Citation Nr: 18154742 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 16-43 518 DATE: December 3, 2018 ORDER Entitlement to service connection for appendicitis is denied. Entitlement to a dental disorder for compensation purposes is denied. Entitlement to an initial compensable rating for a right little finger disability is denied. Entitlement to an initial compensable rating for sinusitis is denied. Entitlement to an initial rating of 30 percent for allergic rhinitis is granted. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to an initial compensable rating for dermatitis prior to September 23, 2016 and a rating in excess of 10 percent thereafter is denied. REMANDED Entitlement to service connection for a right elbow disorder is remanded. Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to an initial compensable rating for a left hip disability prior to September 23, 2016 and a rating in excess of 10 percent thereafter is remanded. Entitlement to an initial rating in excess of 10 percent for a left knee disability prior to September 23, 2016 and a rating in excess of 20 percent thereafter is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of appendicitis. 2. The record does not reflect the Veteran has a current dental disorder for which VA compensation may be paid; and the preponderance of the competent medical and other evidence of record is against a finding any current dental condition is due to in-service dental trauma. 3. The Veteran’s right little finger disability is not manifested by ankylosis, or by involvement of other fingers or the whole hand so as to warrant a compensable or separate rating. 4. The Veteran’s sinusitis is productive of only one non-incapacitating episode within a 12-month period. 5. For the entire appeals period, the Veteran’s allergic rhinitis is productive of polyps. 6. The Veteran’s diastolic pressure readings were predominantly less than 100 mm, and he does not require continuous medication for control. 7. For the period prior to September 23, 2016, the Veteran’s dermatitis affects less than 5 percent of the entire body or exposed areas. 8. For the period since September 23, 2016, the Veteran’s dermatitis affects at least 5 percent but less than 20 percent of the entire body or exposed areas. CONCLUSIONS OF LAW 1. The criteria for service connection for appendicitis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for residuals of a dental injury for compensation purposes are not met. 38 U.S.C. §§ 1110, 1131, 1712, 5107; 38 C.F.R. §§ 3.381, 4.150, 17.161. 3. The criteria for an initial compensable rating for a right little finger disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2017). 4. The criteria for an initial compensable rating for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.97, Diagnostic Code 6512 (2017). 5. The criteria are met for an initial rating of 30 percent for allergic rhinitis. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6522 (2017). 6. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2017). 7. The criteria for an initial compensable rating for dermatitis prior to September 23, 2016 and a rating in excess of 10 percent thereafter have not been met. 38 U.S.C. § 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.118, Diagnostic Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1989 to September 2013. Service Connection 1. Appendicitis The Veteran is seeking service connection for appendicitis. Specifically, he alleges that he has suffered from appendicitis since his in-service treatment. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110,1131; 38 C.F.R. § 3.303 (a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The question for the Board is whether the Veteran has this current disability that he claims began during service or is at least as likely as not related to an in-service injury, event, or disease. For the reasons discussed below, the Board concludes that the Veteran does not have current a diagnosis of appendicitis, or a disability pertaining to the appendix, and has not had a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records do show the Veteran was treated in November and December 2012 for possible appendicitis due to an acute inflammation of the appendix. However, surgery was not performed and the service treatment records indicate the Veteran was given medications and the symptoms subsided. There are no additional indications of treatment or complaints for the remainder of the Veteran’s service. However, since his separation from service in 2013, the available VA treatment records do not include any notations that the Veteran has sought treatment for a disease or disorder pertaining to the appendix during the appeals period. In connection with the Veteran’s claim for service connection, he was afforded a VA examination in February 2014. At that time, the VA examiner noted the in-service treatment but that a diagnosis of appendicitis was not given. Additionally, the VA examiner stated the Veteran had a normal abdominal examination and that there are no other physical findings to suggest a current intestinal disorder. There are no conflicting opinions of record. Additionally, to the extent the Veteran believes he currently suffers from appendicitis, he is not competent to provide a diagnosis in this case. The issue is medically complex and require specialized medical education pertaining to the gastrointestinal system, as well as the ability to interpret complicated diagnostic medical testing are required in order to render a diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The Board finds that the Veteran’s claims fail as he has not met the first element of service connection which is the requirement of a current diagnosis for the claimed disorders. In the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for appendicitis, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107 (b). As such, the claim must be denied. Dental Disorder The Veteran contends that he is entitled to compensation for dental implants during service. In the VA benefits system, dental disabilities are treated differently from medical disabilities. Generally, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses and periodontal disease will be considered service-connected solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment under the provisions of 38 C.F.R. Chapter 17. 