Citation Nr: 18118841 Decision Date: 07/17/18 Archive Date: 07/17/18 DOCKET NO. 07-24 429 DATE: July 17, 2018 ORDER New and material evidence having been received, the appeal to reopen the claim for service connection for a lumbar spine disability is granted. New and material evidence having not been received, the appeal to reopen the claim for service connection for a left ankle disability is denied. New and material evidence having not been received, the appeal to reopen the claim for service connection for asthma is denied. New and material evidence having not been received, the appeal to reopen the claim for service connection for hepatitis C is denied. Entitlement to service connection for a lumbar spine disability is denied. Service connection for bilateral hammer toes is granted. Entitlement to service connection for hypertension, to include as secondary to medications taken for the service-connected eczema, is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to medications taken for the service-connected eczema, is denied. Service connection for an acquired psychiatric disability, to include major depressive disorder with psychotic, posttraumatic stress disorder (PTSD), and anxious distress features, is granted. Entitlement to a disability rating in excess of 10 percent for left knee osteoarthritis is denied. Entitlement to a disability evaluation in excess of 10 percent for right knee arthritis is denied. Entitlement to a disability evaluation in excess of 20 percent for left knee instability is denied. Entitlement to a disability evaluation in excess of 20 percent for right knee instability is denied. Entitlement to a disability evaluation in excess of 60 percent for nummular eczema is denied. Entitlement to a disability evaluation in excess of 10 percent for Bell’s Palsy is denied. REMANDED Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. In a November 1995 rating decision, the Regional Office (RO), in pertinent part, denied the Veteran’s claim for service connection for a lumbar spine disability; the Veteran did not appeal the November 1995 rating decision, and no evidence was received within one year of that rating decision. 2. The evidence associated with the claims file subsequent to the November 1995 final denial includes evidence that relates to an unestablished fact necessary to substantiate the claim, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim for service connection for a lumbar spine disorder. 3. In a November 1995 rating decision, the RO, in pertinent part, denied the Veteran’s claim for service connection for a left ankle disability; the Veteran did not appeal the November 1995 rating decision, and no evidence was received within one year of that rating decision. 4. The evidence associated with the claims file subsequent to the November 1995 final decision is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, i.e., lack of evidence that a left ankle disability was incurred in service or is otherwise related to service. 5. A May 1978 Board decision denied service connection for asthma; the Veteran did not appeal the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). 6. The evidence associated with the claims file subsequent to the May 1978 final denial is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, i.e., lack of evidence that the preexisting asthma was aggravated during service. 7. In an August 2005 rating decision, the RO denied the Veteran’s claim for service connection for hepatitis C. The Veteran neither appealed this decision nor submitted new and material evidence within the one-year appeal period. 8. The evidence associated with the claims file subsequent to the August 2005 final decision is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, i.e., lack of evidence that hepatitis C was incurred in service or is otherwise related to service. 9. The current lumbar spine disability was not incurred in service, is not otherwise related to service, and did not manifest within one year of service separation. 10. The current bilateral hammer toes disability had its onset in service. 11. The current hypertension was not incurred in service, is not otherwise related to service, and is not related to taking Prednisone for the service-connected eczema. 12. The current GERD was not incurred in service, is not otherwise related to service, and is not related to taking Prednisone for the service-connected eczema. 13. The current acquired psychiatric disability, to include major depressive disorder with psychotic, PTSD, and anxious distress features, was incurred in service. 14. For the entire appeal period, the Veteran’s left knee disability has not been productive of ankylosis, dislocation of the semilunar cartilage, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. 15. For the entire appeal period, the Veteran’s right knee disability has not been productive of ankylosis, dislocation of the semilunar cartilage, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. 16. For the entire appeal period, the left and right knee disabilities have not been productive of severe recurrent subluxation or lateral instability, or the functional equivalent thereof. 17. For the entire appeal period, the Veteran’s nummular eczema has not affected the head, face, or neck. 18. For the entire appeal period, the Veteran’s Bell’s palsy has not been productive of severe incomplete paralysis or complete paralysis of the seventh cranial nerve. CONCLUSIONS OF LAW 1. Evidence received since a final November 1995 rating decision is new and material, and the Veteran’s claim of entitlement to service connection for a lumbar spine disability is reopened. 38 U.S.C. §§ 5108, 7105(c) (West 2014); 38 C.F.R. §§ 3.156, 20.1103 (2017). 2. Evidence received since a final November 1995 rating decision is not new and material; reopening of the Veteran’s claim of entitlement to service connection for a left ankle disorder is therefore not warranted. 38 U.S.C. §§ 5108, 7105(c) (West 2014); 38 C.F.R. §§ 3.156, 20.1103 (2017). 3. Evidence received since a final May 1978 Board decision is not new and material; reopening of the Veteran’s claim for entitlement to service connection for asthma is therefore not warranted. 38 U.S.C. §§ 5108, 7103(a), 7104, 7266 (West 2014); 38 C.F.R. §§ 3.156, 20.1100, 20.1104 (2017). 4. Evidence received since a final August 2005 rating decision is not new and material; reopening of the Veteran’s claim of entitlement to service connection for hepatitis C is therefore not warranted. 38 U.S.C. §§ 5108, 7105(c) (West 2014); 38 C.F.R. §§ 3.156, 20.1103 (2017). 5. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 6. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for bilateral hammer toes are met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 7. The criteria for service connection for hypertension, to include as secondary to the service-connected nummular eczema, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 8. The criteria for service connection for GERD, to include as secondary to the service-connected nummular eczema, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 9. