Citation Nr: 20004772 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 16-03 464 DATE: January 21, 2020 ORDER Entitlement to an initial rating in excess of 10 percent for lumbar strain is denied. Entitlement to an initial rating in excess of 10 percent for a left knee disability is denied. Entitlement to an initial rating in excess of 10 percent for a right knee disability is denied. Entitlement to an initial staged 10 percent rating, but no higher, for hypertension prior to May 2, 2019, is granted. Entitlement to an initial rating in excess of 10 percent for hypertension is denied. Entitlement to an initial compensable rating for onychomycosis of the bilateral toenails is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities since August 8, 2014, is granted. FINDINGS OF FACT 1. The Veteran’s lumbar strain is manifested by forward flexion to 90 degrees with pain. 2. The Veteran’s left knee disability is manifested by painful limitation of flexion of 45 degrees or greater, even when considering flare ups of pain, without limitation of extension, recurrent subluxation, lateral instability, or other impairment. 3. The Veteran’s right knee disability is manifested by painful limitation of flexion of 45 degrees or greater, even when considering flare ups of pain, without limitation of extension, recurrent subluxation, lateral instability, or other impairment. 4. Prior to May 2, 2019, the Veteran’s hypertension required continuous medication for control. 5. During the entire initial rating period on appeal, the Veteran’s hypertension did not manifest as diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 6. The Veteran’s onychomycosis of the bilateral toenails is manifested by a total exposed body area of less than five percent, no exposed area, no scarring or disfigurement, and no systemic therapy treatment. 7. Since August 8, 2014, the Veteran was rendered unable to secure or follow substantially gainful employment as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. The criteria for an initial rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 3. The criteria for an initial rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 4. Resolving reasonable doubt in the Veteran’s favor, the criteria for an initial staged 10 percent rating, but no higher, for hypertension have been met for the staged rating period prior to May 2, 2019. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.21, 4.104, Diagnostic Code 7101. 5. The criteria for an initial rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.21, 4.104, Diagnostic Code 7101. 6. The criteria for an initial compensable rating for onychomycosis of the bilateral toenails have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7813-7806. 7. Resolving reasonable doubt in the Veteran’s favor, the criteria for a TDIU since August 8, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, had service from August 1988 to November 1988, July 2007 to August 2008, and from October 2010 to December 2013. He also served additional periods in the Army National Guard. The Board previously considered this appeal in September 2018, and remanded these issues for additional development in order to schedule VA examinations. After the development was completed, the case returned to the Board for further appellate review. An August 2019 rating decision granted the issue of entitlement to service connection for sleep apnea, which was previously remanded by the Board. As this represents a full grant of the issue previously on appeal, it is no longer before the Board. The August 2019 rating decision also granted a staged 10 percent rating for the service-connected hypertension, effective May 2, 2019. The Board notes that because the increase and assignment of a separate evaluation did not constitute a full grant of the benefits sought, the increased rating issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board has thoroughly reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence in the record; not every item of evidence has the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2019). The Court has held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. See Gilbert, 1 Vet. App. at 53. The Court has also stated, “It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.” Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2019). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where, as here, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial rating in excess of 10 percent for lumbar strain. The Veteran generally contends that a higher rating is warranted for his lumbar strain. The Veteran’s lumbar strain is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for lumbar strain. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain with use, including bending, walking, sitting, and standing. However, even considering the Veteran’s lay reports of symptoms, the May 2019 VA examiner found that the pain noted on examination did not result in or cause functional loss. Moreover, the degree of additional limitation reflected by the Veteran’s statements that his back hurts much more with use, including bending and standing, would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Even though a July 2013 Disability Benefits Questionnaire from the Veteran’s medical provider indicated that objective evidence of painful motion began at 45 degrees, a September 2013 medical record indicates that the Veteran has “excellent” forward flexion and was able to touch his toes without pain. An October 2014 private treatment record also found the Veteran’s lumbar spine motion was functional, as well as reflexes, sensation, strength, straight leg raise test and gait were normal. Moreover, the May 2019 VA examination showed forward flexion to 90 degrees on initial and repeated range of motion testing. The May 2019 VA examiner also found there was no additional loss of function or range of motion after three repetitions or repeated use over a period of time. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Veteran asserts that his left leg numbness is related to his lumbar strain. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to relate the condition to his lumbar strain, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Accordingly, the Veteran’s statements that his left leg numbness is related to his spine condition is not competent evidence. An October 2013 private treatment record showed the Veteran endorsed “some vague intermittent numbness in his legs,” and the diagnosis and indication section listed radiculitis, spinal stenosis, neurogenic claudication, and radiculopathy. However, a December 2013 nerve conduction study revealed no acute radiculopathy or peripheral neuropathy. In addition, the May 2019 VA examination determined there was no radiculopathy and the Veteran’s straight leg raise test was negative and his reflex and sensory examinations were normal. Accordingly, the Board finds the more probative medical evidence of record shows the Veteran does not have radiculopathy. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for lumbar strain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to initial ratings in excess of 10 percent for a left and right knee disability. The Veteran contends that he is entitled to higher ratings for his bilateral knee disabilities because he believes the disabilities meet the next higher rating criteria. The Veteran’s left and right knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the left and right knee disabilities. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by these statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees or less. Although no deformity, giving way, or instability was noted during the January 2013 medical board examination, a physical therapist wrote in February 2013 that the Veteran’s left knee suffered from “significant” instability. Similarly, while a fellow servicemember’s July 2013 statement indicated that the Veteran cannot stand for any length of time, a March 2013 treatment record noted that the Veteran walked 2.5 miles per day. An October 2014 private treatment record noted the Veteran walked between one to three miles per day. Examination revealed normal gait and that he was “able to get around well.” Reflexes, sensation and strength were normal, but he did use a left knee brace. January and February 2015 private treatment records indicated the Veteran’s bilateral knees had full range of motion with no effusion or laxity and were negative for anterior and posterior drawers test. On VA examination in May 2019, the Veteran reported left knee pain limiting walking or standing for long periods, and preventing running, jumping, kneeling and squatting. He also endorsed less frequent right knee pain. Upon examination, he had full range of active and passive motion for each knee with flexion to 140 degrees and extension to 0 degrees. Pain was noted with motion and there was tenderness in only the left knee, with no evidence of crepitus in either knee. There was no loss of range of motion with repetitive use, and while pain was noted to result in functional limitation with repetitive use over a period of time or during flare-ups, the VA examiner estimated there would be no loss of range of motion. He had full muscle strength of each lower extremity, with no objective evidence of instability. The Veteran’s bilateral knee scars, which were not found to be painful or unstable, have already been awarded service connection and there is no need to further address them in this decision. The Veteran endorsed using an occasional knee brace due to pain and stiffness and sporadic knee instability. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). While the Veteran has endorsed occasional knee instability, there is no objective evidence to confirm the presence of such disability. The Board assigns the objective medical evidence more probative weight as to the presence of subluxation and lateral instability than to the Veteran’s lay description of his symptoms, particularly as the Veteran’s reported symptoms were considered by the examiner, who nonetheless concluded that no instability was present. Based on the evidence of record, other Diagnostic Codes are not for consideration. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for ratings in excess of 10 percent for the left and right knee disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to an initial staged compensable rating for hypertension prior to May 2, 2019, and in excess of 10 percent thereafter. The Veteran generally asserts that a higher initial disability rating is warranted for his service-connected hypertension. The Veteran’s hypertension was initially rated as noncompensable (effective December 5, 2013) under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101. An August 2019 rating decision granted a staged 10 percent rating, effective May 2, 2019. Under Diagnostic Code 7101, a 10 percent disability rating requires diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or that an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent disability rating requires diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent disability rating requires diastolic pressure predominantly 120 or more. A 60 percent disability rating requires diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104. In every instance in which the Ratings Schedule does not provide a zero percent disability rating for a Diagnostic Code, a zero percent shall be assigned when the requirements for a compensable disability rating are not met. 38 C.F.R. § 4.31. After a full review of the record, and as discussed below, the Board concludes that the evidence is at least in equipoise on the question of whether the criteria for a 10 percent rating for hypertension have been met throughout the entire initial rating period. Review of the evidence does not demonstrate that the diastolic pressure has been predominantly 100 or more or that systolic pressure has been predominantly 160 or more; however, in light of two December 2013 private treatment records showing readings of 186/100 and 165/102, a November 2014 private treatment record that showed 128/84, a January 2015 private treatment record that showed 155/82, while a March 2015 private treatment record showed 129/85, as well as evidence that the Veteran’s hypertension required continuous medication for control, the Board finds the evidence more nearly approximates the criteria for a 10 percent evaluation for the initial rating