38 C.F.R. § 3.381. Service connection may be awarded for missing teeth due to dental trauma or bone loss in service. The law and regulations also provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to a VA dental examination or outpatient dental treatment. See 38 U.S.C. § 171; 38 C.F.R. §§ 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). The Board notes that dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Given the nature of these disabilities, the Board finds that competent medical evidence is required to diagnose whether such is present, and, if so, the etiology thereof. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159 (a)(1). The Veteran’s service treatment records show he received dental treatment on a consistent basis from 2012 to 2013 during service, including orthodontic treatment. Specifically, he underwent a procedure for dental implants in June 2013. However, there is no evidence to suggest the in-service dental disorders treatment are the result of trauma to the head or neck necessitating dental treatment. Post-service VA treatment records show treatment with a dental hygienist in March 2014. However, the March 2014 VA treatment records do not indicate the Veteran sustained any trauma to the head or neck during service. There is no other post-service treatment of record. During his February 2014 VA examination, the VA examiner provided diagnoses of periodontal disease and unspecified malocclusion. It was noted the Veteran underwent in-service dental treatment for caries. Further, while orthodontic treatment was undertaken for the malocclusions, the VA examiner ultimately determined that the malocclusions were not trauma induced. The Board further finds the record does not reflect the Veteran has a current dental disorder for which VA compensation may be paid. As noted, the Veteran did receive dental treatment during service but there is no evidence that it was the result of trauma or disease (not periodontal). In fact, there is no evidence of record that shows the Veteran has ever been diagnosed with chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. Therefore, none of his dental treatment may be considered a disability for which compensation may be provided pursuant to 38 C.F.R. § 4.150. No competent medical evidence is otherwise of record which demonstrates a dental disorder for which VA compensation may be paid. Without such a disorder, the claim must be denied. See 38 U.S.C. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The Board further notes that even if the Veteran did have a dental disorder for which VA compensation may be paid, the claim would still be denied because the preponderance of the competent medical and other evidence of record is against a finding that he has any current dental condition due to in-service dental trauma. See Holbrook v. Brown, 8 Vet. App. 91 (1995) (The Board has the fundamental authority to decide a claim in the alternative.). Accordingly, a preponderance of the evidence is against a finding that service connection of dental disability for compensation purposes is warranted, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, Part 4. 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 the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The current appeals arose from the initially assigned rating, and consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Entitlement to an initial compensable rating for a right little finger disability The Veteran is seeking an initial compensable rating for his right little finger disability. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). A recent United States Court of Appeals for Veterans Claims (Court) decision addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The Veteran’s service-connected right little finger disability is rated under Diagnostic Code 5230. Under Diagnostic Code 5230, a maximum zero percent rating is assigned for any limitation of motion of the little finger (whether on the major (dominant) or minor (non-dominant) hand). 38 C.F.R. § 4.71a, Diagnostic Code 5230. Therefore, the Veteran is in receipt of the maximum disability rating available under Diagnostic Code 5230. The Board must also consider other potentially available Diagnostic Codes. Diagnostic Code 5227 applies to ankylosis of the ring or little finger, whether favorable or unfavorable, and whether on the dominant hand or not. The only available rating under this Diagnostic Code is also noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5227. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2017) pertains to traumatic arthritis. Under that code, traumatic arthritis is to be rated as degenerative arthritis. Ratings for degenerative arthritis are to be based on limitation of motion and, if noncompensable by that method, a rating of 10 percent is warranted for each major joint or group of minor joints affected. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). For rating purposes, a hand is considered a group of minor joints. 38 C.F.R. § 4.45 (f). Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against an initial compensable rating for the Veteran’s service-connected right little finger disability. Specifically, the Veteran has been rated at a noncompensable rating for his service connected right little finger disability for the entire appeals period. His VA treatment records do not show any complaints of ankylosis or that he has ever received treatment for a finger disability. The Veteran was provided VA examinations in February 2014 and September 2016. The February 2014 VA examiner diagnosed the Veteran with right little finger sprain with residual weakness. During both examinations, the Veteran denied flare-ups. Upon physical examination, the examiners did not find any evidence pain on motion and limitation of motion. He reported that he has weakened movement of the right little finger. The examiners both stated that the Veteran does not have ankylosis of any fingers. Based on the evidence described above, the Board finds that the Veteran’s right little finger disability does not warrant a compensable rating. As stated above, Diagnostic Code 5230 does not provide for a compensable rating. 38 C.F.R. § 4.71, Diagnostic Code 5230. The Board acknowledges the Veteran’s report of limited motion, but the provisions of 38 C.F.R. § 4.59 do not apply when the applicable Diagnostic Code does not provide a compensable rating. Sowers v. McDonald, 27 Vet. App. 472 (2016). Therefore, a compensable rating under Diagnostic Code 5230 is not warranted. The Board has also considered whether a compensable rating might be available under another Diagnostic Code. As the Veteran retains some mobility in his right little finger, by definition he does not manifest ankylosis of any form. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). Even if he did, as stated above, the Diagnostic Code for ankylosis of a fifth finger also does not provide for a compensable rating. 38 C.F.R. § 4.71a, Diagnostic Code 5227. There is also no evidence that the Veteran has arthritis. The Board recognizes the Veteran’s lay statements of pain in his right little finger. However, as stated above, under Diagnostic Code 5230, he is already in receipt of the maximum schedular disability rating available for limitation of motion of the right little finger. Thus, even when considering the Veteran’s complaints of pain, the requirements for a compensable disability rating for the right little finger are not met. Accordingly, the Board finds that the current noncompensable evaluation adequately compensates the Veteran for the pain and functional impairment caused by his service-connected disability. DeLuca, 8 Vet. App. at 202; 38 C.F.R. §§ 4.40, 4.45, 4.59. Further, to the extent either the February 2014 or September 2016 VA examinations failed to comply with the holdings in Correia or Sharp, either individually or collectively, such non-compliance is harmless error. In this respect, the Court in Johnston, supra, indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Johnston, 10 Vet. App. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). Thus, as the Veteran is in receipt of the maximum schedular rating based on limitation of motion and a higher rating requires ankylosis or other symptoms unrelated to limitation of motion, 38 C.F.R. § 4.40 and 4.45 are not for application. The Board finds that a preponderance of the evidence is against the Veteran’s claim for compensable rating for his service-connected right little finger disability. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to an initial compensable disability rating for sinusitis The Veteran’s sinusitis was grant service connection and assigned an initial, noncompensable rating under Diagnostic Code 6512, effective from October 1, 2013, the day after is separation from service. Under Diagnostic Code 6512, all forms of sinusitis are evaluated under the General Formula for Sinusitis (Diagnostic Codes 6510 through 6514). A 50-percent rating is appropriate following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A 30-percent rating is appropriate with 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 rating of 10 percent is appropriate with 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 noncompensable rating is assigned where sinusitis is detected by X-ray only. Note: An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6512. The Veteran was initially examined by VA in February 2014 in connection with his claim for service connection for this disability. At that time, the examiner provided a diagnosis of sinusitis and noted the Veteran had not had any treatment in the past year. The Veteran reported pain and tenderness, and reports one non-incapacitating episode in the last 12 months characterized by headaches, pain and purulent discharge or crusting. There is no evidence of any incapacitating episodes in the past 12 months. Finally, the examiner did not indicate the location of the Veteran’s sinusitis. The Veteran was next examined by VA in September 2016 to ascertain the current nature and severity of his sinusitis. The Veteran denied debilitating periods or the need for antibiotics. The examiner determined the Veteran suffers from episodes of frontal sinusitis, characterized by headaches and pain of affected area. The Veteran reported pain and tenderness, and reports one non-incapacitating episode in the last 12 months characterized by headaches, pain and purulent discharge or crusting. There is no evidence of any incapacitating episodes in the past 12 months. No other physical findings were noted. Also of record are VA treatment records dated during the pendency of this appeal. However, there is no evidence of treatment for sinusitis since the Veteran’s separation from service. Based on the evidence above, the Board finds that a compensable rating is not warranted at any point during the appeals period. In denying a compensable rating, the evidence does not show that the Veteran suffered from more than one non-incapacitating episode in a 12-month period. Notably, the Board has carefully considered the Veteran’s pleadings regarding his symptoms. In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through the senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability for his condition, according to the appropriate diagnostic codes, or, to attribute specific symptoms to a disability. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence concerning the nature and extent of the Veteran’s disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and treatment records) directly address the criteria under which the disability is evaluated. The preponderance of the evidence reflects that the Veteran’s sinusitis symptoms have not more nearly approximated the criteria for an initial compensable rating. The benefit-of-the-doubt doctrine is therefore not for application and the claim is denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 4. Entitlement to an initial compensable disability rating for allergic rhinitis prior to September 23, 2016 and a rating in excess of 30 percent thereafter The Veteran was granted service connection for allergic rhinitis and given a noncompensable rating, effective from October 1, 2013, the day after his separation from service. During the pendency of this appeal, a November 2016 rating decision increased the Veteran’s disability rating for his allergic rhinitis to 30 percent disabling, effective from September 23, 2016. According to Diagnostic Code 6522, a 10 percent rating is warranted for allergic or vasomotor rhinitis when it is without polyps, but manifested by a greater than 50-percent obstruction of both nasal passages or complete obstruction of one nasal passage without polyps. A 30 percent disability rating is warranted when polyps are present. 38 C.F.R. § 4.97, Diagnostic Code 6522. In February 2014, the Veteran was afforded a VA examination in connection with his claim for service connection. The examiner provided a diagnosis of rhinitis, and noted the existence of polyps. There was no evidence of obstruction of either or both nasal passages. Further, a CT scan resulted in a finding of mucosal polyposis. The Veteran was next examined by VA in September 2016. At that time, the examiner again confirmed the presence of polyps. There was still no evidence of obstruction of either or both nasal passages. No additional physical findings were noted. Based on the evidence above, the Board finds that the Veteran is entitled to an initial rating of 30 percent due to the presence of polyps as found during the February 2014 VA examination. While the Board notes the CT scan found only the existence of mucosal polyposis, the February 2016 VA examiner marked that polyps were present. Further, the September 2016 VA examiner used the same 2014 CT scan in determining polyps were present. As 30 percent is the highest rating available under this Diagnostic Code, a higher schedular rating is not warranted. The Board has considered whether there are other diagnostic codes that would provide a higher rating, but finds that none apply. The Veteran does not have bacterial rhinitis (Diagnostic Code 6523) or granulomatous rhinitis (Diagnostic Code 6524). As such, an initial rating higher than 30 percent is not warranted. 5. Entitlement to an initial compensable disability rating for hypertension Service connection for hypertension was granted effective October 1, 2013, the day after the Veteran’s separation from service, with an initial noncompensable rating under 38 C.F.R. § 4.104, Diagnostic Code 7101. A 10 percent rating is assigned for hypertensive vascular disease (hypertension and isolated systolic hypertension) when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more or; as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure that is predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. There are three notes to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires the evaluation of hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. The Board emphasizes that more than one blood pressure reading is not required for evaluation purposes for rating hypertension under VA regulations. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (holding that the need for a specific number of blood pressure readings over multiple days is not required for determining disability evaluation, as the need for multiple blood pressure readings pertains only to the confirmation of the existence of hypertension). The Board acknowledges the Court’s holding that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, the Court subsequently determined that for hypertension, the plain language of Diagnostic Code 7101 contemplates the effects of medication and, thus, the Jones case is not applicable to cases involving hypertension. McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016). That is, the rating criteria for hypertension already takes into account the ameliorative effects of medication. Id. As an initial matter, the Veteran reported that he had not been diagnosed with hypertension during service, but was informed that he had higher blood pressure readings. In fact, his service treatment records do not include a specific diagnosis of hypertension. The Veteran was initially examined by VA in April 2014 in connection with his claim for service connection. At that time, the examiner noted the Veteran was diagnosed with hypertension in March 2014. Blood pressure readings conducted on 3 successive dates