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for an acquired psychiatric disability, to include major depressive disorder with psychotic, PTSD, and anxious distress features, have been met. 38 U.S.C. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 10. For the entire appeal period, the criteria for an evaluation in excess of 10 percent for left knee osteoarthritis have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5256, 5258-5263 (2017). 11. For the entire appeal period, the criteria for an evaluation in excess of 10 percent for right knee osteoarthritis with limitation of flexion have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5256, 5258-5263 (2017). 12. For the entire appeal period, the criteria for a disability evaluation in excess of 20 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2017). 13. For the entire appeal period, the criteria for a disability evaluation in excess of 20 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2017). 14. For the entire appeal period, the criteria for a disability evaluation in excess of 60 percent for nummular eczema have been not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7800, 7806 (2017). 15. For the entire appeal period, the criteria for a disability evaluation in excess of 10 percent for Bell’s palsy have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8207 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1972 to October 1972, February 1979 to September 1979, from April 1980 to April 1983, and from April 1987 to June 1989. The appeal was most recently before the Board in May 2016, and was remanded for a Board hearing. The hearing was provided before the undersigned Veterans Law Judge (VLJ) via videoconference in April 2017, and a transcript of the hearing is of record. Therefore, the requested action was completed, and the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). New and Material Evidence VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). “New” evidence is evidence not previously submitted to agency decision makers and “material” evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, the credibility of the evidence is generally presumed. Cox v. Brown, 5 Vet. App. 95, 98 (1993); Justus v. Principi, 3 Vet. App. 510, 513 (1992). VA is required to review for newness and materiality only the evidence submitted by a claimant since the last final disallowance of the claim on any basis, whether a decision on the underlying merits or, a petition to reopen. Evans v. Brown, 9 Vet. App. 273, 283 (1996). In Shade v. Shinseki, 24 Vet. App. 100 (2010), the United States Court of Appeals for Veterans Claims (Court) held that § 3.159(c)(4) does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. Regardless of any RO determinations that new and material evidence has been submitted to reopen service connection, the Board must still determine whether new and material evidence has been submitted in this matter. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). 1. Lumbar spine disability The Veteran seeks to reopen his previously denied claim for service connection for a lumbar spine disability. The Veteran’s claim for service connection for a lumbar spine disability was previously denied in a November 1995 rating decision on the grounds that the Veteran’s service medical records are negative for complaints of or treatment for a chronic disability of the lower back. No appeal was filed, and no evidence or new service records were received within one year of the November 1995 rating decision. The Board therefore finds that the November 1995 rating decision became final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence at the time of the November 1995 rating decision included an August 1995 examination report showing an assessment of mechanical low back pain, but no diagnosis of a lumbar spine disability. Evidence received since the November 1995 rating decision includes a January 2008 treatment record noting a diagnosis of lumbar spondylosis and left convex scoliosis. See also December 29, 2008 Social Security Administration (SSA) record (showing a diagnosis of degenerative joint disease of the lumbar spine). The element of a current lumbar spine disability was not established at the time of the November 1995 rating decision. Evidence received since the last final denial in November 1995 also includes the Veteran’s assertions that he injured the lumbar spine while playing basketball during service. See April 2017 Board hearing transcript. This evidence is presumed credible only for the purpose of reopening the service connection claim. See Justus, 3 Vet. App. 510, 513 (1992). Based on the foregoing, the Board finds that the evidence added to the record since the last final denial constitutes new and material evidence, and that the criteria under 38 C.F.R. § 3.156 (a) have been satisfied; therefore, the claim for service connection for a lumbar spine disability is reopened. 2. Left ankle disability The Veteran seeks to reopen his previously denied claim for service connection for a left ankle disability. The Veteran’s claim for service connection for a lumbar spine disability was previously denied in a November 1995 rating decision on the grounds that the evidence did not show fracture of the left ankle incurred during active service. No appeal was filed, and no evidence or new service records were received within one year of the November 1995 rating decision. The Board therefore finds that the November 1995 rating decision became final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence at the time of the November 1995 rating decision included assertions by the Veteran that he had a left ankle fracture in service. The evidence also included the Veteran’s service treatment records showing no complaints of, treatment for, or diagnosis of a left ankle disorder in service. The evidence at the time of the November 1995 rating decision also included an August 1995 examination report showing a diagnosis of mild traumatic arthritis of the left ankle. Evidence received since the November 1995 rating decision includes similar assertions by the Veteran that he sustained a left ankle fracture in service. See, e.g., July 29, 2015 VA treatment record. The evidence also includes an August 2009 VA examination report showing a diagnosis of traumatic arthritis of the left ankle. This evidence is not new because the Veteran’s assertions of an in-service left ankle fracture, as well as the diagnosis of left ankle arthritis were of record at the time of the November 1995 rating decision. The Board finds that the evidence submitted since the November 1995 final denial is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, and does not tend to establish that the Veteran’s left ankle arthritis was incurred in service or is otherwise related to service. The Veteran has not provided any evidence of a left ankle fracture in service, or any evidence purporting to link the current left ankle arthritis to service. While the theory of service connection for a left ankle disability as secondary to the service-connected right and left knee disabilities was raised during the April 2017 Board hearing, the Veteran did not provide any medical evidence purporting to link his left ankle arthritis to the right and left knee disabilities. At the April 2017 Board hearing, the undersigned informed the Veteran that the record would be kept open for 60 days in order to afford the Veteran a chance to obtain such opinion; however, to date, no such evidence was provided. The Board therefore finds no new evidence that is not cumulative to evidence considered in the November 1995 final denial, and the Veteran’s claim for service connection for a left ankle disability is therefore not reopened. 