back.  As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply.  38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.
9. Entitlement to an initial rating in excess of 10 percent for sinusitis with headaches.
The Veteran is currently in receipt of a 10 percent initial rating for sinusitis with headaches under 38 C.F.R. § 4.97, DC 6512, applicable to frontal, chronic sinusitis.  She contends a higher rating is warranted.
Under DC 6512, a noncompensable or zero percent rating is assigned where sinusitis is detected by x-ray only.  A 10 evaluation is assigned where there are 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.  A 30 percent evaluation is assigned where there are 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.  A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or when there is near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries.  
Turning to the evidence, a March 2011 service treatment record indicated that the Veteran had a history of sinusitis and her voicing problem was getting worse.  She was having a hard time breathing.  A CT scan revealed moderate chronic sinusitis of the left maxillary area.
The Veteran was afforded a VA examination in October 2011.  She reported having sinus problems six times per year, with each episode lasting for two weeks.  She was incapacitated as often as three times per year and each incident lasted two weeks.  She had headaches with sinus episodes, as well as interference with breathing through the nose, hoarseness of the voice, pain and crusting.  There was no purulent discharge from the nose.  She had difficulty sleeping due to throbbing pain around her eyes and in her temples.  The headaches were described as pain in the temples, jaw, forehead, and cheekbones.  She could work with the headaches, but required medication.  The headaches occurred an average of twice per month and lasted for four days.  The headaches resulted in difficulty sleeping.  Examination showed sinusitis present at the maxillary sinuses with tenderness, but no purulent discharge was noted.
The Veteran was afforded a VA examination in January 2013.  She reported getting headaches four times per year that lasted an average of four to five days.  Her current headache had continued for three weeks.  She had been diagnosed with a sinus infection three weeks ago.  The symptoms included pressure over her forehead, behind her eyes, and pain in both sides of the temples.  Her ears were also congested.  The Veteran indicated that she had been diagnosed with sinus infections two times per year.  The longest period that she had been treated for a sinus infection was 14 days.  The Veteran stated that she had trouble sleeping at night, in part due to her congested ears.  She had not been diagnosed with migraines. She stated that she would get prostrating headaches once or twice per year, lasting two to three days.  There were no symptoms of nausea or vomiting, only light sensitivity.  The headache got worse when she bent over, but exercise did not make it worse.  The examiner opined that the Veteran did not have characteristic prostrating attacks of migraine headache pain; however, she did have prostrating attacks of non-migraine headache pain that occurred less than once every two months.  She had tenderness to palpation and percussion in the frontal, maxillary, and temporal areas.  She reported getting recurrent sinus infections two to four times per year.  The examiner indicated that the Veteran currently had frontal sinusitis.  The veteran had four non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months.  She had not had incapacitating episodes of sinusitis requiring prolonged (four to six weeks) of antibiotic treatment in the past 12 months.   The examiner indicated that the Veteran had not had sinus surgery.  The examiner noted that the Veteran’s sinus headaches and blurred vision after 7:30pm associated with her sinuses affected her ability to concentrating while taking classes.
The Veteran was afforded a VA examination in December 2013.  She reported that she had not had a sinus infection since she had been in school since 2012.  She stated that her nasal congestion is constant throughout the year.  The Veteran had maxillary and frontal sinusitis.  She did not have any incapacitating or non-incapacitating episodes of sinusitis over the past year.  She had not had sinus surgery.  Sinus x-rays showed no evidence of acute sinusitis.  The sinusitis did not impact the Veteran’s ability to work.  
In May 2018, the Veteran was afforded a VA examination.  She reported needing a course of antibiotics for sinusitis at least three times per year.  She had headaches with sinus infections, as well as facial pressure and very congested bilateral nostrils.  She had symptoms of pain, tenderness, purulent discharge, and crusting.  She reported four non-incapacitating episodes of sinusitis in the past year, characterized by headaches, pain, and purulent discharge or crusting.  She had not had any incapacitating episodes.  She might miss one to two days of work a year because of a sinus infection, but usually worked through an infection.  
