Citation Nr: 20007183 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 10-34 107 DATE: January 28, 2020 ORDER Service connection for radiculopathy of the left lower extremity is granted. Service connection for a neurologic disability of the right lower extremity is denied. A rating in excess of 30 percent for ulcerative colitis with reflux and anemia, aphthous sigmoid ulcers, and nodular mucosa, is denied. An increased rating for recurrent cysts on back, evaluated as 10 percent disabling prior to October 13, 2017, and as 30 percent disabling thereafter, is denied. FINDINGS OF FACT 1. The Veteran’s radiculopathy of the left lower extremity is related to a service-connected disability. 2. The Veteran does not have a neurological disability of the right extremity that was caused by his service, or that was caused or aggravated by service-connected disability. 3. The Veteran’s ulcerative colitis with reflux and anemia, aphthous sigmoid ulcers, and nodular mucosa, is shown to have been productive of symptoms that include painful cramping, diarrhea with mucus and blood, bloating and bowel obstruction; his disability is productive of no more than moderately severe symptoms with frequent exacerbations. 4. Prior to October 13, 2017, the Veteran’s recurrent cysts on back are not shown to have impacted at least 20 percent of the entire body or of the exposed areas affected, and treatment has not required the use of systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more during the past 12-month period. 5. As of October 13, 2017, the Veteran’s recurrent cysts on back are not shown to have impacted at least 40 percent of the entire body, or of the exposed areas affected; and treatment has not required the constant or near-constant use of systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for service connection for radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310. 2. The criteria for service connection for a neurological disability of the right lower extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for a rating in excess of 30 percent for ulcerative colitis with reflux and anemia, aphthous sigmoid ulcers, and nodular mucosa, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.14, 4.113, 4.114, Diagnostic Codes 7323, 7328, 7329, 7346. 4. The criteria for an increase rating for recurrent cysts on back, evaluated as 10 percent disabling prior to October 13, 2017, and as 30 percent disabling thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 - 4.16, 4.118, Diagnostic Codes 7801, 7804, 7805, 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Following the most recent supplemental statement of the case, dated in September 2019, a waiver of review by the agency of original jurisdiction was received. See 38 C.F.R. § 20.1304; Veteran’s waiver, received in October 2019. Service Connection The Veteran asserts that service connection is warranted for a neurological disability of the bilateral lower extremities. He primarily argues that service connection is warranted for radiculopathy of his lower extremities on a secondary basis, as due to his service-connected back disability, which has resulted in spinal disc pathology and pinched nerves, as documented in imagining studies of his back. See e.g., Veteran’s statement (VA Form 21-4138), dated in June 2014. He has submitted an article which states that scoliosis may be accompanied by numbness and shooting pain down the legs due to pinched nerves, as well as imaging studies of his back. In May 2016, the RO denied the Veteran’s claim. He has appealed. Although the RO characterized the issue as one of service connection for bilateral lower extremity pain in the September 2016 statement of the case, the Board has construed the claim broadly, as stated on the cover page of this decision. Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted, on a secondary basis, for a disability, which is caused or aggravated by a service-connected disorder. 38 C.F.R. § 3.310. The Veteran is currently service-connected for disabilities that include disc replacement, L5-S1, and left knee strain with chondromalacia patella. The Veteran’s service treatment records do not include any complaints, findings, or diagnoses shown to be relevant. As for the post-service medical evidence, a private treatment reports, dated in December 2008, notes that the Veteran was without radicular symptoms. An operative report, dated in July 2010, shows that the Veteran underwent a discectomy and neural decompression L-4-5 to S-1-2 left. The postoperative diagnosis was lumbar radiculopathy. A July 2010 MRI (magnetic resonance imaging) study notes suspected left-sided lateral disk protrusion or bulge at L4-5 which could potentially cause left-sided radiculopathy in the L4 distribution. A VA back disability benefits questionnaire (DBQ), dated in September 2012, shows that then Veteran was noted to have moderate paresthesias or dysesthesias in his left lower extremity, with a notation of spinal disc pathology involving the sciatic nerve roots, and moderate radiculopathy of the left lower extremity. The diagnosis was L-S bulging disc status post laser therapy in 2010. A VA back DBQ, dated in