were as follows: Day 1- 130/78 and 132/90; Day 2- 148/70 and 140/74; and, Day 3- 140/60 and 144/70. The examiner noted the Veteran does not have a history of diastolic blood pressure elevation predominately 100 mm or more. The examiner indicated that there were no other pertinent signs or symptoms related to the Veteran’s hypertension, and that it did not impact the Veteran’s ability to work. The Veteran was next afforded a VA examination in September 2016 to determine the current nature and severity of his hypertension. The examiner again noted the Veteran was not on any medications for his hypertension and it was determined that EKG findings from August 2016 showed no changes from 2014. Blood pressure readings conducted on 3 successive dates were as follows: Day 1- 136/87; Day 2- 125/88; and, Day 3- 128/80. The examiner noted the Veteran does not have a history of diastolic blood pressure elevation predominately 100 mm or more. The examiner indicated that there were no other pertinent signs or symptoms related to the Veteran’s hypertension, and that it did not impact the Veteran’s ability to work. VA treatment records associated with the claims file shows the Veteran denied any symptoms associated with hypertension during the pendency of the appeal. See August 2016 VA Treatment Record. These records do not contain any other indication of treatment for hypertension. The Board has carefully considered the evidence of record, which includes the Veteran’s belief that his hypertension warrants an initial compensable rating. In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through the senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability for his condition, according to the appropriate diagnostic codes, or, to attribute specific symptoms to a disability. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence concerning the nature and extent of the Veteran’s disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and treatment records) directly address the criteria under which the disability is evaluated. Thus, the totality of the evidence is against finding a history of diastolic pressure predominantly at or above 100mm or systolic pressure predominantly 160 mm or more. In order to warrant a compensable rating for service-connected hypertension, the Veteran would need evidence that his diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more or; as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. The evidence establishes that the Veteran does not meet any of these requirements. Accordingly, the preponderance of evidence is against the claim for an initial compensable rating for hypertension; there is no doubt to be resolved; and an increased rating is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 6. Entitlement to an initial compensable rating for dermatitis prior to September 23, 2016 and a rating in excess of 10 percent thereafter The Veteran was granted service connection for dermatitis pursuant to Diagnostic Code 7806 and assigned an initial noncompensable rating, effective from October 1, 2013. Thereafter, the disability rating was increased to 10 percent, effective from September 23, 2016. He is seeking higher ratings for both periods on appeal. The Board notes that the Veteran is also in receipt of service connection for other skin diseases which are not currently before the Board. Therefore, the evidence as discussed below is limited only to the manifestations attributed to the Veteran’s dermatitis. Pursuant to this diagnostic code, a 10 percent rating is assigned when 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 is affected, or; when intermittent systemic therapy such as corticosteroids or immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent rating is assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 60 percent rating is assigned where there is more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. Id. Regarding skin disabilities, the U.S. Court of Appeals for Veterans Claims (Court) held that topical use of corticosteroids constitutes systemic therapy under this diagnostic code. Johnson v. McDonald, 27 Vet. App. 497 (2016). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit), however, subsequently reversed that decision by the Court. Johnson v. Shulkin, 862 F. 3d 1351 (Fed. Cir. 2017). In reversing, the Federal Circuit agreed with the Secretary that the Veterans Court erred when it “read DC [Diagnostic Code] 7806 as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of ‘systemic therapy.’” The Federal Circuit noted that Diagnostic Code 7806 “draws a clear distinction between ‘systemic therapy’ and ‘topical therapy’ as the operative terms of the diagnostic code.” The Federal Circuit went on to explain that “systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.’” Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. The Veteran’s service treatment records show he was diagnosed with dermatitis of the face during his service and was prescribed antifungal cream. The Veteran was initial examined by VA in February 2014 in connection with his claim for service connection for a skin disability. At that time, the VA examiner provided a diagnosis of dermatitis based on the Veteran’s in-service treatment. During the examination, the VA examiner noted that the Veteran’s skin condition has not caused scarring or disfigurement of the head, neck, or face. The Veteran does not have any benign or malignant skin neoplasm. The Veteran does not exhibit any systematic manifestations to any skin disease. In terms of treatment, the VA examiner noted that the Veteran has not used topical or systemic medications in the past 12 months. During the physical examination, in terms of dermatitis, the VA