3. Asthma The Veteran seeks to reopen his previously denied claim for service connection for asthma. The Veteran’s claim for service connection for asthma was denied in May 1978 Board decision on the basis that the veteran had a respiratory ailment upon entering service and there was no increase in the basic underlying pathology of the respiratory system during service. The Veteran did not appeal this denial to the Court, and it is therefore final. 38 U.S.C. §§ 7103, 7104; 38 C.F.R. § 20.1100. Evidence at the time of the May 1978 Board decision included assertions by the Veteran that his asthma is related to service. The evidence also included the Veteran’s service treatment records, which showed that a medical board determined that the asthma condition existed prior to the Veteran’s enlistment in the Navy, that he did not meet the minimal requirements for enlistment, and that he was recommended to be discharged. The service treatment records also included an examination upon enlistment in the Army, which noted that, from the information given by the Veteran, it did not sound like the Veteran had asthma, and that it appeared that the Veteran had a respiratory infection. It was noted that there was no clinical history of asthma. The Veteran was cleared for enlistment in the Army from a medical standpoint. Evidence received since the May 1978 Board decision includes similar assertions by the Veteran that he was released from the Navy due to asthma, and was accepted in the Army because it was felt that the initial diagnosis of asthma was erroneous, and that his asthma was aggravated during his service in the Army. See April 2017 Board hearing transcript. The Board finds that this evidence is not new because similar evidence was of record at the time of the May 1978 Board decision. The evidence received since the May 1978 Board decision also includes reports by the Veteran that he had asthma as a child. See July 17, 2007 VA treatment record. The Board finds that the evidence submitted since the May 1978 final denial is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, and does not tend to establish that the Veteran’s asthma was aggravated during service. The Board therefore finds no new evidence that is not cumulative to evidence considered in the May 1978 final denial, and the Veteran’s claim for service connection for asthma is therefore not reopened. 4. Hepatitis C The Veteran seeks to reopen his previously denied claim for service connection for hepatitis C. The Veteran’s claim for service connection for hepatitis C was previously denied in an August 2005 rating decision on the grounds that there was no evidence of treatment for hepatitis C in service, or that hepatitis C is related to vaccination guns in service. No appeal was filed, and no evidence or new service records were received within one year of the August 2005 rating decision. The Board therefore finds that the August 2005 rating decision became final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence at the time of the August 2005 rating decision included assertions by the Veteran that his hepatitis C was incurred in service as a result of jet inoculations in service. The evidence also included the Veteran’s service treatment records showing no complaints of, treatment for, or diagnosis of hepatitis C. Evidence received since the August 2005 rating decision includes similar assertions by the Veteran that his hepatitis C is related to jet injections in service. This evidence is not new because such assertions were of record at the time of the August 2005 rating decision. Based on the foregoing, the Board finds that the evidence submitted since the August 2005 final denial is essentially cumulative of the evidence previously of record with regard to the basis for the prior denial, and does not tend to establish that the Veteran’s hepatitis C was incurred in service or is otherwise related to in-service jet injections. The Board therefore finds no new evidence that is not cumulative to evidence considered in the August 2005 final denial, and the Veteran’s claim for service connection for hepatitis C is therefore not reopened. Service Connection 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). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Federal law specifically limits entitlement for service-connected disease or injury to cases where such incidents result in a disability. It is not enough for a claimant to seek some sort of benefit simply because he had a disease or injury on active duty. In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (upholds Court of Appeals for Veterans Claims decision to require a current existing disability). For certain chronic diseases, including cardiovascular disease and arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 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. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 5. Lumbar spine disability The Veteran seeks service connection for a lumbar spine disability. As discussed above, the record reflects that the Veteran has a current lumbar spine disability. For the reasons set forth below, the Board finds that the evidence weighs against that the Veteran’s lumbar spine disability was incurred in service, or is otherwise related to service. The Veteran asserts that he injured the lumbar spine while playing basketball during service. See April 2017 Board hearing transcript. Service treatment records, however, show no complaints, treatment, or diagnosis of a lumbar spine disorder. While the service treatment records contain multiple references to left and right knees injuries while playing basketball, no reference is made in any of the service treatment records that the Veteran injured his lumbar spine. At the April 2017 Board hearing, the undersigned informed the Veteran that the record would be kept open for 60 days in order to afford the Veteran a chance to obtain an opinion as to the relationship between the current lumbar spine disability and service; however, to date, no such evidence was provided. The Veteran has not otherwise submitted any medical evidence that his current lumbar spine disability may be related to service, other than his general assertions that his current lumbar spine disability is related to an in-service injury while playing basketball. Although lay persons are competent to report back