October 2017, notes mild numbness and intermittent pain in the left lower extremity, with a finding of mild left radiculopathy. The diagnoses were L5/S1disc bulging, disc desiccation and facet hypertrophy, and left lumbar radiculopathy L5-S1. The examiner concluded that it is less likely as not that the Veteran has a neurological disorder of his lower extremities due to his service, explaining that the Veteran’s service treatment records are silent regarding diagnosis of neurological disability of the bilateral lower extremities, and that the earliest documentation of left lumbar radiculopathy was July 2010. The examiner stated that the diagnosis of disc protrusion, disc desiccation, facet hypertrophy of lumbar spine is not service connected, and that, “therefore a secondary service connection opinion is not rendered.” A VA back DBQ, dated in September 2019, shows that the Veteran was noted to be status post L5-S1 disc replacement for a degenerative disc at the same level in January 2013. He reported that he had a successful surgery and that he does not have left leg pain any more. However, certain movements still generate low back pain, such as swinging motions during golf and bowling. The examiner indicated that the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy. The diagnosis was disc replacement L5-S1 With regard to the claim for a neurological disability of the left lower extremity, the Board finds that service connection is warranted for radiculopathy of the left lower extremity. There is credible and competent evidence to show that, during the period on appeal, the Veteran had left lower extremity radiculopathy. See July 2010 operative report: October 2017 VA back DBQ. To the extent that the Veteran many have experienced a reduction or resolution of his left extremity radiculopathy symptoms following back surgery in January 2013, the relevant issue is whether the claimed condition existed at the time the claim for service connection was filed, or during the pendency of that claim. McLain v. Nicholson, 21 Vet. App. 319, 321 (2007). A claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim. Id. The medical evidence is also sufficient to show that this disability is related to the Veteran’s service-connected back disability. See 38 C.F.R. § 3.310. Accordingly, affording the Veteran the benefit of all doubt, the evidence is at least in equipoise, and service connection for radiculopathy of the left lower extremity is granted. With regard to the claim for a neurological disability of the right lower extremity, there is no evidence to show that the Veteran has this disability. Although the Board has considered the Veteran’s submission of articles involving scoliosis, service connection is not warranted where the claimed condition is not shown. See Mattern v. West, 12 Vet. App. 222, 228 (1999). The Board also finds probative that the Veteran’s claim in June 2014 reported pain in his left hip, leg and foot. As the competent evidence of record does not indicate a neurological disability of the right lower extremity, the claim must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Increased Ratings Ulcerative Colitis with reflux and anemia, aphthous sigmoid ulcers, and nodular mucosa. The Veteran asserts that he is entitled to a rating in excess of 30 percent for service-connected ulcerative colitis with reflux and anemia, aphthous sigmoid ulcers, and nodular mucosa. The Veteran argues that he was hospitalized for gastrointestinal symptoms twice in 2019, and that VA has not provided him with adequate medication. He essentially argues that the combined effect of his disabilities warrants a higher rating. See Veteran’s statement, receive in November 2019. With regard to the history of the disability in issue, in February 1992, prior to his third period of active duty service, the Veteran underwent a colonoscopy, with a postoperative diagnosis of nodular lymphoid hyperplasia, terminal ileum moderate severe enterocolitis lympho follicularis involving the rectum, multiple biopsies and photos taken with aspirate obtained to rule out enteric pathogens. In June 2000, the Veteran underwent an esophagogastroduodenoscopy with small intestine endoscopy. The postoperative diagnosis was recurrent gastric polyps, Barrett’s esophagus, excess duodenal fluid and duodenitis. In 2003, he was noted to have scattered aphthous sigmoid ulcerations with nodular mucosa at the rectal and sigmoidal area. In 2006, during his third period of active duty service, the Veteran was treated for rectal bleeding with blood on toilet paper, with a noted history of rectal and sigmoidal colon ulcer, questionable. A June 2006 colonoscopy showed nodularity and a terminal ileum biopsy was done. In November 2007, the Veteran was noted to weigh 238 pounds. With regard to the administrative history of the disabilities in issue, in May 2010, the RO granted service connection for aphthous sigmoid ulcers and nodular mucosa, evaluated as 10 percent disabling; separate service connection was also granted for Barrett’s esophagus, evaluated as noncompensable. The Veteran appealed the issue of entitlement to an initial evaluation in excess of 10 percent for his aphthous sigmoid ulcers and nodular mucosa. In February 2016, the Board denied the claim. In May 2016, the RO combined the Veteran’s Barrett’s esophagus with his aphthous sigmoid ulcers and nodular mucosa, and increased the Veteran’s rating to 30 percent, with an effective date of June 11, 2014. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), and in an October 2016 Order, the Court granted a Joint Motion (JMR) of the parties and remanded the case to the Board for action consistent with the Joint Motion. In August 2017, the Board remanded the appeal in for action consistent with the October 2016 JMR. In January 2019, the RO determined that the grants of service connection for aphthous sigmoid ulcers and nodular mucosa, evaluated as 10 percent disabling, for the period January 15, 2009 to June 11, 2014, and the grant of service connection for Barrett's esophagitis, evaluated as noncompensable, for the period January 15, 2009 to June 11, 2014 were not appropriate. The RO assigned a 30 percent rating pursuant to Diagnostic Code 7323 for ulcerative colitis with reflux and anemia and aphthous sigmoid ulcers and nodular mucosa with an effective date that was commensurate with the date of service connection, i.e., January 15, 2009. The Board notes that this rating action did not result in a reduction of the Veteran’s combined disability rating. See O'Connell v. Nicholson, 21 Vet. App. 89, 93-94 (2007); VAOPGCPREC 71-91, 57 Fed. Reg. 2,316 (1992). Under 38 C.F.R. § 4.114, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran’s disability has been evaluated under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7323. Under DC 7323, a 30 percent evaluation is warranted for ulcerative colitis that is moderately severe; with frequent exacerbations. A 60 percent evaluation is warranted for severe ulcerative colitis; with numerous attacks a year and malnutrition, the health only fair during remissions. 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. Use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Private treatment records, dated in February 2009, show that the Veteran was noted to experience occasional hematochezia that was not accompanied by diarrhea, abdominal pain, nausea, vomiting or weight loss or loss of appetite. He was noted to weigh 250 pounds. The reports note acid reflux, Barrett’s esophagus, and colon polyps. He underwent an EGD (esophagogastroduodenoscopy) and colonoscopy, with a diagnosis of ulcerative colitis with moderate activity. A VA examination report, dated in August 2009, shows that the Veteran reported that almost every day he had medium to small amounts of rectal pains with occasional itching and burning. He used suppositories. Occasionally he has soilage on his underwear, but not very often. He has periods where it bothers him and other times it does not bother him. There was no diarrhea, constipation, melena, abdominal pains or cramping. His weight was stable. There was/were no fevers, chills, sweats, fecal incontinency, hemorrhoids, ulcerative colitis, or relevant hospitalizations or surgeries. There were no effects on his occupation or daily activities. The Veteran weighed 240 pounds. He was noted to have mild reflux esophagitis productive of burning in his chest and throat, but not into his mouth. His diet seemed to work fairly well. He was not on medications for GERD. He has no nausea, vomiting, diarrhea, constipation, melena, bright red blood in his stools (except for what was noted earlier in the report), pyrosis, dysphagia to solids or liquids, hematemesis, nausea or vomiting. There were no relevant hospitalizations or surgeries. There were no effects on his occupation or his daily activities. The relevant diagnoses were scattered aphthous sigmoid ulcers and nodular mucosa at the rectosigmoid junction with mild proctitis with reactive lymphoid chronic rectal discomfort and recurrent bleeding, and Barrett’s esophagitis with mild reflux esophagitis by panendoscopy, occasional reflux symptoms with burning in chest and throat controlled by diet, which is stable. A VA examination report, dated in April 2011, shows that the Veteran’s reports of his symptoms were generally similar to those reported at his previous VA examination in August 2009. A colonoscopy performed in February 2009 was noted to have resulted in a diagnosis of aphthous ulceration, with treatment that included Canasa suppositories. The Veteran denied any history of diarrhea, constipation or melena. He weighed 234 pounds. The examiner noted that there was no abdominal pain or cramping. The Veteran’s appetite is fair and there was no history of weight loss or weight gain. There was no fecal incontinence. The Veteran denied hemorrhoids, ulcerative colitis, Crohn’s disease, fistula or neoplasm. There was bleeding per rectum and pain that did not affect his occupation or his activities of daily living. The relevant assessment was aphthous sigmoid ulcer with mild proctitis and chronic rectal discomfort with recurrent rectal bleeding last confirmed by colonoscopy done in February 2009, presently being managed with Canasa suppositories. A VA examination report, dated in July 2012, shows that the Veteran was noted to have daily diarrhea, anemia, and blood and mucous in his stool. He was taking Canasa. He had occasional episodes of bowel disturbance with abdominal distress, which the examiner described as occurring three times a year, lasting about 45 days, with frequent diarrhea with mucous, and constant blood in his stool. There was no relevant weight loss. There was no malnutrition, serious complication, or other general health effects attributable to the intestinal condition. There was no impact on the Veteran’s ability to work. The diagnoses were uncreative proctitis, and enterocolitis lympho follicularis. A VA esophageal conditions DBQ, dated in October 2014, notes that the Veteran uses a proton pump inhibitor (Omeprazole). He was noted to have four or more episodes per year, lasting 10 days or more, with symptoms that included dysphagia, pyrosis, reflux, anemia, nausea, melena, and sleep disturbance. He weighed 225 pounds. The diagnosis was Barrett’s esophagitis. The examiner concluded that there was no impact on his ability to work. A VA esophageal conditions DBQ, dated in October 2017, notes daily use of Omeprazole, with infrequent episodes of epigastric distress. The Veteran was also noted to have pyrosis, reflux, regurgitation, substernal pain, and sleep disturbance. His symptoms were noted to be productive of recurrence four or more times a year, with an average duration of one day. There was no esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. The examiner concluded that there was no impact on his ability to work. The examiner further stated that the diagnosis of Barrett’s esophagus was incorrect, and that the Veteran’s appropriate diagnosis was GERD. A VA intestinal conditions DBQ, dated in October 2017, shows that the Veteran complained of rectal bleeding, with loose mucoid stools, and abdominal cramps several times a year. He said that he had been anemic in the past and took iron, and that he was no longer anemic. The examiner indicated that the Veteran did not need continuous medication for control of his intestinal condition, and that there was no relevant history of surgery. His symptoms were noted to be abdominal distension, diarrhea, and anemia. He was noted to have had three exacerbations and/or attacks in the past year. There was no relevant weight loss, and no malnutrition, serious complications or other general health effects attributable to his intestinal condition. The impact on the Veteran’s ability to work was that during flare-ups, and that he has to take excessive bathroom breaks, which impact his productivity and efficiency. A diagnosis of ulcerative colitis was provided. A VA intestinal conditions DBQ, dated in September 2019, shows that the Veteran reported a history of being hospitalized during service in 2006, at which time he was diagnosed with Crohn’s disease. Following separation from service, he reported having had to seek emergent treatment for bowel blockage, with hospitalization in September 2018 and August 2019, and said that he was told that the cause of his blockage was Crohn’s disease. The Veteran complained of symptoms that included painful cramping-like feeling, diarrhea mixed with mucus and blood about three times a year for about one month, bloating, and bowel obstruction. He said that he quit eating animal products 12 years ago, with some improvement in his symptoms. The examiner provided a diagnosis of ulcerative colitis. The DBQ also notes the following: There is no relevant history of surgery. The Veteran had three exacerbations or attacks in the past 12 months, with painful cramping, bloating, and/or passing of blood or mucus. There was/were no malnutrition, weight loss, serious complications, or other general health effects, attributable to an intestinal condition. There were no other pertinent physical findings, complications, conditions, signs or symptoms. There were no other significant diagnostic test findings or results. With regard to the impact on his employability, the Veteran reported that he has to make more trips to the restroom, and that while he is in the field, he has to hold his urge to defecate, which leads to poor performance at work and low work output. The examiner noted that the Veteran had lost no more than one week of work time in the last 12 months. VA progress notes, dated between 2017 and 2019, include problems lists that include GERD, obesity, blood in stool, and ulcerative colitis. The Veteran’s weight was between 230 and 238 pounds, with multiple notations that it was stable. The Veteran reported that he has worked for a telecommunications company since 2000, most recently as an installer. See e.g., April 2018 report. Private treatment reports, dated between 2010 and 2017, include reports for a 2011 colonoscopy for work up of intermittent hematochezia and a history of ulcerative proctitis. Overall, the diagnoses were melena/hematochezia, ulcerative proctitis and blood in stool. A November 2014 small intestinal capsule endoscopy report notes that there was no ulceration, polyp, inflammation, mass lesion, vascular malformation, or active bleeding identified. Continued current management as Crohn’s disease is not identified. An