examiner noted that less than 5 percent of the total body area was affected. The Veteran was reexamined in September 2016 to determine the nature and severity of his service-connected dermatitis. The Veteran reported that his dermatitis flares are worse in summer months and he uses cream and facial cleansing to reduce the number of flares. Upon physical examination, the VA examiner noted that the Veteran’s skin condition has not caused scarring or disfigurement of the head, neck, or face. The Veteran does not have any benign or malignant skin neoplasm. The Veteran does not exhibit any systematic manifestations to any skin disease. In terms of treatment, the VA examiner noted that the Veteran requires the constant or near constant use of topical corticosteroids, but has required no other treatment. During the physical examination, in terms of dermatitis, the VA examiner noted that greater than 5 percent but less 20 percent of the total body area was affected. Finally, discoloration of areas of hypopigmentation of the face around the nose, chin, and mouth were noted. Also associated with the Veteran’s claims file are VA treatment records noting the Veteran’s treatment for his dermatitis in the form of topical corticosteroids. See September 2016 VA Treatment Record. However, these treatment records do not show any percentage of total body area exposed. Based on the evidence of record, the Board does not find an initial compensable rating for dermatitis is warranted for the period prior to September 23, 2016. Specifically, the February 2016 VA examination shows that the Veteran’s dermatitis affects at least 5 percent, but less than 20 percent of the total body area, as is required for the next higher 10 percent rating. Similarly, a rating in excess of 10 percent for the period since September 23, 2016 is not warranted because September 2016 VA examination report does not show the dermatitis affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas as is required for the next higher 30 percent rating. Also, there is no evidence that systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Lastly, the highest rating of 60 percent rating is not warranted because the Veteran’s dermatitis does not affect more than 40 percent of the entire body or more than 40 percent of exposed areas. Also, there is no evidence that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. The Board finds that no higher or alternative rating under a different diagnostic code can be applied. Diagnostic Code 7800 does not apply because it pertains to scars of the head, face, or neck. Diagnostic Code 7801 does not apply because the Veteran’s skin condition was not considered deep or linear. Diagnostic Code 7802 does not apply because it is not described as superficial and nonlinear. Diagnostic Codes 7804 and 7805 do not apply because the Veteran does not have any scarring. Finally, the Veteran does not have diagnoses or symptoms that more closely approximate those necessary for a rating under Diagnostic Codes 7807, 7809, 7811, 7815, 7817-7833. Accordingly, the preponderance of evidence is against the claim; there is no doubt to be resolved; and higher ratings are not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND 1. Right elbow, left wrist, and left hip disorders The Veteran seeks service connection for right elbow, left wrist, and left hip disorders that he believes are due to his military service. The Veteran’s contention is that he suffers from chronic pain in his right elbow, left wrist, and left hip. The Board notes that the symptomatology of these disorders, pain, is observable by lay persons. Further, due to the holding in the recent Federal Court decision of Saunders v. Wilkie, 886 F.3d 1356 (2018), the RO is required to schedule the Veteran for VA examinations to determine whether the right elbow, left wrist, and left hip pain causes functional impairment such that it may qualify as a disability in the event an underlying diagnosis is not provided. Therefore, a remand is required for new examinations for these claimed disorders. 2. Entitlement to an initial compensable rating for a left elbow disability prior to September 23, 2016 and a rating in excess of 10 percent thereafter The Veteran is seeking higher ratings for both periods on appeal for the service-connected left elbow disability. During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (Court) issued a decision in Correia v. McDonald, 28 Vet. App. 158 (2016), which held that an adequate VA examination of the joints must include testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing. See 38 C.F.R. § 4.59 (2017). The Veteran underwent a VA examination pertaining to the left elbow in September 2016, which noted the Veteran’s complaints of pain on weight-bearing. However, this examination report did not include all the required testing pursuant to § 4.59 and Correia. This examination provided ranges of motion, but did not indicate whether pain was present during both active and passive range of motion, or whether pain was observed on nonweight-bearing. As such, a new VA examination is needed. The Court also issued a decision in Sharp v. Shulkin, 29 Vet. App. 26 (2017) which is applicable to this case. In Sharp, the Court held that, pursuant to VA regulations and the VA Clinician’s Guide, when conducting evaluations for musculoskeletal disabilities, VA examiners are obligated to inquire whether there are periods of flare-ups and, if the answer is yes, to state their “severity, frequency, and duration; name the precipitating and alleviating factors; and estimate, ‘per [the] veteran,’ to what extent, if any, they affect functional impairment.” Id. at 32. The Court further explained that, in the event an examination is not conducted during a flare-up, the “critical question” in assessing the adequacy of the examination was “whether the examiner was sufficiently informed of and conveyed any additional or increased symptoms and limitations experienced during flares.” Id. at 34 (quoting Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011)). In the September 2016 VA examination, it was also noted the Veteran suffered from flare-ups in the left elbow and that the examination was conducted during a flare-up. While the report notes the range of motion of the left elbow during a flare-up, it does not contain additional information regarding the frequency and duration of such flare-ups, as well as certain types of functional impairment resulting therefrom. Therefore, in light of Sharp, a new examination is necessary. 