Citation Nr: 1808603 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 09-23 573 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a rating in excess of 60 percent for lichen planus. 2. Entitlement to an increased rating for a mood disorder with sleep problems, rated as 30 percent disabling prior to September 14, 2015 and 50 percent disabling thereafter. 3. Entitlement to a higher initial rating for a chronic right wrist sprain, rated as noncompensable prior to September 11, 2015 and 10 percent disabling thereafter. 4. Entitlement to a rating in excess of 10 percent for hypertension. 5. Entitlement to an initial compensable rating for chronic sinusitis. 6. Entitlement to an initial compensable rating for external hemorrhoids. 7. Entitlement to service connection for diabetes mellitus. 8. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus or service-connected hypertension. 9. Entitlement to service connection for residuals of a left wrist injury, to include carpal tunnel syndrome (CTS). 10. Entitlement to service connection for posttraumatic stress disorder (PTSD). 11. Entitlement to an effective date earlier than August 5, 2010 for the award of a total disability rating due to individual employability resulting from service-connected disability (TDIU). REPRESENTATION Appellant represented by: Robert C. Brown, Jr., Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from May 1987 to May 1993. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in October 2014. A copy of the transcript is associated with the record. This case was previously before the Board in February 2015. At that time, the Board reopened the claims for entitlement to service connection for right and left knee disabilities and adjudicated some other claims on appeal. The reopened claims, along with the other claims currently on appeal, were then remanded for further action by the originating agency. The case returned to the Board in April 2016 and service connection was awarded for the disabilities of the bilateral knees and low back. The remaining claims were again remanded for additional development and have now returned to the Board. In an August 2013 rating decision, the RO awarded service connection for supraventricular arrhythmia and gastroesophageal reflux disease (GERD). The Veteran initiated an appeal with the initial ratings and effective dates assigned these disabilities. Similarly, in June 2016, the RO implemented a decision of the Board granting service connection for right and left knee disabilities and the Veteran also disagreed with the assigned original ratings and effective dates. The RO has acknowledged the Veteran's appeals and is actively developing the claims, to include scheduling the Veteran for a hearing in response to requests contained in the September 2016 and March 2017 substantive appeals. As the RO is still developing the claims, they are not currently before the Board and are not addressed in this decision. In a November 2017 statement, the Veteran reported that his service-connected hypertension had caused changes in his eyes, to include hypertensive retinopathy. The matter of entitlement to an eye disability as secondary to service-connected hypertension, to include retinopathy, is referred to the agency of original jurisdiction (AOJ) for appropriate action, to include forwarding the Veteran and his representative a VA standard form in paper or electronic form, if necessary. 38 C.F.R. § 3.155(b)(1)(ii) (2017); see also 79 Fed. Reg. 57660 (Sep. 25, 2014) (all claims governed by VA's adjudication regulations must be filed on standard forms prescribed by VA, regardless of the type of claim or posture in which the claim arises.) The issues of entitlement to service connection for diabetes mellitus, a left wrist disability, erectile dysfunction, and entitlement to an earlier effective date for the award of TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's lichen planus manifests diffuse areas of hyper and hypopigmented lesions and papules over the Veteran's body without visible or palpable tissue loss or gross distortion or asymmetry of three or more features or paired sets of features or six or more characteristics of disfigurement. 2. The Veteran's mood disorder with sleep impairment manifests impairment in most areas without total social and occupational impairment. 3. The Veteran's chronic right wrist sprain manifests pain and limited motion throughout the claims period without ankylosis. 4. The Veteran's hypertension does not most nearly approximate diastolic pressure predominantly 110 or more; or, systolic pressure predominantly 200 or more. 5. The Veteran's chronic sinusitis manifests occasional symptoms with congestion, headaches, and blocked nasal passages without one or two incapacitating episodes per year requiring prolonged antibiotic treatment, or; three to six non-incapacitating episodes per year. 6. The Veteran's hemorrhoids are mild or moderate in severity without excessive or redundant tissue and without frequent recurrences. 7. PTSD is not etiologically related to any incident of active military service. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 60 percent for lichen planus are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, 4.20, Diagnostic Codes 7800-7806 (2017). 2. The criteria for a rating of 70 percent, but not higher, for a mood disorder with sleep impairment throughout the claims period are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9434. 3. The criteria for an initial 10 percent rating, but not higher, for a chronic right wrist strain throughout the claims period are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.59, 4.71a, Diagnostic Codes 5214, 5215. 