April 2017 colonoscopy notes hematochezia and ulcerative colitis with rectal bleeding. Private treatment reports, received in August 2019, show that the Veteran received treatment as of 2017, and that in 2019 he was evaluated for recurrent small bowel obstruction thought to be secondary to intra-abdominal adhesions. The Veteran reported a one-year history of severe abdominal pain progressing in severity. He was noted to have been hospitalized for two days in September 2018. A subsequent endoscopy was noted to show ulcerative colitis. Reports from the Methodist Health System, dated in August 2019, show that the Veteran was hospitalized for his abdominal pain. He was noted not to have unintentional weight loss, fevers or chills, or excessive fatigue. The diagnosis was small bowel obstruction. His weight was noted to be 193 pounds, and 225 pounds. The Veteran was hospitalized again in September 2019. His symptoms resolved quickly, and he was discharged after three days. He was noted to have abdominal pain, Barrett’s esophagitis, gastroesophageal reflux disease (GERD), small bowel obstruction, and ulcerative colitis. There was a history of peptic ulcer. There was no history of recent weight gain or weight loss, or night sweats. On examination, there was no abdominal pain, nausea, heartburn, diarrhea, constipation, or melena. The Veteran was 6’3” tall and weighed 225 pounds. There were two weight findings in 2017 of 220 pounds. The assessment was abdominal pain, GERD, and small bowel obstruction. The examiner noted a history of two attacks in the past 12 months, and indicated that surgery was not recommended, although it may be warranted if his symptoms return. In a statement, dated in October 2019, a private physician, C.O., M.D., stated that upon admission to a hospital in August 2019, the Veteran did not have evidence of enteritis (small intestinal Crohn disease) on imaging, and that an October 2018 CT (computerized tomography) scan had not shown enteritis or colitis. The most likely etiology of the Veteran’s bowel obstruction was due to intra-abdominal adhesions, probably from prior surgery (appendectomy, inguinal hernia surgery). Unfortunately, after review of the evidence of record, the Board finds that the claim must be denied. The Board first notes that the September 2019 VA examiner stated that a diagnosis of Crohn's disease was not warranted, as the Veteran has not been officially diagnosed with Crohn's disease and his history of colonoscopies have shown that his colon conditions are compatible with ulcerative colitis. See also November 2014 private endoscopy report; September 2019 VA examiner’s medical opinion (concluding that the Veteran it is less likely as not that the Veteran has Crohn’s disease, and explaining there is no objective testing, imaging, or biopsy evidence of this disease, and discussing the Veteran’s April 2017 colonoscopy results). Therefore, the Veteran is not shown to have this condition. However, the Board has not attempted to dissociate any of the Veteran’s intestinal symptoms from his service-connected disabilities. See generally Mittleider v. West, 11 Vet. App. 181 (1998). The Board further notes that the regulations clearly contemplate the assignment of a single rating in order to avoid violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. Particularly, the Board notes that the rating schedular specifically precludes separate ratings for certain co-existing abdominal conditions. 38 C.F.R. § 4.113. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348, inclusive, are not to be combined with each other. Rather, a single rating is to be assigned under the DC reflecting the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such rating. 38 C.F.R. § 4.114. As such, the Board can find no basis to assign separate ratings for the Veteran's gastrointestinal disabilities. Despite consideration of multiple diagnostic codes, the Board finds that a rating in excess of 30 percent is not warranted during the appeal period. Initially the Board finds that a rating in excess of 30 percent is not warranted under the Veteran currently assigned diagnostic code DC 7323. The Veteran’s symptoms do not more nearly approximate severe symptoms with numerous attacks a year and malnutrition, with health only being fair when disease is in remission. The Veteran's ranges of weight have been considered together with the other evidence, to include the evidence of anemia, and the Board finds that the evidence does not support that the Veteran suffers from malnutrition or significant impairment of general health. The Board notes that the Veteran was described as obese during an evaluation on February 21, 2009 and was reported to have a body mass index of either 29 or 30 on evaluations in February 2012, January 2013, March 2015, April 2017, and June 2018. The Veteran’s record of hospitalizations has been considered, however, the July 2012, October 2017, and September 2019 VA examiners all concluded that there was/were no malnutrition, weight loss, serious complications, or other general health effects, attributable to his gastrointestinal condition. In summary, the medical evidence of record does not show that the required criteria have been met. See DC 7323. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). As for the possibility of a rating in excess of 30 percent under any other potentially applicable diagnostic code, see Schafrath v. Derwinski, 1 Vet. App. 589 (1991), under 38 C.F.R. § 4.114, DC 7329, a 40 percent rating is warranted for resection of the large intestine with severe symptoms objectively supported by examination findings. However, in this case, the aforementioned evidence does not reflect any objective findings of severe symptoms, as would be required for a 40 percent rating under DC 7329. Specifically, in addition to the noted range of weight, there is no evidence of malnutrition, and the other aspects of his general health have been previously discussed. Such findings do not reflect disability in excess of that contemplated by the 30 percent rating currently in effect. Under Diagnostic Code 7328, "resection of the small intestine," a 40 percent rating is given when there is definite interference with absorption and nutrition, manifested by impairment of health objectively supported by examination findings including definite weight loss. Under DC 7346, a 60 percent rating is warranted for: Hernia hiatal: Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptoms combinations productive of a severe impairment of health. The Board finds that an initial evaluation in excess of 30 percent is not warranted under either DC 7328 or DC 7346. To the extent that these DCs list the criteria conjunctively, all of the listed symptoms must be shown. See e.g., Melson v. Derwinski, 1 Vet. App. 334 (1991). Here, the Veteran is shown to have had abdominal pain, with symptoms that include melena, ulcerative proctitis, and diarrhea, anemia, and small bowel obstruction. However, the evidence is insufficient to show that his service-connected disabilities have been productive of definite or material weight loss, sufficiently severe hematemesis or melena, or other symptoms combinations productive of a severe impairment of health. Accordingly, the Board finds that the criteria for an initial evaluation in excess of 30 percent under DCs 7328 and 7346 have not been met, and that the claim must be denied. The Board notes that it has considered the provisions of 38 C.F.R. § 4.114, where a higher rating may be granted where multiple comorbid abdominal conditions have been assigned one rating. Here, the predominant disability picture are the symptoms associated with the Veteran’s ulcerative colitis. The Board does not find that the severity of the overall disability warrants such rating, particularly, as the Veteran’s overall condition has not been demonstrated to result in malnutrition or a general impairment of health. See 38 C.F.R. § 4.114. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim, and that the impairment resulting from the Veteran’s disability warrants no higher than a 30 percent rating. Recurrent cysts on back. The Veteran asserts that an increased initial evaluation is warranted. He argues that he has cysts on areas other than his back that include his buttocks, chest, and under his arms. See Veteran’s letter, received in July 2019. The Veteran’s service treatment records show that he was treated for cysts, abscesses, and other skin symptoms at areas that include the buttocks, arms, and at the left axilla. In May 2010, the RO granted service connection for recurrent cysts on back, evaluated as 10 percent disabling, with an effective date of January 15, 2009. The Veteran appealed the issue of entitlement to an initial evaluation in excess of 10 percent. In September 2019, the RO granted the claim, to the extent that it assigned a 30 percent evaluation, with an effective date of October 13, 2017. Since this increase did not constitute a full grant of the benefit sought, the increased initial evaluation issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board notes that a separate rating is currently in effect for scars, residuals of excisions of the face and neck, and that the evaluation of that disability is not currently on appeal. Under 38 C.F.R. § 4.118, DC 7806, a 10 percent rating is warranted with 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 6 weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema that affects 20 percent to 40 percent of the entire body, or 20 percent to 40 percent of exposed areas, 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. Id. A 60 percent rating is warranted when more than 40 percent of the entire body, or more than 40 percent of exposed areas are affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. Id. DC 7806 draws a clear distinction between “systemic therapy” and “topical therapy” as the operative terms of the diagnostic code." Johnson v. Shulkin, 862 F.3d 1351 (2017). Systemic therapy means treatment pertaining to or affecting the body as a whole. Topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Prior to October 13, 2017. A VA examination report, dated in August 2009, shows that the Veteran was noted to have a history of treatment during service in 2006 for a cyst and furuncle on his back, with treatment for another cyst in 2007, and