symptoms experienced at any time, as well as provide opinions on some medical issues, the specific disabilities in this case, lumbar spine degenerative joint disease and lumbar spondylosis scoliosis, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the Veteran statements purporting to link the current lumbar spine disability to service are assigned no probative value. Finally, as the Veteran’s degenerative arthritis of the spine has not been shown to have manifested within one year of service separation, the presumptive service connection provisions of 38 C.F.R. §§ 3.307 and 3.309(a) are not applicable in this case. For these reasons, the Board finds that a preponderance of the evidence is against a finding that the Veteran’s lumbar spine disability is related to service or manifested within one year of separation. Accordingly, service connection for a lumbar spine disability must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 6. Hammer toes The Veteran seeks service connection for bilateral hammer toes. He asserts that he was treated for hammertoes during service in 1981 and in 1987. See May 2017 VA Form 21-4138. The record reflects that the Veteran has been diagnosed with hammertoes of the right and left feet. See, e.g., May 2017 VA examination report. For the reasons set forth below, the Board finds that the evidence is in relative equipoise on the question of whether the current bilateral hammer toes began in service, that is, whether the bilateral hammer toes disability was directly “incurred in” service. Evidence weighing in favor of this finding includes the Veteran’s assertions that he was treated for hammer toes in service. Moreover, a July 1, 1987 service treatment record noted the Veteran had mild hammertoe deformity of both feet. See also August 17, 1987 service treatment record. Evidence weighing against this finding includes an October 6, 1995 orthopedic examination report and an August 2009 VA examination report, neither of which indicated a diagnosis of hammer toes. However, attached to the October 1995 examination report were photographs of the Veteran’s feet showing symptoms consistent with hammer toes. For the reasons discussed above and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral hammer toes is warranted as directly incurred in service. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303(a), (d). 7. Hypertension The Veteran seeks service connection for hypertension. For VA rating purposes, hypertension means that diastolic blood pressure is predominately 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, Note 1 (2017). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The record reflects that the Veteran has been diagnosed with hypertension. See, e.g., February 14, 2017 VA treatment record. For the reasons set forth below, the Board finds that the evidence weighs against that the Veteran’s hypertension disability was incurred in service, is otherwise related to service, or related to medication (Prednisone) taken for the service-connected eczema disability. The April 2017 Board hearing transcript reflects that the Veteran asserted that he was diagnosed with hypertension during service. He also advanced that his hypertension was caused by taking Prednisone for his service-connected eczema for a long period of time, which caused a thinning of the stomach lining, which in turn caused him to have high blood pressure. See April 2017 Board hearing transcript. Service treatment records show no complaints of, treatment for, or diagnosis of hypertension. A September 9, 1988, service treatment record shows that the Veteran denied a history of high or low blood pressure. See also November 18, 1981, service treatment record. While not dispositive, the post-service evidence does not reflect complaints or treatment related to hypertension or any cardiovascular disability for at least 19 years following separation from active service. The first evidence of record of treatment for hypertension was in a July 2009 VA treatment record that noted a diagnosis of hypertension, and indicated that the Veteran did not seem to have a prior diagnosis of hypertension. Further, a January 19, 2010, VA treatment record shows that the Veteran reported onset of hypertension two years earlier. Prior to July 2009, the Veteran denied hypertension problems. The Board emphasizes that the multi-year gap between discharge from active duty service to when the Veteran sought medical care for his hypertension (2009) is a factor that weighs against in-service incurrence of hypertension. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board’s denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability); Kahana, 24 Vet. App. at 440 (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder). Furthermore, to the extent that the Veteran now asserts that he was diagnosed with hypertension in service, the Board finds that these assertions are not credible because they are contradicted and outweighed by the evidence of record, including the Veteran’s own reports, showing that the Veteran was not diagnosed with hypertension until 2008 (per the Veteran’s reports) or 2009 (per the medical records). See also August 27, 2004 VA treatment record (noting a normal clinical evaluation of the cardiovascular system, and no hypertension). The Veteran’s VA treatment records have characterized the Veteran’s hypertension as “essential,” which means that it occurs without discoverable organic cause. See Dorland’s Illustrated Medical Dictionary 909 (31st ed., 2007). This evidence weighs against a finding that the Veteran’s hypertension is related to service or to the medication (Prednisone) taken for the service-connected eczema. The Veteran has not otherwise submitted any medical evidence that his current hypertension may be related to service or to the medications taken for eczema, other than his general assertions that his current hypertension was incurred in service or related to taking Prednisone for the service-connected eczema for a long period of time. The Board finds that establishing the etiology of hypertension, where, as here, the onset is temporally remote from the alleged cause, is not the equivalent of relating a broken bone to a concurrent injury to the same body part. The relationship between the Veteran’s hypertension and active service or taking Prednisone for an extended period of time, falls outside the realm of common knowledge of a lay person. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372. Such an opinion requires specialized training and knowledge and is not capable of lay observation. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between the claimed hypertension and service. Accordingly, the Veteran’s statements purporting to link the current hypertension to service or to Prednisone taken for service-connected eczema are assigned no probative value Finally, as the Veteran’s hypertension (a cardiovascular disease) has not been shown to have manifested within one year of service separation, the presumptive service connection provisions of 38 C.F.R. §§ 3.307 and 3.309(a) are not applicable in this case. For these reasons, the Board finds that a preponderance of the evidence is against a finding that the Veteran’s hypertension is related to service or manifested within one year of separation, or otherwise related to taking Prednisone for the service-connected eczema. Accordingly, service connection for hypertension disability must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 8. GERD The Veteran seeks service connection for GERD. The record reflects that the Veteran has been diagnosed with GERD. See, e.g., January 2014 VA treatment record; March 2011 VA treatment record. For the reasons set forth below, the Board finds that the evidence weighs against that the Veteran’s GERD was incurred in service, is otherwise related to service, or related to medication (Prednisone) taken for the service-connected eczema disability. The April 2017 Board hearing transcript reflects that the Veteran asserted that he has a stomach ulcer as a result of taking Prednisone for his service-connected nummular eczema. The record does not, however, show a diagnosis of a stomach ulcer disability at any point during, or immediately prior to, the appeal period. In a May 2017 statement, the Veteran asserted that, while he was stationed in Augsburg, Germany in 1983, he was seen for several symptoms that were later diagnosed as GERD. A 1987 service treatment record noted complaints of stomach pain for five days, and an assessment of a possible stomach ulcer. However, a September 1988 service treatment record (dental health questionnaire) shows that the Veteran denied stomach problems/ulcer. This evidence shows that, to the extent that the Veteran had in-service stomach condition, such condition resolved prior to service separation. While not dispositive, the post-service evidence does not reflect complaints or treatment related to GERD or any gastrointestinal disability for at least 21 years following separation from active service. The first evidence of treatment for GERD was in a November 2010 VA treatment record that noted an impression of GERD. Prior to November 2010, the Veteran consistently denied gastrointestinal problems. See, e.g., August 2004 VA treatment record; November 2009 VA treatment record. The Board emphasizes that the multi-year gap between discharge from active duty service to when the Veteran sought medical care for his GERD (2010) is a factor that weighs against in-service incurrence of GERD. See Maxson, 230 F.3d at 1333; see also Mense, 1 Vet. App. at 356; Kahana, at 440. At the April 2017 Board hearing, the undersigned informed the Veteran that the record would be kept open for 60 days in order to afford the Veteran a chance to obtain an opinion as to the relationship between any current gastrointestinal disability and the medication (Prednisone), which the Veteran takes for eczema; however, to date, no such evidence was provided. The Veteran has not otherwise submitted any medical evidence that his current GERD may be related to service or to the medications taken for eczema, other than his general assertions that his current GERD was incurred in service or related to Prednisone, which he takes for the service-connected eczema. Although lay persons are competent to report some gastrointestinal symptoms experienced at any time, such as heart burn or stomach pain, as well as provide opinions on some medical issues, the specific disability in this case, GERD, and its relationship to a possible ulcer in service or to taking Prednisone for an extended period of time, fall outside the realm of common knowledge of a lay person. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372. Thus, the Veteran statements purporting to link the current GERD to service or to Prednisone taken for service-connected eczema are assigned no probative value. For these reasons, the Board finds that a preponderance of the evidence is against a finding that the Veteran’s GERD is related to service or to the medication taken for the service-connected eczema. Accordingly, service connection for GERD must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 9. Acquired psychiatric disability The Veteran seeks service connection for an acquired psychiatric disability. He contends that his psychiatric disability is related to service. The record reflects that the Veteran has a current acquired psychiatric disability of major depressive disorder with psychotic, PTSD, and anxious distress features. See, e.g., April 19, 2018 mental disorders disability benefits questionnaire (DBQ). For the reasons set forth below, the Board finds that the evidence is in relative equipoise that the current acquired psychiatric disability was incurred in service. The October 2009 VA examination report includes an opinion that it is more likely than not that the Veteran’s military experiences significantly increased anxiety and depression leading to his current PTSD symptoms. In reaching this opinion, the VA examiner provided a thorough review of the Veteran’s psychiatric history and noted an in-service accident where the Veteran’s close friend was run over by an armored personnel carrier (APC). In an April 19, 2018, statement, Dr. H.G. opined that the Veteran’s psychiatric disability more likely than not began in service and continues uninterrupted to the present. Dr. H.G. provided a thorough review of the Veteran’s psychiatric symptoms and history, and noted the same in-service accident where the Veteran’s close friend was killed by an APC during a training exercise. The Board finds that, taken together, the October 2009 VA opinion and April 2018 private opinion are highly probative with respect to service connection for an acquired psychiatric disability, and are adequately based on objective findings as shown by the record, and accordingly, the Board concludes that the medical opinions rendered was based upon a full and accurate factual premise, including the Veteran’s history, and provided a rationale for the opinions given. See Stegall, 11 Vet. App. 268; Barr v. Nicholson, 21 Vet. App. 303 (2007); Jones v. Shinseki, 23 Vet. App. 382 (2010); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Therefore, the Board finds that the October 2009 VA opinion and April 2018 private opinion provide competent, credible, and probative evidence which shows that the current acquired psychiatric disability was incurred in service. There is no contrary medical evidence or medical opinion of record. For the reasons discussed above and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disability, major depressive disorder with psychotic, PTSD, and anxious distress features, is warranted as directly incurred in service. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303(a), (d). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). When assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent (“flare-ups”) due to the extent of her pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. 