4. The criteria for a rating in excess of 10 percent for hypertension are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7101. 5. The criteria for an initial compensable rating for chronic sinusitis are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Codes 6510-6524. 6. The criteria for an initial compensable rating for external hemorrhoids are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7336. 7. PTSD was not incurred in or aggravated by active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304(f). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Increased Rating Claims Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are also appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Lichen Planus Service connection for an inflammatory skin disability, lichen planus, was awarded in a February 2004 rating decision with an initial 30 percent evaluation assigned effective May 11, 1993. An increased 60 percent evaluation was granted in a June 2009 rating decision and the January 2012 rating decision on appeal continued the 60 percent evaluation. The Veteran contends that increased or separate ratings are warranted for the skin condition under the criteria pertaining to burn scars and/or disfigurement of the head, face, or neck. After review of the evidence, the Board finds that increased or separate ratings are not warranted. As a preliminary matter, the Board notes that while the Veteran's claim was pending, new rating criteria for evaluating skin disabilities became effective on January 20, 2012. The regulatory change was essentially administrative does not affect the adjudication of this claim for an increased rating. The Veteran's lichen planus is not specifically listed in the VA rating schedule contained in 38 C.F.R. Part 4. Unlisted conditions are rated 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. The Veteran's lichen planus is currently rated as 60 percent disabling by analogy to Diagnostic Code 7806 for dermatitis or eczema. This code provides for rating the disability under the included criteria or as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. The Veteran is currently in receipt of the maximum possible 60 percent rating under Diagnostic Code 7806 and an increased evaluation is therefore not possible if rating the disability by analogy with dermatitis. The Board has also considered whether an increased rating is warranted if the Veteran's disability is rated as disfigurement of the head, face, or neck, or as scars. Assuming the Board determined that the Veteran's lichen planus manifested scarring as a predominant disability, the maximum rating possible under Diagnostic Code 7804 is 30 percent for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. This is a lower rating than the 60 percent evaluation currently assigned under Diagnostic Code 7804 and an increased evaluation is not possible. An increased rating is also not possible under Diagnostic Code 7800 for disfigurement of the head, face, or neck. A maximum 80 percent evaluation under this diagnostic code requires 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; six or more characteristics of disfigurement. The eight characteristics of disfigurement are as follows: Scar is 5 or more inches (13 or more cm.) in length. Scar is at least one-quarter inch (0.6 cm.) wide at the widest part. Surface contour of scar is elevated or depressed on palpation. Scar is adherent to underlying tissue. Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.). Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800. The Veteran has stated at several times throughout the claims period that his lichen planus is disfiguring, is repugnant to others, and prompts staring and rude comments. The Board finds that the Veteran's statements and October 2014 testimony are credible, but is outweighed by the objective medical evidence establishing that the disability does not most nearly approximate the criteria associated with an 80 percent maximum rating under Diagnostic Code 7800. The medical and lay evidence establishes that the Veteran's lichen planus manifests diffuse areas of hyper and hypopigmented lesions of his neck, scalp, and hairline with raised papules on these areas and the gums during flare-ups. The lesions and papules itch, bleed, and crust. The October 2011 VA examiner found that the Veteran's skin condition included his permanent lesions/scars and noted that the Veteran's history regarding the social effects of his disability was credible. However, none of the medical evidence, including the Veteran's VA treatment records and VA examinations in August 2010, October 2011, and September 2015 are consistent with finding of visible or palpable tissue loss and gross distortion or asymmetry of the features. In fact, the September 2015 VA examiner specifically noted that the Veteran did not manifest tissue loss or gross distortion or asymmetry of the features. In addition, while the Veteran's condition certainly results in some characteristics of disfigurement, such as abnormal skin texture and hypo-or hyperpigmentation of the skin, he does not manifest six or more characteristics of disfigurement. There is no evidence the Veteran's lesions are adherent to the underlying tissue, missing any of the underlying soft tissue, or that the skin is indurated and inflexible on the head, face, or neck. Furthermore, none of the Veteran's treating physicians or VA examiners have identified these characteristics of the disability. The September 2015 VA examiner specifically found the Veteran did not manifest six characteristics of disfigurement. In short, although the Veteran's lichen planus has resulted in some disfigurement