a history of several I&Ds (incision and drainage) for back cysts. On current examination, the Veteran stated that he did not have any cysts, but it was noted that there was scarring present. He said that his last flare-up had been two to three months before. His scars were too numerous to count, on the entire thoracic spine and to each side over the scapulae. They were of various sizes, with the largest being one-quarter inch in diameter. They were noted to be well-healed, nontender, and hyper-pigmented with good adherence and texture. There was no limitation of function, or functional irregularities. Three cysts were noted, two of which were described as one-quarter inch in size. The examiner stated that there are no real residuals from his scars. The relevant diagnosis noted recurrent cysts and furuncles on back with numerous scars from lancing. The examiner estimated that at least five to six percent of total body area was affected, and 0 percent of exposed areas were affected. VA progress notes, dated in 2009 and 2010, note use of bacitracin/polymyxin topical ointment for infection, and menthol/camphor gel for pain. Treatment included a simple incision and drainage of 2 x 2 cm cyst/abcess in 2012. A VA examination report, dated in April 2011, notes show that the Veteran complained of cysts on the back for the last 20 years off and on, with cysts also present in the frontal chest and in the buttocks area. He said that he has had these incised at least 4 or 5 times. He said that his last I&D was done in 2010. On examination, there were hyper-pigmented scars on the back and in the chest region. They were too numerous to count. They were hyper-pigmented brownish in color Their size varies from 0.5 centimeters (cm.) to 1.0 cm. They were well-healed and nontender. They had good texture without any underlying soft tissue damage. They were not elevated or depressed. There were no breakdowns, ulcerations, surrounding redness, inflammation, atrophic changes, irregularities, or limitation of function from the scars. There were two cysts one in the left upper back and one in the mid-back with a small head 0.5 cm. in size with surrounding redness. There were two small cysts on the anterior chest. The relevant diagnosis was recurrent cysts on back and chest with multiple scars from I&D with no limitation of function from the healed scars. The estimated surface area of scarring was about 5 percent with 0 percent of exposed body surface area. There was keloid formation in the left axilla from I&D with no limitation of function. Two cysts were present on the back which are less than 1 (one) percent of total body area, and cover 0 (zero) percent of exposed body surface area. It does not interfere with his daily activities or functions. A VA skin examination report, dated in July 2012, shows that the Veteran was noted to have a left axillary region cyst and skin removed with decreased range of motion in the left arm due to scar tissue. The Veteran had not been treated with oral or topical medications in the past 12 months for any skin condition. He had chronic cyst formation on his trunk, arm, legs, and head that affects 5 percent of his body, and less than five percent of exposed areas. There was no impact on the Veteran’s ability to work. The diagnosis was cysts. A VA scar examination report, dated in July 2012, shows that there were no painful or unstable scars. The left axillary region had a 20 cm. x 1-2 cm. scar or lesion. There were four scars on the anterior trunk, at the upper chest, and right upper chest (medial and lateral), and four lesions on the anterior trunk. All lesions/scars were 1 cm. x 1 cm. or smaller. There were four lesions on the lower back, all 2 cm. x 2 cm. or smaller. All lesions and scars were superficial and nonlinear. The area affected on the left upper extremity was 65 square cm., 2.8 square cm. for the anterior trunk, and 7 square cm. for the posterior trunk. The Board finds that an initial evaluation in excess of 10 percent is not warranted prior to October 13, 2017. There is no evidence of record indicating that at least 20 percent of the Veteran's body or at least 20 percent of exposed areas were affected by his service-connected condition. There is no evidence to show that he required systemic therapy or immunosuppressive drugs for treatment of his skin disorder for at least six weeks. To the extent that the Veteran is shown to have used topical ointments, they are not shown to be corticosteroids or immunosuppressive drugs. As for the possibility of a higher initial evaluation under another diagnostic code, Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), under 38 C.F.R. § 4.118, DC 7801, a 20 percent evaluation is warranted for scars not of the head, face or neck, that are deep and nonlinear, with an area or areas of at least 12 square inches (77 square centimeters). Under DC 7804, a 20 percent rating is warranted for scars, unstable or painful, Three or four scars that are unstable or painful. Under DC 7805, scars, other (including linear scars) and other effects of scars, may be evaluated for their disabling effects that are not considered under DCs 7800, 7801, 7802 and 7804. There