3. Entitlement to an initial disability rating in excess of 10 percent for a left knee disability prior to September 23, 2016 and a rating in excess of 20 percent thereafter The Veteran is also seeking higher ratings for both periods on appeal for the service-connected left knee disability. Regarding this disability, the Veteran underwent a VA examination pertaining to the left knee in September 2016, which noted the Veteran’s complaints of pain on weight-bearing. However, this examination report did not include all the required testing pursuant to § 4.59 and Correia. This examination provided ranges of motion, but did not indicate whether pain was present during both active and passive range of motion, or whether pain was observed on nonweight-bearing. As such, a new VA examination is needed. See Correia v. McDonald, 28 Vet. App. 158 (2016). In the September 2016 VA examination, it was also noted the Veteran suffered from flare-ups in the left knee and that the examination was conducted during a flare-up. While the report notes the range of motion of the left knee during a flare-up, it does not contain additional information regarding the duration of such flare-ups, as well as certain types of functional impairment resulting therefrom. Therefore, in light of Sharp, a new examination is necessary. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all of the Veteran’s outstanding VA treatment records, from November 2016 to the present. All actions to obtain the requested records should be documented fully in the claims file. 2. Schedule the Veteran for a VA examination(s) to determine the nature and etiology of any identified residuals of right elbow, left wrist, and/or left hip disorders, to include pain. A complete rationale for all opinions offered must be provided. The examiner should specifically state whether any identified disorder is at least as likely as not (50 percent or greater probability) related to the Veteran’s military service. The examiner must discuss the rationale of the opinion, whether favorable or unfavorable, based on the findings on examination and information obtained from review of the record. 3. Schedule the Veteran for a VA examination to ascertain the severity and manifestations of his service-connected left elbow disability. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran’s service-connected left elbow under the rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. (a.) The examiner should provide the range of motion in degrees for left elbow. In so doing, the examiner should test the Veteran’s range of motion in active motion and passive motion, and state whether there is pain with weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (b.) The examiner shall inquire as to periods of flare-up, and note the frequency and duration of any such flare-ups for the left elbow. Any additional impairment on use or during flare-ups should be described in terms of the degrees of additional range of motion lost. The examiner should specifically describe the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also review the prior February 2014 and September 2016 examinations and provide a retrospective opinion as to the degrees of additional range of motion lost during flare-ups, if possible. If unable to provide this retrospective estimate, the examiner should state why and provide a reasoned explanation for the determination. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Schedule the Veteran for a VA examination to ascertain the severity and manifestations of his service-connected left knee disability. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran’s service-connected left knee disability under the rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. (a.) The examiner should provide the range of motion in degrees for the left knee. In so doing, the examiner should test the Veteran’s range of motion in active motion and passive motion, and state whether there is pain with weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (b.) The examiner shall inquire as to periods of flare-up, and note the frequency and duration of any such flare-ups for left knee. Any additional impairment on use or during flare-ups should be described in terms of the degrees of additional range of motion lost. The examiner should specifically describe the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also review the prior February 2014 and September 2016 examinations and provide a retrospective opinion as to the degrees of additional range of motion lost during flare-ups, if possible. If unable to provide this retrospective estimate, the examiner should state why and provide a reasoned explanation for the determination. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE, CORRECTIVE ACTION MUST BE IMPLEMENTED. (Continued on the next page)   IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Berry, Counsel