Based on a review of the evidence, lay and medical, the Board finds that an initial rating in excess of 10 percent is not warranted.  Throughout the appeal period, the Veteran has not been shown to have three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, nor has she been shown to have more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  At no time has she had sinus surgery.  As such, a rating in excess of 10 percent for sinusitis is not warranted.  
In the March 2015 substantive appeal, the Veteran raised the issue of whether a separate compensable rating should be assigned for the Veteran’s headaches associated with sinusitis.  
As an initial matter, the Board finds that the Veteran’s headaches associated with sinusitis are analogous to migraine headaches, which are rated under 38 C.F.R. § 4.124a, DC 8100.  The Board notes that DC 8100 is the only diagnostic code that specifically rates a type of headache.  
Under DC 8100, a 50 percent rating is warranted with very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. A 30 percent evaluation is warranted with characteristic prostrating attacks occurring on an average once a month, over the preceding several months. A 10 percent evaluation is warranted with characteristic prostrating attacks averaging once per two months, over the preceding several months. A noncompensable rating is warranted with less frequent attacks. 38 C.F.R. § 4.124a.
The Rating Schedule does not define “prostrating,” nor has the Court.  See Fenderson v. West, 12 Vet. App. 119 (1999) (quoting DC 8100 verbatim, but not specifically addressing the matter of what is a prostrating attack).  By way of reference, “prostration” is defined as “extreme exhaustion or powerlessness.”  See Dorland’s Illustrated Medical Dictionary 1531 (32nd ed. 2012).  Similarly, “prostrate” is defined as “physically or emotionally exhausted; incapacitated.”  See Webster’s II New College Dictionary 889 (2001). 
Further, “severe economic inadaptability” is also not defined in VA law.  See Pierce v. Principi, 18 Vet. App. 440, 446 (2004).  In addition, the Court has held that nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating.  Id.  In this regard, it was explained by the Court that if “economic inadaptability” were read to import unemployability, the appellant, should he or she meet the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating.  Id., citing 38 C.F.R. 
§ 4.16.  The Court discussed the notion that consideration must also be given as to whether the disability was capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability.  See Pierce, 18 Vet. App. at 446.  In this regard, VA conceded that the words “productive of” could be read to mean either “producing” or “capable of producing.”  Id. at 446-47.
Based on review of the evidence, lay and medical, the Board finds that a compensable rating is not warranted for the Veteran’s headaches under DC 8100, as the evidence has consistently indicated that her headaches are not prostrating.  See October 2011 and January 2013 VA examination reports.  In addition, the Veteran has not contended that her headaches are prostrating.  As such, a compensable rating for migraine headaches under DC 8100 is not warranted.
For these reasons, the Board finds that the weight of the evidence is against a separate compensable rating for headaches associated with sinusitis under DC 8100, as the criteria for a compensable 10 percent rating are not met.  As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 
10. Entitlement to an initial compensable rating for CFS.
The Veteran is in receipt of a noncompensable initial rating for CFS under 38 C.F.R. § 4.88b, DC 6354, applicable to CFS.  She contends that a higher rating is warranted for the entire period on appeal.  
DC 6354 provides that CFS includes debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms.  A 10 percent rating is assigned for symptoms that wax and wane, resulting in periods of incapacitation of at least one but less than two weeks total duration per year, or symptoms that are controlled by continuous medication.  A 20 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least two but less than four weeks total duration per year. 
A 40 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or the signs and symptoms wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year.  A 60 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year.  A 100 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care.  A Note to DC 6354 provides that, for the purpose of rating CFS, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician.  38 C.F.R. § 4.88b.