of the head, face, or neck, even if the Board finds that this is the predominant feature of the disability an increased rating of 80 percent is not warranted under Diagnostic Code 7800. To the extent the Veteran contends that separate ratings are warranted for disfigurement and scarring under Diagnostic Codes 7800-7805, the assignment of separate evaluations is expressly prohibited by the rating criteria which provide for rating a skin disability as dermatitis "[o]r rate as disfigurement...or scars...depending upon the predominant disability" (emphasis added). The regulations's use of the disjunctive establishes that separated ratings are not possible under the criteria for rating dermatitis, disfigurement, and scarring. With consideration of the above, the Board finds that the Veteran's lichen planus most nearly approximates a maximum 60 percent evaluation under Diagnostic Code 7806. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. The claim for an increased rating is therefore denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Mood Disorder with Sleep Impairment Service connection for a mood disorder as secondary to lichen planus was awarded in a March 2006 rating decision with an initial 30 percent evaluation assigned effective August 1, 2005. In the January 2010 rating decision on appeal, the RO issued a rating decision again granting service connection for a mood disorder with a 30 percent evaluation assigned effective January 6, 2009-effectively severing service connection for the first award of service connection. The Board restored the original grant of service connection from August 1, 2005 in a February 2015 decision and remanded the claim for an increased rating. In August 2017, the RO granted an increased evaluation of 50 percent for the mood disorder effective from September 14, 2015. The Veteran's mood disorder is therefore rated as 30 percent disabling prior to September 14, 2015 and 50 percent thereafter. The Veteran contends that an increased rating is warranted as his mood disorder is productive of a higher degree of impairment throughout the claims period. The Veteran's service-connected psychiatric disorder is currently rated under Diagnostic Code 9434 for major depressive disorder and the General Rating Formula for Mental Disorders (General Rating Formula). See 38 C.F.R. § 4.130. 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: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events), a 30 percent rating. Under the General Rating Formula, 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine actives; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board finds that a rating of 70 percent, but not higher, is warranted for the Veteran's mood disorder with sleep impairment throughout the claims period. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Regarding the Veteran's specific symptoms, VA treatment records and examination reports document consistent findings of mood swings, depressed mood, impulse control problems, irritability, outbursts of rage, social isolation, and mild memory impairment. VA treatment records regularly document the Veteran's problems with controlling his temper and specifically note an incident in June 2008 when he physically assaulted an elderly attorney while appearing in court and received two years probation for assault and battery. The Veteran reported similar instances during an October 2009 VA contract examination when he stated he was kicked out of court in September 2009 and in April 2016 when he told his VA provider he beat a customer earlier in 2016. An October 2008 examiner from the Social Security Administration (SSA) found that the Veteran had limited insight with judgment subject to his anxiety and rages. Additionally, VA and SSA examiners in March 2008, October 2008, October 2009, August 2015, and September 2015 all found that the Veteran experienced difficulty or even an inability to perform his activities of daily living or establish and maintain effective relationships. With consideration of all the evidence, the Board finds that the Veteran's disability most nearly approximates deficiencies in most of areas and symptoms of similar severity, frequency, and duration as those contemplated by a 70 percent evaluation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). An increased rating of 70 percent is therefore warranted throughout the claims period. The Board has also considered whether a total schedular rating is warranted. The Veteran does not endorse any of the symptoms listed in the criteria for a 100 percent evaluation, and the symptoms he does experience are not of similar severity, frequency, and duration as those associated with a total rating. The Veteran has never endorsed any suicidal ideation and clearly does not manifest hallucinations, delusions, or gross impairment in thought processes or communication. The Veteran has poor impulse control and has acted out with violence on several occasions, including reporting in April 2016 that his marriage since 2002 was marked with verbal abuse and occasional domestic violence. However, none of his treating providers or psychiatric examiners has ever found that the Veteran posed a "persistent danger of hurting [him]self or others." Furthermore, his memory impairment is repeatedly characterized as mild and does not most nearly approximate disorientation to time or place or memory loss for names of close relatives, own occupation, or own name. Therefore, the Board clearly does not experience symptoms in the severity contemplated by a total schedular rating. With respect to occupational and social functioning, the Veteran has also not experienced total impairment