period prior to May 2, 2019. See 38 C.F.R. § 4.21 (it is not expected that all cases will show all the findings specified). The Veteran received a VA examination in May 2019. The examiner noted that the Veteran was using medication continuously to treat hypertension with good results and no side effects. Blood pressure readings showed 175/100, 160/95, and 165/97, with an average blood pressure reading of 167/97. There were no other pertinent findings, complications, conditions, signs, and or symptoms noted by the examiner. The Board has considered the Veteran’s statements of record that a higher disability rating is warranted for his hypertension. The Veteran is competent to report symptomatology related to his hypertension because this requires only personal knowledge as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran alleges greater severity, the Board finds that the probative value of his allegations is outweighed by the aforementioned private treatment records and VA examiner’s findings. Competent medical evidence concerning the nature and extent of the Veteran’s disability has been provided during the appeal and provided relevant medical findings in conjunction with the examination. In this regard, the medical findings (as provided in the examination report and private treatment records) directly addresses the evaluation criteria for this disability. Accordingly, the Board finds that the medical records, as well as the medical examination opinion and findings are of greater probative value than the Veteran’s allegations regarding the severity of his hypertension. Notwithstanding that blood pressure readings do not meet the schedular criteria for a 10 percent disability rating under DC 7101, the evidence does show that for each rating period the hypertension has required continuous medication to control of symptoms. For this reason, and resolving reasonable doubt in the Veteran’s favor, the Board finds that a 10 percent disability rating for hypertension under Diagnostic Code 7101 is also warranted for the initial rating period prior to May 2, 2019. The Board concludes that the Veteran’s hypertension more nearly approximates the criteria for a 10 percent disability rating due to continuous use of medication prior to May 2, 2019. See 38 C.F.R. § 4.21 (it is not expected that all cases will show all the findings specified). A rating in excess of 10 percent is not warranted for any period because the evidence of record indicates that the Veteran’s service-connected hypertension disorder is primarily manifested by diastolic pressure predominantly less than 100 and continuous use of medication. The hypertension symptoms are clearly accounted for in the 10 percent rating pursuant to DC 7101. Throughout the entirety of both periods on appeal, the evidence has consistently shown the Veteran’s diastolic pressure to be less than 110 and systolic pressure less than 200, as required for at least the next higher rating of 20 percent. For these reasons, a rating is excess of 10 percent is not met or more nearly approximated for any period on appeal. The hypertension symptomatology was essentially stable throughout the first appeal period, and it is only with resolution of reasonable doubt that the 10 percent criteria are met, as the evidence only shows the required use of medication. Specifically, as the objectively confirmed predominant blood pressure readings alone do not even show that a 10 percent rating is warranted for the period prior to May 2, 2019, the criteria for a higher rating are not met (DC 7101). Since May 2, 2019, the evidence shows continuous use of medication and only systolic pressure that was predominantly 160 or more. Accordingly, the criteria for the next highest rating are not met. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Entitlement to an initial compensable rating for onychomycosis of the bilateral toenails. The Veteran generally contends that he is entitled to a compensable rating for onychomycosis of the bilateral toenails. This disability is rated under Diagnostic Code 7813-7806. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Prior to August 13, 2018, Diagnostic Code 7813 instructed to rate as disfigurement of the, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. Here, the evidence of record demonstrates that the predominant disability is onychomycosis, rated under the General Rating Formula for the Skin. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran’s onychomycosis does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. During the Veteran’s January 2013 medical board examination, the examiner observed thickened toenails on the great toe of both feet and of the second and fifth toes of the right foot. However, the examiner never specified how much of the Veteran’s skin was affected by his condition in terms of a percentage of bodily coverage. The Veteran reported no problems with this condition. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran’s onychomycosis does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. The May 2019 VA examination revealed a diagnosis for onychomycosis of both big toes. The Veteran reported that he does not take medication to treat this condition because he was told it would worsen his kidney condition. The VA examiner found that the total exposed body area was less than five percent, and there was no exposed area. There was no scarring or disfigurement. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include toenail fungus and pain, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, medical treatment records do not show that the Veteran’s disability more nearly approximates the criteria for a compensable rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for onychomycosis of the bilateral toenails. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to a TDIU. The Veteran contends that he is entitled to a finding of total disability due to individual unemployability. Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16(a). There is no requirement that employment be in a certain field or provide a certain standard of living or income level beyond the poverty level. Factors to be considered in determining entitlement to TDIU include but are not limited to employment history, educational achievement, and vocational attainment. Age is not a factor. 