10. Left knee osteoarthritis The Veterans seeks a higher disability rating than percent for left knee osteoarthritis. For the entire appeal period, the Veteran has been in receipt of a 10 percent disability rating for left knee osteoarthritis based on painful non-compensable limitation of motion. See 38 C.F.R. § 4.59, 4.71a, DC 5003. DC 5003 provides that degenerative arthritis is rated on the basis of limitation of motion of the specific joint involved. When limitation of motion is noncompensable, a 10 percent rating is for application for each major joint. In the absence of limitation of motion, a maximum schedular 20 percent rating is assigned for degenerative arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. Alternative and additional diagnostic codes for the knee are available under 38 C.F.R. § 4.71a, as follows: Under 38 C.F.R. § 4.71a, DC 5256, ankylosis of the knee with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, is rated at 30 percent; ankylosis in flexion between 10 and 20 degrees is rated at 40 percent; ankylosis in flexion between 20 and 45 degrees is rated at 50 percent; and extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, is rated at 60 percent. Under 38 C.F.R. § 4.71a, DC 5257, recurrent subluxation or lateral instability is rated at 10 percent for slight instability, 20 percent for moderate instability, and 30 percent for severe instability. In this case, the Veteran is in receipt of a separate 20 percent rating for instability of each knee, which will be discussed in more detail below. Under 38 C.F.R. § 4.71a, DC 5258, dislocation of semilunar cartilage with frequent episodes of “locking” pain and effusion into the joint is rated at 20 percent. Under 38 C.F.R. § 4.71a, DC 5259, symptomatic removal of semilunar cartilage is rated at 10 percent. Under 38 C.F.R. § 4.71a, DC 5260, flexion of the leg is rated noncompensable when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. In order to warrant a separate rating under DC 5260, the evidence must approximate the functional equivalent of flexion of the leg limited to 45 degrees or less. Under 38 C.F.R. § 4.71a, DC 5261, extension of the leg is rated noncompensable when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. Under 38 C.F.R. § 4.71a, DC 5262, malunion of the tibia and fibula is rated at 10 percent with slight disability, 20 percent with moderate disability, and 30 percent with marked disability. Nonunion of the tibia and fibula, with loose motion and requiring a brace, is rated at 40 percent. Under 38 C.F.R. § 4.71a, DC 5263, acquired traumatic genu recurvatum, with objectively demonstrated weakness and insecurity in weight-bearing is rated at 10 percent. The Board notes that the criteria under DCs 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. In a January 2008 statement, Dr. V.R. recorded left knee flexion to 100, as well as full extension with pain on motion, but did not indicate the point at which pain began. In August 2009, the Veteran underwent a VA examination. He reported pain, weakness, and stiffness, but denied flare-ups. On examination, left knee flexion was to 120 degrees, and extension to 0 degrees without pain. There was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness. In June 2013, the Veteran underwent another VA examination. He reported left knee pain, with no flare-ups. On examination, left knee flexion was to 120 degrees, with pain beginning at 90 degrees. Left knee extension was to 0 degrees with no evidence of painful motion. There Veteran had functional loss due to less movement than normal, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran did not have any meniscal conditions. A June 19, 2015 VA treatment record noted full active range of motion of the left knee. In May 2017, the Veteran underwent another VA examination. He reported left knee pain, with flare-ups with prolonged standing and walking. On examination, left knee flexion was to 90 degrees, to include as due to pain and after repetitive use testing. Left knee extension was to 0 degrees with no evidence of painful motion. There was no evidence of additional functional loss. The Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s left knee disability. His current 10 percent rating is granted for painful motion with functional limitation caused by pain. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. § 4.59. Alternative or higher ratings are available for ankylosis, dislocation or removal of the semilunar cartilage, flexion limited to 30 degrees or less, extension limited to a compensable level, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. The Board finds no lay or medical evidence in the record of such manifestations. Neither the Veteran’s treating physicians nor the VA examiners have found any evidence of ankylosis, limitation of flexion to 30 degrees, limitation of extension to any degree, dislocation of the semilunar cartilage, malunion or nonunion of the tibia and fibula, or genu recurvatum. There is evidence of limitation of left knee flexion, but not to less than 90 degrees. As to functional equivalence, the Board notes that there is evidence of pain and tenderness of the left knee; however, the Board finds that these manifestations taken together are not the functional equivalent of a 20 percent rating under the rating criteria, as such symptoms can be accurately described as the painful motion warranting a 10 percent rating. See 38 C.F.R. § 4.59. Stated differently, neither the objective nor subjective evidence suggests that there is the functional equivalent of limitation of flexion to 30 degrees or that there is limitation of extension. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as none of the symptomatology for one condition is “duplicative of or overlapping with the symptomatology” of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In VAOPGCPREC 9-98, General Counsel considered a hypothetical situation in which a knee disability was evaluated under DC 5259 that was productive of pain, tenderness, friction, and osteoarthritis established by x-rays. For the purposes of the hypothetical, it was assumed that the knee disability rated under DC 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel interpreted that, where a DC 5259 disability did not involve limitation of motion, a separate rating under DC 5003 in light of 38 C.F.R. §§ 4.40, 4.45, 4.59 may be warranted. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The VA General Counsel opinion did not interpret that ratings could be assigned for both DCs 5003 and 5259 in all cases. The General Counsel further interpreted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, and that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion; therefore, if the knee disability rated under DC 5259 does involve limitation of motion, then to assign a separate rating under DC 5003 would violate the rules against pyramiding because the symptomatology contemplated by the different rating criteria would overlap with respect to limitation of motion. 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 261 (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). In this case, the May 2017 VA examination report noted that the Veteran underwent a meniscectomy in September 2015 with residual symptoms of pain and limitation of motion. The Board finds that a separate 10 percent rating under DC 5259 is not warranted in the present case. Under DC 5259, a maximum 10 percent rating is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a, DC 5259. That is, there are only two requirements for a compensable rating under DC 5259. First, the semilunar cartilage or meniscus must have been removed. Second, it must be symptomatic. Looking to the plain meaning of the terms used in the rating criteria, “symptomatic” means indicative, relating to, or constituting the aggregate, of symptoms of disease. STEDMAN’S MEDICAL DICTIONARY, 1743 (27th ed. 2000). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, the second DC 5259 requirement being “symptomatic” is broad enough to encompass all symptoms, including pain, limitation of motion, stiffness, and instability. The Board finds that the symptomatic residuals associated with the Veteran’s left knee meniscectomy are already compensated in the assigned 10 percent rating discussed above under DC 5003. The record shows that the Veteran’s left knee disability is manifested by findings and symptoms which include arthritis, noncompensable limitation of motion, and functional loss due to pain, less movement than normal, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. These symptoms are contemplated in the 10 percent rating currently assigned under DC 5003. The critical element in permitting the assignment of separate ratings under various Diagnostic Codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban, at 261-62. As the symptoms of pain and noncompensable limitation of motion that have been attributed to the meniscectomy overlap with the symptomatology upon which the 10 percent rating under DC 5003 has been based, the Board finds that assigning a separate compensable rating under DC 5259 would constitute pyramiding prohibited by 38 C.F.R. 4.14 because pain and noncompensable limitation of motion are already contemplated in the rating assigned under DC 5003 for arthritis with painful limitation of motion. See id.; 38 C.F.R. § 4.14. To assign the Veteran a separate rating under DC 5259 would compensate the Veteran twice for the same symptoms. Moreover, the highest available rating under DC 5259 in this case is 10 percent; thus, DC 5259 does not allow for a higher rating than the 10 percent disability rating currently assigned under DC 5003. For these reasons, the Board finds that an increased evaluation in excess of 10 percent is not warranted for the Veteran’s left knee osteoarthritis for the entire appeal period. 38 C.F.R. §§ 4.3, 4.7. 11. Right knee arthritis The Veterans seeks a higher disability rating than percent for right knee arthritis with limitation of flexion. For the entire appeal period, the Veteran has been in receipt of a 10 percent disability rating for right knee osteoarthritis based on limitation of flexion to 45 degrees. See 38 C.F.R. § 4.71a, DC 5260. In a January 2008 statement, Dr. V.R. recorded right knee flexion to 100, as well as full extension with pain on motion, but did not indicate the point at which pain began. In August 2009, the Veteran underwent a VA examination. He reported pain, weakness, and stiffness, but denied flare-ups. On examination, right knee flexion was to 120 degrees, and extension to 0 degrees without pain. There was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness. In June 2013, the Veteran underwent another VA examination. He reported left knee pain, with no flare-ups. On examination, right knee flexion was to 130 degrees, with pain beginning at 100 degrees. Right knee extension was to 0 degrees with no evidence of painful motion. There Veteran had functional loss due to less movement than normal, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran did not have any meniscal conditions. A June 19, 2015 VA treatment record noted full active range of motion of the right knee. In May 2017, the Veteran underwent another VA examination. He reported right knee pain, with flare-ups with prolonged standing and walking. On examination, right knee flexion was to 90 degrees, to include as due to pain and after repetitive use testing. Right knee extension was to 0 degrees with no evidence of painful motion. There was no evidence of additional functional loss. The Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s right knee disability. His current 10 percent rating is granted for limitation of flexion to 45 degrees. Alternative or higher ratings are available for ankylosis, dislocation or removal of the semilunar cartilage, flexion limited to 30 degrees or less, extension limited to a compensable level, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. The Board finds no lay or medical evidence in the record of such manifestations. Neither the Veteran’s treating physicians nor the VA examiners have found any evidence of ankylosis, limitation of flexion to 30 degrees, limitation of extension to any degree, dislocation of the semilunar cartilage, malunion or nonunion of the tibia and fibula, or genu recurvatum. There is evidence of limitation of flexion, but not to less than 90 degrees. As to functional equivalence, the Board notes that there is evidence of pain and tenderness of the left knee; however, the Board finds that these manifestations taken together are not the functional equivalent of a 20 percent rating under the rating criteria, as such symptoms can be accurately described as the painful motion warranting a 10 percent rating. See 38 C.F.R. § 4.59. Stated differently, neither the objective nor subjective evidence suggests that there is the functional equivalent of limitation of flexion to 30 degrees or that there is limitation of extension. In this case, the May 2017 VA examination report noted that the Veteran underwent a right knee meniscectomy in November 2016 with residual symptoms of pain and limitation of motion. Similar to the analysis of the left knee above, the Board finds that a separate 10 percent rating under DC 5259 is not warranted in the present case. Here, the 10 percent rating assigned under DC 5260 for Veteran’s right knee arthritis contemplated limitation of right knee flexion to 45 degrees, to include as due to pain. These symptoms are contemplated by the rating criteria under both DC 5259, as a symptomatic residual of the semilunar cartilage removal, and DC 5260, as limitation of flexion. As the limitation of flexion manifested by the right knee disability is contemplated by the criteria for both Diagnostic Codes, the Board finds that assigning separate ratings under both DC 5259 and DC 5260 would constitute pyramiding as it would compensate the Veteran twice for the same symptomatology (here, limitation of flexion, including as due to pain). See Esteban, at 261-62; 38 C.F.R. 4.14. For these reasons, the Board finds that an increased evaluation in excess of 10 percent is not warranted for the Veteran’s right knee arthritis for the entire appeal period. 38 C.F.R. §§ 4.3, 4.7. 