due to the service-connected mood disorder. He last worked full-time in 2004 when his beauty supply business went bankrupt, but throughout most of the claims period worked as a pastor at his church. The Veteran reported to his VA provider in April 2016 that his minister license was rescinded due to his anger management problems. However, the Veteran has not manifested total social impairment-he has remained active in his church despite the loss of his minister license and has stayed married throughout the claims period. The Veteran reported in April 2016 that he and his wife separated in approximately April 2016 due to a history of verbal/emotional abuse and domestic violence, but in June 2016 stated that they were working to reconcile and he was attending anger management therapy. Thus, while the Veteran's mood disorder has clearly causes severe occupational and social impairment, his psychiatric symptoms are not of similar severity, frequency, or duration as those contemplated by a total schedular rating with total occupational and social impairment. The Board has considered whether there is any other schedular basis for granting a higher rating other than that discussed above, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the award of a rating higher than that assigned above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Right Wrist Sprain Service connection for a chronic right wrist sprain was granted in the May 2011 rating decision on appeal with an initial noncompensable evaluation assigned effective July 21, 2010. In an August 2017 rating decision, an increased 10 percent evaluation was assigned effective September 11, 2015. The Veteran's right wrist disability is therefore rated as noncompensably disabling prior to September 11, 2015 and 10 percent disabling thereafter. The Board notes that the Veteran is also in receipt of a temporary total rating from September 30, 2011 to October 31, 2011 for surgery of the right wrist necessitating convalescence under 38 C.F.R. § 4.30. The Veteran is in receipt of the maximum scheduler rating during this period and it is therefore not addressed in the analysis below. The Board finds that an initial 10 percent evaluation is warranted throughout the claims period for the service-connected right wrist disability under 38 C.F.R. § 4.59 and Diagnostic Code 5215 for limitation of motion of the wrist. Under this diagnostic code, maximum 10 percent ratings are assigned for dorsiflexion limited to less than 15 degrees and limitation of palmar flexion in line with the forearm. In 38 C.F.R. § 4.59, VA recognized that the intent of the rating schedule is to recognize painful motion of a joint as productive of disability. Therefore, actually painful healed injuries are "entitled to at least the minimum compensable rating for the joint." Id. Prior to September 11, 2015, the Veteran manifested painful noncompensable limitation of motion of the right wrist. Upon VA contract examination in October 2010, he complained of weakness and pain of the right wrist with flare-ups causing a loss of grip strength and rotation. Dorsiflexion and palmar flexion were limited upon physical examination, but did not meet the criteria for a compensable rating under Diagnostic Code 5215. Similar findings were noted during a physical therapy consultation at the Tulsa VA Medical Center (VAMC) in November 2011. The Veteran noted that his carpal tunnel symptoms had resolved as a result of surgery in September 2011, but he still experienced tightness, variable pain, and reduced limitation of motion of the wrist. The findings of painful limited motion that do not meet the criteria for a compensable rating under Diagnostic Code 5215 are sufficient to warrant a 10 percent evaluation under 38 C.F.R. § 4.59 during the period prior to September 11, 2015. The Board has considered whether an initial rating in excess of 10 percent is warranted at any time during the claims period under the other criteria for rating the wrist. The Veteran is now in receipt of a 10 percent rating for painful and limited motion throughout the claims period and this is the maximum evaluation possible under Diagnostic Code 5215 for limitation of motion of the wrist. See 38 C.F.R. § 4.71a, Diagnostic Code 5215. A higher rating is possible under Diagnostic Code 5214 for ankylosis of the wrist, but the record clearly shows that the Veteran's right wrist is not ankylosed. VA examiners who physically examined the Veteran's wrist in October 2010 and September 2015 concluded that it was not ankylosed. The Veteran clearly experiences reduced motion of the right wrist due to his chronic sprain, but none of the lay or medical evidence establishes that the disability manifests ankyloses. Furthermore, as the Veteran is already in receipt of the highest available rating based on restriction of motion, the provisions regarding pain in 38 C.F.R. §§ 4.40 and 4.45 do not apply. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Therefore, the assignment of an initial rating higher than 10 percent for the service-connected chronic right wrist sprain based on ankylosis under Diagnostic Code 5214 is not appropriate. In sum, the Veteran's chronic right wrist sprain warrants an initial 10 percent rating, but not higher, throughout the claims period. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against a schedular rating higher than that assigned above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Hypertension Service connection for hypertension was awarded in a February 1994 rating decision with an initial 10 percent evaluation assigned effective May 11, 1993. The May 2011 rating decision on appeal continued the 10 percent evaluation. The Veteran contends that an increased rating is warranted as his hypertension requires continuous medication and is more severe than contemplated by the current 10 percent rating. The Veteran's hypertension is currently rated under Diagnostic Code 7101 pertaining to hypertensive vascular disease. Under Diagnostic Code 7101, a 10 percent rating is applicable if diastolic pressure is predominantly 100 or more, or systolic pressure is predominantly 160 or more, or there is a history of diastolic pressure of predominantly 100 or more and continuous medication is required to control blood pressure. A 20 percent evaluation is warranted if diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The competent evidence of record shows that a disability rating in excess of 10 percent for hypertension is not warranted. The Veteran's blood pressure was measured as 130/80, 130/78, and 130/78 upon VA contract examination in October 2010 with similar findings noted at the most recent September 2015 VA examination. These results are contemplated by the current 10 percent evaluation, which is also consistent with the use of continuous hypertensive medication. The Veteran's highest systolic reading during the claims period was 163, measured in the emergency department of the Muskogee VAMC in September 2015 when he reported running out of pain medication after right knee surgery. His highest diastolic reading was 87, recorded at the Tulsa VA outpatient clinic in October 2011. Systolic pressure of 163 and Diastolic pressure of 87 are contemplated by the current 10 percent evaluation and do not most nearly approximate the criteria associated with an increased rating under Diagnostic Code 7101. In short, there is no competent evidence indicating that the Veteran's diastolic pressure is predominantly 110 or more or his systolic pressure is predominantly 200 or more. Therefore, the service-connected hypertension does not most nearly approximate the criteria contemplated by a rating in excess of 10 percent and the claim is denied. Sinusitis Service connection for chronic sinusitis was awarded in the March 2014 rating decision on appeal. An initial noncompensable evaluation was awarded effective September 5, 2013. The Veteran contends that a higher rating is warranted as he experiences symptoms including congestions, headaches, and blocked nasal passages that are more severe than a noncompensable evaluation. The Veteran's sinusitis is rated under Diagnostic Code 6512 pertaining to chronic frontal sinusitis and the General Rating Formula for Sinusitis. Under the rating formula, a noncompensable evaluation is assigned when sinusitis is detected by X-ray only. A 10 percent rating is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A maximum 50 percent rating is assigned 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. 38 C.F.R. § 4.97, Diagnostic Code 6512. The Board finds that an initial compensable rating is not warranted. None of the competent evidence establishes that the Veteran manifests any incapacitating episodes of sinusitis requiring antibiotics or three to six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. VA examiners in February 2014 and September 2015 found that the Veteran did not experience incapacitating or non-incapacitating episodes of sinusitis. The Veteran's symptoms are well-controlled with continuous medication and the Board notes that he has never sought specific medical treatment for sinusitis. He also stated in December 2013 during an annual examination at the Tulsa VAMC that since moving to Tulsa he had not experienced any sinus or allergy problems. Additionally, the September 2015 VA examiner described the Veteran's sinusitis as "quiescent" at the time of the examination. The Veteran has described experiencing symptoms of congestion, headaches, and blocked nasal passages due to sinusitis, but the competent lay and medical evidence does not establish that the Veteran's disability most nearly approximates the criteria for an increased rating by manifesting one or two incapacitating episodes per year or three to six non-incapacitating episodes per year of sinusitis. The Board has considered whether there is any other schedular basis for granting a compensable rating, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher scheduler rating other than that discussed above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Hemorrhoids Service connection for external hemorrhoids was granted in the March 2014 rating decision on appeal. An initial noncompensable evaluation was assigned effective September 5, 2013. The Veteran contends that a higher rating is warranted as his symptoms are controlled only with the use of medication and suppositories. The Veteran's hemorrhoids are currently rated as noncompensably disabling under Diagnostic Code 7336 for hemorrhoids, external or internal. Under this diagnostic code, mild or moderate hemorrhoids are rated noncompensably (0 percent) disabling. Large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are rated 10 percent disabling. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are rated 20 percent disabling. 