As an initial matter, the Board notes that via this decision the Veteran is in receipt of a separate 70 percent rating for acquired psychiatric disorders for the entirety of the appeal period.  Her acquired psychiatric disorder is rated under 38 C.F.R. § 4.130, DC 9434, and her 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships.  In addition, the criteria also contemplate symptoms of disturbances of motivation and mood, impairment of short- and long-term memory, mild memory loss, and chronic sleep impairment under the criteria for a rating of less than 70 percent.  Id.  As discussed below, the evidence is inconsistent as to whether the Veteran has a diagnosis of CFS and whether the Veteran’s symptoms of memory loss, cognitive impairment, and fatigue are attributable to CFS or the diagnosed acquired psychiatric disorders.  Therefore, in order to avoid pyramiding and in light of the fact that service connection for CFS has been severed based on a lack of current diagnosis effective November 1, 2015, the Board has attributed these symptoms to the Veteran’s service-connected acquired psychiatric disorders instead of the service-connected CFS. 
An April 2008 service treatment record indicated that the Veteran complained of fatigue.  She reported dizziness and lightheadedness.  She was placed on a profile to walk at her own pace and distance for two months while a cause was medically investigated.  The Veteran reported a lack of energy and stated that she felt her body trembling inside.
The Veteran was afforded a VA examination in October 2011.  The examiner noted that the Veteran needed to nap in the afternoon, so any job must accommodate this afternoon nap.  
The Veteran was afforded a VA Gulf War examination in January 2013.  The examiner opined that the Veteran had a current diagnosis of CFS.  The Board notes that the Veteran never served in Southwest Asia.  Continuous medication was not required for control of CFS.  The Veteran reported recurrent episodes of fatigue, with her worse episode in January 2011, when she was out of work for 30 days due to fatigue.  She received outpatient therapy for depression and death wishes.  She said she had to force herself to bathe and was sleeping 14 hours per day.  She was placed on antidepressants which helped, and did group therapy.  This was the only episode with this high level of fatigue and it resolved after a month.  Although less severe than the January 2011 episode, she continued to get daily fatigue requiring bed rest.  She stated that she had daily symptoms of fatigue that lasted about 10 minutes, until she takes a nap.  She had energy in the morning and then after three to four hours she becomes very fatigued and takes a nap for one and a half to two hours, which rejuvenates her.  She becomes tired again at about 8pm.  The examiner opined that the Veteran did not have debilitating fatigue that reduced her daily activity level to less than 50 percent of pre-illness level.  Her symptoms of CFS included sleep disturbance, neuropsychological symptoms, non-exudative pharyngitis, and cognitive impairment, including poor attention, inability to concentrate, forgetfulness, and confusion.  The symptoms waxed and waned.  The examiner opined that the Veteran’s CFS symptoms restricted routine daily activities by less than 25 percent of the pre-illness level.  The Veteran’s symptoms of CFS resulted in incapacitation, for a total duration of less than one week over the prior year.  The examiner noted that the Veteran stated that she missed 30 days of work at a time due to the fatigue and reported that it was hard to concentrate and focus when she had the bouts of fatigue during the day.  The examiner stated that the Veteran’s symptoms of CFS were not explained by a psychological disorder, specifically citing the December 2012 VA mental disorders examination report indicating that the Veteran had energy, interest, and motivations levels that were fairly good.
In December 2013, the Veteran was afforded a VA examination.  The examiner opined that based on the history of this claim, the Veteran does not meet the criteria for CFS.  Instead, her fatigue is a manifestation of her depression and poor sleep quality.
Based on review of the evidence, lay and medical, the Board finds that a compensable initial rating for CFS is not warranted.  As discussed above, the Veteran’s symptoms of fatigue, memory impairment, and cognitive impairment have been considered in rating her service-connected acquired psychiatric disorders.  Thus, in light of the prohibition on pyramiding, they cannot be considered in assigning a rating for CFS.  As such, there are no symptoms or functional impairments remaining to be considered in rating the CFS.  Thus, a compensable rating for CFS must be denied.  
For these reasons, the Board finds the preponderance of evidence supports a finding that an initial compensable rating for CFS is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.
11. Entitlement to an initial compensable rating for condyloma.
The Veteran is currently in receipt of a noncompensable initial rating for condyloma under 38 C.F.R. § 4.118, DC 7899-7820, applicable to infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic diseases).  She contends that a higher rating is warranted for the entire period on appeal.
Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  38 C.F.R. § 4.27.  When an unlisted condition is encountered, as with condyloma, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  38 C.F.R. § 4.20.  According to the policy in the Rating Schedule, when a disability is not specifically listed, the Diagnostic Code will be “built up,” meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be “99.”  38 C.F.R. § 4.27.
DC 7820 directs that the disability should be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801-7805), or dermatitis (DC 7806), depending upon the predominant disability. As the Veteran’s condyloma is not a scar, DCs 7801-7805 are not applicable. 
Thus, the Board will consider the appropriate rating for HSVII under DCs 7800, applicable to disfigurement of the head, face, or neck, and 7806, applicable to dermatitis. 
DC 7800 provides that a skin disorder with one characteristic of disfigurement of the head, face, or neck be rated 10 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling.  A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. 
Note (1) to DC 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: (A) Scar is 5 or more inches (13 or more cm.) in length; (B) Scar is at least one-quarter inch (0.6 cm.) wide at the widest part; (C) Surface contour of scar is elevated or depressed on palpation; (D) Scar is adherent to underlying tissue; (E) Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (F) Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (G) Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); and (H) Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.).
DC 7806 states that dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling.  A 30 percent rating is warranted for dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period.  A 60 percent rating is warranted for dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 
Turning to the evidence, the Veteran was afforded a VA examination in October 2011.  The skin disease was located on the Veteran’s face and genital area.  She did not have any exudation, ulcer formation, itching, shedding, or crusting.  She had not undergone any treatment over the prior 12 months.  The Veteran reported that she did not experience any overall functional impairment from this condition.  On examination, small condyloma were noted on both external labia.  
A July 2012 VA treatment note indicated that the Veteran did not have any lesions on her labia.
In a December 2012 addendum opinion, a VA examiner opined that the Veteran’s condyloma covered no exposed areas and less than five percent of her total body area.
In May 2018, the Veteran was afforded a VA examination.  The VA examiner stated that the Veteran’s condyloma had resolved and she no longer had any spots on the genitalia. 
Based on review of the evidence, lay and medical, the Board finds that an initial compensable rating is not warranted for condyloma under DC 7800, as the evidence does not reflect that the condyloma of the face was characterized by any characteristics of disfigurement or visible or palpable tissue loss.  To the contrary, while the October 2011 VA examination report indicated that the condyloma was located, in part, on the Veteran’s face, no significant disfigurement or tissue loss was noted and the December 2012 addendum opinion indicated that the Veteran’s condyloma covered no exposed areas.  As such, a compensable initial rating under DC 7800 is not warranted.  In addition, the Board finds that a compensable rating is not warranted under DC 7806 for the entire period on appeal.  This is based on the December 2012 VA addendum medical opinion indicating that the Veteran’s condyloma covered less than five percent of her total body area, as well as the May 2018 VA examination report indicating that the Veteran’s condyloma had resolved.  As such, a compensable rating under DC 7806 is not warranted for the entire period on appeal.
For these reasons, the Board finds the preponderance of evidence supports a finding that an initial compensable rating for condyloma is not warranted.  38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a.

REASONS FOR REMAND
Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  
1. Entitlement to service connection for a deviated nasal septum is remanded.
The Veteran was afforded a VA examination in December 2013.  The examiner stated that it was unclear based on the Veteran’s history if the deviated septum was acquired or not.  The Veteran reported a single traumatic event, but was unsure at what point the deviated septum was noted.  The Board notes that this VA medical opinion appears to be based on an incomplete medical history.  During service, the Veteran was diagnosed with a mild deviation of the nasal septum to the left.  See March 2011 service treatment record.  A December 2008 service treatment record indicated that the Veteran had a history of breaking her nose in childhood, with repeated, milder trauma in September 2007 and May 2008.  A March 2009 service treatment record indicated that the Veteran had recently had a septorhinoplasty and turbinoplasty.  A February 2011 psychiatric evaluation indicated that the Veteran had a septorhinoplasty in 1993.  As the December 2013 medical opinion did not consider all of this evidence, it is inadequate and remand is required to obtain a medical opinion that is based on the Veteran’s full medical history.
2. Entitlement to service connection for a jaw disability, including TMJ syndrome and bruxism, is remanded.
The Veteran was afforded a VA examination in October 2011.  The examiner opined that the Veteran did not have a TMJ disability, but attributed her muscle fatigue, joint pain, and boney remodeling of the left and right condyle to her active bruxism habit.  The examiner did not provide an opinion as to whether her bruxism is etiologically related to service.  In addition, in October 2013, the Veteran was diagnosed with TMJ disorder NOS.  Therefore, remand is required to obtain an adequate opinion as to the etiology of the Veteran’s TMJ disorder NOS and bruxism.
3. Entitlement to initial compensable ratings and effective dates prior to May 24, 2011 for the awards of service connection for rhinitis, right elbow tendonitis, and status post removal of left great toenail, is remanded.
In April 2015, the Veteran submitted a notice of disagreement as to the issues of entitlement to initial compensable ratings and effective dates prior to May 24, 2011 for the award of service connection for rhinitis, right elbow tendonitis, and status post removal of left great toenail.  To date, a statement of the case (SOC) has not been issued as it relates to these issues.  The Board is required to remand the claims for issuance of a SOC.  Manlicon v. West, 12 Vet. App. 238 (1999).  These matters are not before the Board at this time, and will only be before the Board if the Veteran timely files a substantive appeal of the issues after the SOC is issued.
The matters are REMANDED for the following action:
1. Issue a SOC on the issues of entitlement to initial compensable ratings for rhinitis, right elbow tendonitis, and status post removal of left great toenail, as well as the issues of entitlement to effective dates prior to May 24, 2011 for the awards of service connection for these issues.  The Veteran and her representative should be advised of the time limit for perfecting an appeal, and afforded such period of time to do so.  If she timely perfects an appeal in the matter, it should be returned to the Board.
2. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record.
3. Obtain an addendum medical opinion regarding the nature and etiology of the Veteran’s diagnosed deviated nasal septum.  The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner.  Another examination is not required; however, if the examiner indicates that he or she cannot respond to the Board’s questions without examination of the Veteran, another examination should be afforded to the Veteran.
The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current deviated nasal septum is related to or caused by service.
The examiner should note the following evidence:
a)	The March 2011 service treatment record reflecting a diagnosis of mild deviation of the nasal septum to the left.  
b)	The December 2008 service treatment record indicating that the Veteran had a history of breaking her nose in childhood, with repeated, milder trauma in September 2007 and May 2008.  
c)	The March 2009 service treatment record indicating that the Veteran had recently had a septorhinoplasty and turbinoplasty.  
d)	The February 2011 psychiatric evaluation indicating that the Veteran had a septorhinoplasty in 1993.  
A detailed rationale should be provided for the opinions rendered.  If the examiner cannot provide the requested information without resort to speculation, he or she must state the reasons why.
4. Obtain an addendum medical opinion regarding the nature and etiology of the Veteran’s jaw disability, including TMJ syndrome and bruxism.  The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner.  Another examination is not required; however, if the examiner indicates that he or she cannot respond to the Board’s questions without examination of the Veteran, another examination should be afforded to the Veteran.
The examiner is asked to provide the following opinions:
a)	Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current bruxism, is related to or caused by service?
b)	Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current TMJ syndrome is related to or caused by service?  
The examiner should note the October 2013 VA treatment record reflecting a diagnosis of TMJ disorder NOS.  
A detailed rationale should be provided for the opinions rendered.  If the examiner cannot provide the requested information without resort to speculation, he or she must state the reasons why.
5. After completing the above, and any other development deemed necessary, readjudicate the appeal as to the issues of entitlement to service connection for a deviated septum and a jaw disability, to include TMJ syndrome and bruxism.  If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and her representative, and return the appeal to the Board.
 
J. GALLAGHER
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Thomas, Associate Counsel