12. Left knee instability 13. Right knee instability The Veterans seeks higher disability ratings than 20 percent for instability of each knee. For the entire appeal period, the Veteran has been in receipt of a 20 percent rating for instability of each knee under DC 5257. After a review of all the evidence, the Board finds that the weight of the evidence is against assigning a higher rating than 20 percent for instability of each knee. The currently-assigned 20 percent rating for each knee contemplates moderate instability of the knees. A higher rating requires a finding of severe instability of the knee. However, the weight of the evidence discussed above weighs against such a finding. In this case, at no point during the appeal period did the evidence show severe instability of either knee, or the functional equivalent thereof. The August 2009 VA examination report shows that the Veteran complained of instability but denied recurrent subluxation. It was noted that there was no objective evidence of instability. The June 2013 VA examination report shows normal bilateral anterior and posterior instability, and that medial-lateral instability was assessed as “1+ (0-5 millimeters),” which is indicative of mild instability. While the June 2013 VA examiner noted a history of recurrent patellar subluxation/dislocation, the examiner did not indicate the severity of such subluxation. The May 2017 VA examination report assessed normal bilateral anterior, posterior, medial, and lateral stability in both knees. Based on the foregoing, the Board finds that a disability rating in excess of 20 percent for instability of each knee is not warranted for the entire rating period on appeal because, as discussed above, the weight of the lay and medical evidence does not show the severity required for a rating in excess of 20 percent under DC 5257 based on the relevant symptomatology and impairment. 38 C.F.R. §§ 4.3, 4.7, 4.71a. 14. Nummular eczema The Veterans seeks a higher evaluation in excess of 60 percent for the service-connected nummular eczema disability. For the entire appeal period, the Veteran’s service-connected nummular eczema disability is rated as 60 percent disabling under DC 7806, which provides that a 60 percent rating is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of the exposed body area; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. The 60 percent rating assigned for the nummular eczema disability is the maximum schedular rating available under DC 7806. 38 C.F.R. § 4.118. Accordingly, a higher rating than 60 percent for nummular eczema is not possible under DC 7806. The only potentially applicable diagnostic code providing for a disability rating in excess of 60 percent for skin disabilities is DC 7800 for disfigurement of the head, face, and neck. In this case, the evidence shows that the Veteran’s nummular eczema does not affect the head, face, or neck. See, e.g., June 2013 VA examination report; June 2016 VA examination report. Accordingly, there is no basis for a higher rating for the nummular eczema disability under DC 7800. See 38 C.F.R. § 4.118. Because the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 15. Bell’s palsy The Veterans seeks a higher evaluation in excess of 10 percent for the service-connected Bell’s palsy disability. For the entire appeal period, the Veteran’s Bell’s palsy is rated as 10 percent disabling under DC 8207, for impairment of the seventh (facial) cranial nerve. DC 8207 provides for a 10 percent disability rating for moderate incomplete paralysis of the seventh cranial nerve. A 20 percent disability rating is assigned for severe incomplete paralysis of the seventh cranial nerve. A 30 percent disability rating is assigned for complete paralysis of the seventh cranial nerve. 38 C.F.R. § 4.124a. A note to 38 C.F.R. § 4.124a states that the term “incomplete paralysis” where involving peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Also, when peripheral nerve involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. The words “mild,” “moderate,” and “severe” are not defined in the above rating criteria. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6 (2017). The Veteran underwent a VA examination in June 2013. The Veteran reported that he had some facial twitching. The VA examiner assessed that the Veteran did not have any findings, signs, or symptoms affecting the seventh cranial nerve. It was noted that the Veteran had no motor or sensory impairment of the seventh cranial nerve. It was further observed that the Veteran was able to raise both eyebrows, general wrinkle of forehead, raise corners of the mouth with symmetry. The VA examiner assessed that the Veteran did not have any impairment of the cranial nerves. The Veteran underwent another VA examination in June 2016. The Veteran reported pain in the left side of the face, but denied difficulty sleeping or swallowing, and reported that he had not had a recurrence of Bell’s palsy. The VA examiner assessed that the Veteran did not have any findings, signs, or symptoms affecting the seventh cranial nerve. It was noted that the Veteran had no motor or sensory impairment of the seventh cranial nerve. The Board finds that a higher rating than 10 percent for the service-connected Bell’s palsy disability is not warranted. The currently-assigned 10 percent rating contemplated moderate incomplete paralysis of the seventh cranial nerve. A higher rating requires a finding of severe incomplete paralysis, or complete paralysis of the seventh cranial nerve. However, the weight of the evidence discussed above weighs against such a finding. The medical examiners consistently assessed that the Veteran did not have any findings, signs, or symptoms affecting the seventh cranial nerve. Based on the foregoing, the Board finds that a disability rating in excess of 10 percent for Bell’s palsy is not warranted for the entire rating period on appeal because, as discussed above, the weight of the lay and medical evidence does not show the severity required for a rating in excess of 10 percent under DC 8207 based on the relevant symptomatology and impairment. 38 C.F.R. §§ 4.3, 4.7, 4.124a. REASONS FOR REMAND TDIU The Veteran contends that he is unemployable due to the service-connected disabilities, and is therefore entitled to TDIU. Basic eligibility is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). As explained above, the Board has granted service connection for an acquired psychiatric disability and bilateral hammer toes. As this action may result in a new combined total rating and alter the evidentiary basis for the TDIU claim, the Board will defer adjudication of this matter pending implementation of the Board’s decision with respect to the above-referenced claims by the Agency of Original Jurisdiction. The matter is REMANDED for the following action: 1. Implement the Board’s decision to grant service connection for an acquired psychiatric disability and bilateral hammer toes. 2. Take any additional action deemed necessary to adjudicate TDIU. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Ragheb, Counsel