38 C.F.R. § 4.16. Basic schedular eligibility for TDIU is shown where a Veteran is in receipt of compensation for a disability rated 60 percent disabling, or for multiple disabilities combining to a 70 percent rating, with one condition rated at least 40 percent disabling. Certain disabilities, to include all those affecting a single body system, may be considered one disability. 38 C.F.R. § 4.16(a). If a Veteran does not meet these standards, TDIU may still be granted; it is the established policy of VA that all Veterans who are unemployable shall be rated totally disabled. However, such cases must be referred to the Director, Compensation Service, for extra-schedular consideration. 38 C.F.R. § 4.16(b). The Veteran is service-connected for the following: sleep apnea (50 percent); lumbar strain (10 percent); right knee (10 percent); left knee (10 percent); tinnitus (10 percent); hypertension (10 percent), and; noncompensable rating for bilateral knee scars, bilateral toenails onychomycosis, and bilateral lower extremities periodic limb movement. All ratings are effective December 5, 2013. The combined rating of these service-connected disabilities is 70 percent, with a qualifying single disability rated over 40 percent under 38 C.F.R. § 4.16(a). While the Veteran meets the schedular criteria for TDIU, the central inquiry is whether he is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The Board’s decision is based on consideration of all lay and medical evidence, and consideration of the functional limitations of each service-connected disability rather than reliance only on the opinion of a VA examiner viewing the disability in isolation. Furthermore, the Board has considered the interplay between the Veteran’s service-connected disabilities and his previous background, education, and employment history. Some VA examiners found the Veteran was able to work despite his service connected disabilities; these opinions are not binding on the Board, but are informative. The Board has considered all medical opinions, but focuses primarily on their discussion of functional capacities. The Veteran’s VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, noted he last worked full-time on August 8, 2014. He endorsed prevention of securing or following any substantially gainful employment due to his back, knees, tinnitus, hypertension, onychomycosis, and legs. The Veteran reported he had not tried to obtain employment since becoming too disabled to work. He indicated that he left his last job because of his disabilities. His highest level of education achieved was one year of college. He completed maintenance and leadership classes and trainings while in the military before he was too disabled to work, but had not had any further education or training since then. Private medical evidence from August 2014 shows that the Veteran is permanently and totally disabled since August 8, 2014, preventing him from securing or following any substantially gainful work due to his service-connected disabilities. In particular, the lumbar strain and bilateral knee disability prevents him from any work that required heavy lifting, prolonged standing, sitting, or walking. The limitations on function and employment imposed by the August 2014 private examiner due to the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. However, some of the May 2019 VA examiners found his service-connected disabilities would not impact his ability to work in a limited capacity. The VA examiner for onychomycosis found the Veteran’s skin condition would impact his ability to work because “if he has to wear steel toe boots it would hurt.” The VA examiner for sleep apnea found the Veteran would be tired all day until he started using a CPAP machine. The VA examiner for hypertension found it would not impact his ability to work. The VA examiner for knees found he cannot walk or stand for long periods, he cannot squat or knee, and stairs are very difficult for him to traverse. The VA examiner for the spine found the Veteran cannot stand or walk for long periods, he cannot bend or sit without pain. The Board finds the private medical records coupled with the May 2019 VA examiners’ opinions highly probative because it shows the totality of the Veteran’s service-connected disability in relation to his past work experience, education, and training. As a result, the Board finds that the Veteran meets the schedular criteria for a TDIU since August 8, 2014. Prior to that date, the Veteran endorsed being engaged in substantially gainful employment. In consideration of the foregoing, and resolving reasonable doubt in favor of the Veteran, the service-connected disabilities are of sufficient severity to render the Veteran unable to follow or maintain substantially gainful employment since August 8, 2014. 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.15, 4.16. Entitlement to special monthly compensation (SMC) is an “inferred issue” in the context of an increased rating claim that must be considered when the record indicates that it may be available, even if the claimant does not place eligibility for this ancillary benefit at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); see also Bradley v. Peake, 22 Vet. App. 280 (2008). SMC is payable at the housebound rate where the Veteran has a single service-connected disability rated at 100 percent and one or more distinct service-connected disabilities, which are independently ratable at 60 percent and involve different anatomical segments or bodily systems. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). For the purposes of a single 100 percent disability, a grant of a TDIU based on a single disability can qualify. See Bradley v. Peake, 22 Vet. App. 280 (2008). The Board’s decision above grants TDIU since August 8, 2014, based on all of the Veteran’s service connected disabilities. As a result, the Veteran does not qualify for SMC because he does not have one service-connected disability rated at 100 percent. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). E. Blowers Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Connally, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.