38 C.F.R. § 4.114, Diagnostic Code 7336. The Board finds that an initial compensable rating is not warranted. The lay and medical evidence of record does not establish the presence of hemorrhoids that most nearly approximate large or thrombotic; rather, the evidence clearly establishes that the Veteran's hemorrhoids are mild, or at most, moderate in severity. Upon VA examination in February 2014, the Veteran reported experiencing occasional pain and burning in the anal region and a diagnosis of mild external hemorrhoids was rendered. Almost two years later, in September 2015, the hemorrhoids were described as quiescent and a physical examination was normal. The diagnosis was again mild or moderate hemorrhoids, rendered based on review of the Veteran's treatment records and his description of symptoms including bleeding and use of medication. The Board notes that the Veteran contacted his VA physician in October 2014 reporting an exacerbation of hemorrhoids over the past four days requiring the use of pads and hot water soaks. This represents the only instance when the Veteran sought medical treatment specifically for hemorrhoids at any time during the claims period. His condition is controlled with the use of medication and aside from one instance in October 2014 when his symptoms flared-up, there is no other objective evidence of hemorroids that are more than mild or moderate. Furthermore, the Board finds that the one isolated example of a hemorrhoid exacerbation in October 2014 does not establish the presence of "frequent recurrences." There is also no evidence of excessive redundant tissue associated with the hemorrhoids. The Board has considered the Veteran's testimony and statements regarding the severity of his service-connected hemorrhoids, but finds that the lay and medical evidence, including the findings of the two VA examinations, clearly establishes the presence of mild or moderate hemorrhoids. Hemorrhoids that are mild or moderate are contemplated by the currently assigned noncompensable evaluation and the claim for an initial compensable rating is denied. Service Connection for PTSD The Veteran is service-connected for a mood disorder with sleep impairment and contends that service connection is also warranted for the specific diagnosis of PTSD as it was incurred due to combat and non-combat stressors during active duty. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th ed. (2013) (DSM V)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). 38 C.F.R. § 3.304(f). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The record contains evidence weighing both for and against the finding of current PTSD. PTSD was initially diagnosed by a SSA psychologist in October 2008 and by VA providers in February and April 2009. However, these three incidents are the only instances of a PTSD diagnosis during the entire claims period, despite the Veteran's numerous psychiatric examinations and years of mental health treatment. Additionally, a September 2015 VA psychiatric examiner specifically found that the Veteran did not meet the criteria for a diagnosis of PTSD. As the record contains evidence weighing both for and against a finding of PTSD, the Board will resolve any doubt in favor of the Veteran and find that a current disability is demonstrated. The Board will also resolve any doubt in favor of the Veteran regarding the in-service stressor and finds that he participated in combat. The Veteran's statements and testimony before the Board includes reports of numerous combat and non-combat stressors including the stress of working as a marksmanship instructor, witnessing the wounding of recruits and other soldiers, witnessing a helicopter crash, physical abuse during boot camp, and the threat of combat and actual combat with the enemy while serving in Panama as part of Operation Just Cause from November to December 1989. The Veteran has also provided conflicting statements regarding whether he actually participated in combat with the enemy. In a May 2008 statement and at the October 2014 hearing the Veteran indicated that he did not engage in combat, but rather went on security patrols in Panama with live ammunition and the threat of combat. In contrast, he reported participating in combat while in Panama to his VA provider in April 2009, on the July 2010 substantive appeal, and during a September 2015 VA examination. Review of the Veteran's personnel records shows that he is in receipt of Marine Corps Expeditionary Medal and a Navy Unit Commendation-medals which can be awarded for combat service, though they are also awarded in non-combat situations. The Veteran's participation in security operations in Panama is also listed under the "Combat History and Expeditions" header of the personnel records, indicating that the Veteran may have engaged in combat. The Board will therefore once again resolve all doubt in favor of the Veteran and finds that he engaged in combat and an in-service stressor is established. Despite the presence of a current disability and in-service stressor, the Board finds that service connection is not warranted for the Veteran's PTSD. Rather than establishing a link between the Veteran's PTSD and his service stressor, the competent medical evidence establishes that the Veteran's PTSD is due to childhood trauma and abuse. The October 2008 SSA examiner who initially diagnosed the condition noted that the Veteran's home life as a child was "characterized by poverty, fear, chaos, neglect and the natural father's alcoholism and severe domestic violence." The SSA examiner also found that the Veteran had flashbacks and re-experiencing of his childhood trauma. A VA provider in April 2009 also diagnosed PTSD related to the Veteran's childhood abuse. The Board further notes that the Veteran was psychiatrically normal at the May 1993 service discharge examination and denied experiencing any psychiatric problems on the accompanying report of medical history. There is also no evidence of PTSD until October 2008-15 years after the Veteran's discharge from active duty. The medical evidence therefore does not establish a link between the Veteran's PTSD and active duty. The Board has considered the Veteran's lay statements linking his