are no findings to show the criteria for an initial evaluation in excess of 10 percent have been met prior to October 13, 2017 under DC 7801. The Veteran is not shown to have scars that affect at least 12 square inches (77 square centimeters), or to have at least three scars that are unstable or painful. DCs 7801 and 7804. Although the July 2012 VA scar DBQ notes a finding of decreased range of motion in the left arm due to scar tissue, this was contrary to the April 2011 DBQ findings, and overall, there are no findings to show that his scars are productive of sufficiently disabling effects in the left shoulder to warrant even a compensable rating under another diagnostic code. See DC 7805; see also 38 C.F.R. § 4.71a, DCs 5200 - 5203. Therefore, an initial evaluation in excess of 10 percent is not warranted under DCs 7801, 7804, or 7805. As of October 13, 2017. A VA skin DBQ, dated in October 2017, indicates that the examination was performed on October 13, 2017. The Veteran reported that he had a long history of multiple skin cysts (“hundreds”) since the 1980’s. He said that his cysts frequently become inflamed/infected and require I&D or excision, usually but not always with po abx (antibiotics by mouth), with no use of antibiotics in the past month. The cysts have involved his forehead, neck, chest, buttocks, and especially and extensively on his back. He said that the previous week he had two cysts removed from his chest, the wounds of which were sutured and are healing well now. Scarring and significant postinflammatory hyperpigmentation are the residuals of the previously excised cysts. The examiner indicated that the Veteran had been treated with constant or near-constant oral or topical medications in the past 12 months for a skin condition. The diagnosis was cysts. The impact on the Veteran’s ability to work was in the form of absenteeism from work for treatment and follow-up of cysts. Back and buttock cysts are often painful when sitting in a chair. There is a large area of multiple (TNTC) (too numerous to count) small non-inflamed cysts with extensive confluent scarring and post-inflammatory hyperpigmentation on the back. The total body are affected was estimate as 20 to 40 percent, with the total exposed area affected estimated as 5 to 20 percent. A VA skin DBQ, performed October 13, 2017, notes excision of multiple left axillary cysts. This scar is very irregular in shape, the width varies widely. Superficial non-linear scars on the left upper extremity measuring 20 x 5 cm were reported. The anterior trunk had essentially linear scars with hyperpigmentation blurring their border, on the left chest (cyst excision), right chest (cyst excision), upper abdomen, left and right (cyst excision), middle abdomen, left and right (laparotomy appendectomy), umbilicus (laparotomy appendectomy), and vertical suprapubic (back surgery). One scar was 8 cm., five scars were 2 cm., and three scars were 1 cm. For the posterior trunk, there was an estimated total area affected of 525 square cm. (three 3 x 3 cm. buttock scars are included in this estimate). The left upper extremity area affected was 35 square cm. The posterior trunk area affected was 525 square cm. For the head, face, and neck, with hypo- or hyperpigmented areas, the approximate combined total area in centimeters for each characteristic of disfigurement was: 0.2 square cm. There was mild limitation of extreme left arm abduction due to tightness and pulling of a band of left axillary scar tissue. No impact on the Veteran’s ability to work was reported. There are no findings to show the criteria for an evaluation in excess of 30 percent have been met as of October 13, 2017. There is also no evidence to show that the Veteran’s scars affect at least 144 square inches (929 square centimeters), or that his scars are productive of disabling effects warranting a higher evaluation. See DCs 7801, 7805. To the extent that the October 2017 VA DBQ notes that there was mild limitation of extreme left arm abduction due to tightness and pulling of a band of left axillary scar tissue, the examiner concluded that there was no impact on the Veteran’s ability to work. In addition, a VA shoulder and arm conditions DBQ for the left shoulder, dated in September 2019, shows that the Veteran denied any shoulder complaints or flare-ups. On examination, there was no pain. There was no left shoulder functional loss or functional impairment, and no additional functional loss or range of motion after three repetitions. The examiner stated that there is no evidence of limitation of range of motion of the left shoulder as a result of scar in the left axillary region and that the left shoulder range of motion is normal. In summary, there are no findings to show that his scars are productive of sufficiently disabling effects in the left shoulder to warrant even a compensable rating under another diagnostic code. See DC 7805; see also 38 C.F.R. § 4.71a, DCs 5200 - 5203. Therefore, an evaluation in excess of 30 percent is not warranted under DCs 7801 or 7805. Patrick M. Johnson Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S.E., 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.