PTSD to service, but as a lay person, he is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to testify as to observable symptoms, but finds that his opinion as to the cause of his PTSD simply cannot be accepted as competent evidence, especially in light of the Veteran's numerous conflicting statements and history of the condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Furthermore, 38 C.F.R. § 3.304(f) specifically requires that medical evidence establish a link between current symptoms and an in-service stressors; in this case, the medical evidence establishes that the Veteran's PTSD is due to nonservice-connected childhood abuse. Therefore, service connection is not warranted for PTSD. ORDER Entitlement to a rating in excess of 60 percent for lichen planus is denied. Entitlement to a rating of 70 percent, but not higher, for mood disorder with sleep impairment is granted. Entitlement to an initial 10 percent rating, but not higher, for a chronic right wrist sprain is granted. Entitlement to a rating in excess of 10 percent for hypertension is denied. Entitlement to an initial compensable rating for chronic sinusitis is denied. Entitlement to an initial compensable rating for external hemorrhoids is denied. Entitlement to service connection for PTSD is denied. REMAND The Board regrets further delay in this case, but finds that a remand is necessary to obtain VA medical opinions regarding the etiology of the claimed diabetes mellitus and left wrist disability. The Veteran's diabetes and left wrist were examined in September 2015, but the provided medical opinions are not adequate. Specifically, the September 2015 VA examiner did not provide any accompanying rationale in support of the finding that the Veteran's diabetes is not due to service. The medical opinion addressing the etiology of the claimed left wrist disability was also not based on an accurate review of the facts. The September 2015 VA examiner noted that "[r]ecords do not discuss left wrist issues in service; only right wrist." However, the Veteran's service treatment records show that he was treated for left wrist pain and swelling in July 1987. The Veteran has also reported several other in-service left wrist injuries and he is competent to report injuries that occur during service. New medical opinions are therefore necessary to comply with VA's duty to assist the Veteran. The claims for entitlement to service connection for erectile dysfunction and entitlement to an earlier effective date for TDIU are intertwined with the claims for service connection for diabetes mellitus and a left wrist disability. Accordingly, the claims for service connection for erectile dysfunction and an earlier effective date for TDIU are also remanded. Accordingly, the case is REMANDED for the following action: 1. Provide the claims file to a VA examiner with the appropriate expertise to issue a medical opinion in this case. After reviewing the claims file, the examiner should determine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that diabetes mellitus is etiologically related to any incident of active duty service, to include the Veteran's chemical exposure to pesticides and insecticides. Service treatment records are negative for evidence of diabetes mellitus and the Veteran's blood sugar levels were normal upon examination in March 1991 and May 1993. The Veteran contends that he was exposed to various chemicals during active duty, including pesticides, insecticides, and herbicide agents. His exposure to herbicide agents is not established, but the Board finds that exposure to other chemicals is consistent with the circumstances of his active duty service. The Veteran also reports that he was told his blood was abnormal at separation with low iron which he contends is related to the development of diabetes. Diabetes mellitus was diagnosed in August 2002 based on laboratory findings in January 2002. An isolated high blood sugar reading was also noted as early as June 1999. A full rationale, i.e. basis, must be provided for all medical opinions. 2. Provide the claims file to a VA examiner with the appropriate expertise to issue a medical opinion in this case. After reviewing the claims file, the examiner should determine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that a left wrist sprain and left carpal tunnel syndrome are etiologically related to any incident of active duty service, to include a left wrist injury in July 1987 and the other injuries reported by the Veteran. Service records document a left wrist injury in July 1987 when the Veteran went on sick call with complaints of pain and swelling and striking his left wrist on a bed. The Veteran also sprained his left middle finger in November 1989 and states that he injured his wrist in the same incident. He reports additional injuries including blocking a kick with his left wrist during boot camp and multiple falls on his hands and wrists. The Veteran's upper extremities were normal upon physical examination in March 1991, May 1993, and a few months after service in September 1993. The Veteran first complained of left wrist problems after service in October 2005, when he reported having tingling in his left hand to his VAMC physician. Probable tendonitis was diagnosed in March 2009 and a VA orthopedist identified carpal tunnel syndrome in September 2009. The September 2015 VA examiner diagnosed a left wrist sprain and a history of left carpal tunnel syndrome. A full rationale, i.e. basis, must be provided for all medical opinions. 3. Then, readjudicate the claims on appeal. If the benefits sought on appeal are not fully granted, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs