Citation Nr: 20021682 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 17-60 328 DATE: March 26, 2020 ORDER The reduction in the rating for lumbar sprain and scoliosis with degenerative arthritis of the thoracic spine, from 20 to 10 percent, effective March 23, 2015, was proper and the appeal for restoration of the 20 percent disability rating is denied. A rating in excess of 10 percent for lumbar sprain and scoliosis with degenerative arthritis of the thoracic spine, is denied. The reduction in the rating for dermatitis of the hands, palm region and elbows to include tinea pedis of the feet from 10 to 0 percent disabling effective March 23, 2015, was proper and the appeal for restoration of the 10 percent disability rating is denied. A rating in excess of 10 percent for dermatitis of the hands, palm region and elbows to include tinea pedis of the feet, is denied. REMANDED The appeal for a rating greater than 30 percent for depression is remanded. The appeal for a rating greater than 10 percent for a right knee disability is remanded. The appeal for a compensable rating for a disability of the right hand little finger is remanded. The appeal for a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The evidence of record at the time of the reduction demonstrated a sustained improvement in the Veteran’s spine disability under ordinary conditions of life and work. 2. For the entire period, the Veteran’s service-connected back disability did not more nearly approximate forward flexion of the thoracolumbar spine to 60 degrees or less, combined range of motion of the thoracolumbar spine of 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or ankylosis; and there were no incapacitating episodes as defined by the applicable regulation. 3. The evidence of record at the time of the reduction demonstrated a sustained improvement in the Veteran’s skin disability under ordinary conditions of life and work. 4. For the entire period, the Veteran’s skin disability was manifested by intermittent outbreaks of bumps and itching on the hands, feet, sides of chest and abdomen, resulting in coverage of less than five percent of his entire body and none of his exposed areas, and required no oral or topical therapy during a 12-month period. CONCLUSIONS OF LAW 1. The reduction of the assigned rating for service-connected lumbar sprain and scoliosis with degenerative arthritis of the thoracic spine from 20 to 10 percent was proper, and the criteria for restoration of the 20 percent rating, effective March 23, 2015, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.10, 4.13, 4.71a (2019). 2. The criteria for a rating greater than 10 percent for service-connected lumbar sprain and scoliosis with degenerative arthritis of the thoracic spine, from March 23, 2015, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.10, 4.13, 4.71a (2019). 3. The reduction of the assigned rating for service-connected skin disability 10 percent to noncompensable was proper, and the criteria for restoration of the 10 percent rating, effective March 23, 2015, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.10, 4.13, 4.118 (2019). 4. The criteria for a compensable rating for service-connected skin disability from March 23, 2015, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.10, 4.13, 4.118 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1979 to October 1979, from October 1984 to October 1988, and from January 2002 to October 2010. The Board acknowledges that the Veteran initially requested a hearing in connection with his appeals but in correspondence dated in November 2019, the Veteran, through his attorney, withdrew the request for a hearing. The same November 2019 correspondence also requested an extension of 60 days from the date of the scheduled hearing (December 9, 2019) to submit additional evidence. As more than 60 days has passed since December 9, 2019, the Board proceeds with appellate review of the case. Increased Ratings and Rating Reductions Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Thus, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The provisions of 38 C.F.R. § 3.105 (e) allow for the reduction in evaluation of a service-connected disability when warranted by the evidence, but only after following certain procedural guidelines if the reduction would affect the combined disability rating. In this case, neither reduction resulted in a reduction in the combined disability rating. Consequently, the AOJ was not required to comply with the procedural guidance in 38 C.F.R. § 3.105 (e). The Board will address the merits of the reduction. Service connection for both the spine and skin disabilities was granted in April 2011 and effective in October 2010. Thus, neither disability had been rated for five years. As such, 38 C.F.R. § 3.44(c) applies to the present case. Reexaminations disclosing improvement in disabilities that have not continued at the same level for five years or more, will warrant a reduction in rating. Regulations “impose a clear requirement that VA rating reductions... be based upon a review of the entire history of the Veteran’s disability.” Brown v. Brown, 5 Vet. App. 413, 420 (1993); 38 C.F.R. §§ 4.1, 4.2, 4.13. A rating reduction is not proper unless the veteran’s disability shows actual improvement in his ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 349 (2000). The evidence must reflect an actual change in the Veteran’s condition and not merely a difference in the thoroughness of the examination or in the use of descriptive terms. 38 C.F.R. § 4.13. It must also be determined that any such improvement also reflects an improvement in the veteran’s ability to function under ordinary conditions of life and work. 38 C.F.R. §§ 4.2, 4.10; Brown, supra. Significantly, in a rating reduction case, VA has the burden of establishing that the disability has improved. A rating reduction case focuses on the propriety of the reduction and is not the same as an increased rating issue. See Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991). In considering the propriety of a reduction, the Board must focus on the evidence available to the AOJ at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition has demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282 (1992). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). 1. Whether the reduction from a 20 percent rating to a 10 percent rating, effective March 23, 2015, was proper. Service connection for the Veteran’s spine disability was granted in April 2011, and rated 20 percent disabling, effective in October 2010. The Veteran was provided with a periodic compensation and pension examination in March 2015. The AOJ reduced the Veteran’s spine rating from 20 percent to 10 percent based upon findings in the March 2015 VA examination report. See March 2015 rating decision. The present appeal arises from the Veteran’s disagreement with the reduction. The Veteran’s back disability was rated under Diagnostic Codes 5237-5242 at all points pertinent to the appeal. These diagnostic codes instruct the rater to apply the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine holds that a 20 percent rating is warranted for lumbar spine disabilities if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, if the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if the disability is manifested by 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 when forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A rating of 100 percent is warranted when there is unfavorable ankylosis of the entire spine. Prior to March 23, 2015, the Veteran’s spine disability was rated 20 percent disabling based on findings in a September 2010 VA examination report. During the September 2010 VA examination, the Veteran had flexion of 45 degrees; extension of 20 degrees; right lateral flexion of 20 degrees; left lateral flexion of 20 degrees; right rotation of 20 degrees; and left rotation of 20 degrees. Combined range of motion was 145 degrees. Pain was noted at all maximums of range of motion movements; and, the examiner reported that the Veteran was unable to complete repetitive range of motion testing due to pain. The Veteran was provided with another VA examination in July 2013. At that time, he had flexion to 90 or greater with no objective evidence of pain. It is unclear whether the repetitive testing was completed. The AOJ provided the Veteran with another VA examination for the back in March 2015. At that time, the Veteran had flexion to 80 degrees and full extension, full bilateral flexion, and full bilateral rotation. The examiner noted that there was no objective evidence of pain on examination but that the Veteran reported pain in flexion at 80 degrees. The Veteran was able to perform repetitive testing with no additional loss of function or range of motion. The Veteran denied experiencing flare-ups. The March 2015 VA examiner noted that the Veteran had localized tenderness of the thoracolumbar spine but that it did not result in an abnormal gait or spinal contour. The examiner also noted the Veteran’s report that he used a cane all the time for ambulatory support, due in part to the back disability, but noted that the Veteran did not use it during the examination. The March 2015 VA examiner noted that he could not answer the question of whether pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time, without resort to mere speculation. The examiner explained that all of the evidence had been reviewed in reaching such conclusion and explained that it would be speculative to report whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during prolonged use without objective evidence in the record, or when the reported symptoms were incongruent to findings on imaging and clinical examination. In a subsequent section of the report, the examiner explained that the Veteran’s reports of pain were out of proportion to the objective findings. The examiner explained that the Veteran subjectively reported pain in flexion at 80 degrees but that there was no objective evidence of pain in forward flexion while standing. Moreover, the examiner noted that the Veteran was able to bend forward while sitting, to tie his shoes and likewise, there was no objective evidence of pain. The Board finds that the requirements of Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) are met as the examiner reviewed all of the evidence in reaching the conclusion and explained the evidence required in order to make an estimation as to whether repetitive use would be limited due to pain, weakness, fatigability, or incoordination. In this regard, the examiner explained that speculation was required when the reported symptoms are incongruent to findings on imaging and clinical examination, as is the case here. Further, the Board finds that the March 2015 VA examination results were similar to the July 2013 VA examination results, which supports the finding that the Veteran’s forward flexion had significantly improved since the September 2010 VA examination where he had flexion to 45 degrees and limited motion in all other tested areas. Moreover, the evidence shows sustained improvement for approximately two years based on the objective findings during the July 2013 and March 2015 VA examinations. Further, even considering the Veteran’s subjective complaints of pain at 80 degrees of flexion, such limitation of forward flexion does not meet the requirements for a 20 percent disability rating. VA treatment records do not indicate worse symptoms than those reported and noted during the July 2013 and March 2015 VA examinations. Because the evidence demonstrates improvement in the Veteran’s spine disability for approximately two years prior to the reduction, the Board is satisfied that the evidence supports a finding of sustained improvement under ordinary conditions of life and work so as to warrant a rating reduction in this case. The Veteran’s range of motion in the back improved such that his forward flexion went from 45 degrees in 2010 to 80 degrees or greater for approximately two years prior to the reduction in March 2015. As such, the reduction of the assigned rating for the spine disability from 20 percent to 10 percent was proper, and the claim for restoration of the 20 percent rating, effective March 23, 2015, is denied. In reaching this conclusion, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against restoration of the 20 percent rating for the service-connected spine disability. Therefore, the benefit of the doubt doctrine is not applicable and the claim for restoration must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a rating greater than 10 percent for lumbar sprain and scoliosis with degenerative arthritis Further, the Board has considered whether a rating greater than 10 percent is warranted for the lumbar spine disability from March 23, 2015 but for the same reasons that it found the reduction proper on the merits, it finds a rating greater than 10 percent is not warranted at any time. As an initial matter, the Board acknowledges that additional VA treatment records were added to the record subsequent to the October 2017 statement of the case; however, the additional records are not pertinent to the rating for the service-connected back disability. The only record concerning the back is a December 2017 radiological report indicating scoliosis in the back, which is duplicative of evidence already of record. Therefore, the Veteran is not prejudiced by the Board adjudicating the claim. The Board has considered whether a disability rating higher than 10 percent is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint but finds that there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The March 2015 VA examiner noted that the Veteran complained of pain at forward flexion of 80 degrees. Notably, the examiner also noted there was no objective evidence of such pain because the Veteran was able to bend forward, while sitting, to tie his shoes without evidence of pain. Similarly, the examiner determined that there was no additional loss of range of motion following repetitive testing. The Veteran denied experiencing flare-ups. The Board acknowledges that the examiner could not make a finding with respect to any additional functional loss with repeated use over a period of time, without resort to mere speculation because the Veteran’s reported symptoms were incongruent with the clinical examination. Even resolving any doubt in favor of the Veteran to find that his functional ability for flexion ended at 80 degrees (when the Veteran asserts pain begins), the Board finds the criteria for a rating greater than 10 percent are not met. In this regard, flexion is not shown to be limited to 60 degrees or less. The Board has also considered whether a higher rating is warranted under the criteria for IVDS but finds that it is not. In this regard, the March 2015 VA examiner noted that the Veteran does not have IVDS. Likewise, VA treatment records do not indicate physician-prescribed bedrest at any time. The Board acknowledges the Veteran’s belief that his back disability is worse than that reflected by the currently-assigned 10 percent disability rating; however, the Veteran’s lay evidence regarding his symptoms are outweighed by the competent and credible medical evidence that evaluates the true extent of impairment due to the back disability based on objective data coupled with the lay complaints. Based on the foregoing, a rating greater than 10 percent for the back disability is not warranted. The Board has also considered whether separate, compensable ratings are warranted for neurological abnormalities associated with the lumbar spine disability, but finds that they are not. In this regard, there is no indication that the Veteran has neurological disorders such as radiculopathy in either lower extremity, or bowel or bladder disorders. The Veteran does not assert otherwise. In reaching this conclusion, the Board acknowledges the Veteran’s report to the March 2015 VA examiner that he had pain in his left hip and but notes that the Veteran attributed the pain to arthritis in the left hip. The Board also acknowledges that the March 2015 VA examination report did not specifically address whether there were any associated neurological symptoms; however, such was not necessary as treatment records do not indicate any findings of neurological manifestations related to the low back disability and the Veteran has not asserted otherwise. In reaching the foregoing determinations, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of a rating greater than 10 percent for the spine disability. Therefore, the benefit of the doubt doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Whether the reduction in the rating for dermatitis of the hands, palm region and elbows to include tinea pedis of the feet, from 10 to 0 percent, was proper. As noted above, service connection for the Veteran’s skin disability was granted in an April 2011 rating decision, and rated 10 percent disabling effective October 2, 2010. The 10 percent disability rating was continued in an August 2013 rating decision. The Veteran was provided with a periodic compensation and pension examination in March 2015. The AOJ reduced the Veteran’s skin disorder rating based upon findings in the March 2015 VA examination report. See March 2015 rating decision. The present appeal arises from the Veteran’s disagreement with the reduction. The Veteran’s skin disability was rated under Diagnostic Code 7806 at all points pertinent to the appeal. The Schedule of ratings for the skin were amended effective August 13, 2018. See 38 Fed. Reg. 32,592 (July 13, 2018). As the reduction here involved a period prior to August 13, 2018, the Board will consider the former version of the diagnostic codes only with respect to the reduction, and will consider the current version for the portion of the period after the effective date of the updated codes with respect to the increased rating. Under DC 7806 (dermatitis or eczema), a noncompensable rating is warranted where there is 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-month period. A 10 percent evaluation is assigned where there is involvement of 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 evaluation requires involvement of 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 with involvement of 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. 38 C.F.R. § 4.118. Further, DC 7806 also offers the option to rate under Diagnostic Codes 7800-7805, depending on the predominant disability. Diagnostic Code 7800 deals with scars of the head, face, or neck and is not applicable to this claim. Diagnostic Code 7801 provides for a 10 percent disability evaluation for a scar that is not of the head, face, or neck, that is deep and nonlinear, and that has an area of at least 6 square inches (39 sq. cm.). Higher ratings are available if larger areas are affected. A “deep scar” is defined as one associated with underlying soft tissue damage. Diagnostic Code 7802 provides for a 10 percent disability evaluation for a scar not of the head, face, or neck, that is superficial and nonlinear and which covers an area of at least 144 square inches (929 sq. cm.) or more. A “superficial scar” is defined as one not associated with underlying soft tissue damage. Diagnostic Code 7804 provides for a 10 percent disability evaluation for one or two scars that are unstable or painful. A 20 percent disability evaluation is assigned where there are three or four scars that are unstable or painful. A 30 percent disability evaluation is assigned where there are five or more scars that are unstable or painful. An unstable scar is one where there is frequent loss of skin covering over the scar. If one or more scars are both unstable and painful 10 percent is added to the evaluation. Pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of Diagnostic Codes 7801 to 7804. The AOJ initially assigned the 10 percent disability rating for the skin disorder because the evidence showed that the Veteran had dermatitis and tinea pedis involving 5 percent of his exposed body skin area. See April 2011 rating decision. The AOJ provided the Veteran with a VA examination for his dermatitis in March 2015. At that time, the Veteran reported that his dermatitis resulted in bumps all over the hands and sides of his chest and abdomen and the bumps sometimes itched. He also reported that the tinea pedis of the feet was constant and sometimes itched. He denied using oral or topical treatment. The examiner determined that the Veteran’s dermatitis covered less than 5 percent of the Veteran’s entire body and none of his exposed areas. The prior VA examination report, dated in July 2013, contained substantially the same reports regarding itching. At that time, the examiner noted that the Veteran did not have a current outbreak and determined that the skin disorder affected zero percent of the Veteran’s body. VA treatment records do not reflect worse complaints or findings than those in the March 2015 VA examination report. As the percentage of the body affected by the Veteran’s skin disability appears to have improved such that it covered less than 5 percent of the body during the March 2015 VA examination, the appropriate rating was zero percent under Diagnostic Code 7806. The Board acknowledges that even though the area affected by the Veteran’s skin disorder improved, he still had occasional itching in the affected areas. The Board finds that such occasional itching is contemplated by Diagnostic Code 7806, which specifically applies to dermatitis and eczema. The Board has considered whether any of the diagnostic codes from 7800 to 7805 would have supported a higher rating but finds that they were not applicable. In this regard, Diagnostic Code 7806 specifically applies to the Veteran’s dermatitis disability. Moreover, the Board finds that the Veteran’s tinea pedis was more akin to dermatitis than a scar as it was a recurring skin condition and not a permanent mark on the skin. Based on the foregoing, the reduction of the assigned rating for the skin disability from 10 percent to 0 percent was proper, and restoration of the 10 percent rating March 23, 2015, is not warranted. In reaching this conclusion, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against restoration of the 10 percent rating for the service-connected skin disability. Therefore, the benefit of the doubt doctrine is not applicable and the claim for restoration must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a compensable rating for a skin disorder, from March 23, 2015. Further, the Board has considered whether a compensable rating is warranted for the skin disability but for the same reasons that it found the reduction proper on the merits, it finds a compensable rating is not warranted at any time. As discussed above, the Veteran’s skin disorder has been rated under Diagnostic Code 7806. Amendments were made to the criteria for rating the skin, effective August 13, 2018. See 83 Fed. Reg. 32, 592 (July 13, 2018). The amendments did not substantially change the criteria for rating scars under Diagnostic Codes 7804 or 7805. With regard to Diagnostic Codes 7801 and 7802, the terms deep, nonlinear, and superficial, were replaced with “underlying soft tissue damage.” The revisions also divided the previously referenced body parts into various zones of the body and indicated that separate evaluations may be assigned for each affected zone under Diagnostic Codes 7801 and 7802. Under the amended rating, skin conditions under Diagnostic Code 7806 are rated under the General Rating Formula for Skin. In the new General Rating Formula for Skin a noncompensable rating is warranted 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 warranted for characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body; or for at least 5 percent, but less than 20 percent, of exposed areas; or for 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 warranted for characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or for 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 warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or for 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. Under the new 38 C.F.R. § 4.118, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. As discussed above, the Veteran was provided with a VA examination in March 2015. Further, the Board acknowledges that additional VA treatment records were added to the record subsequent to the October 2017 statement of the case; however, the additional records are not pertinent to the rating for the service-connected skin disability. In this regard, the records do not concern the Veteran’s service-connected skin disorder. The only records mentioning the Veteran’s skin are records regarding a knee brace and its effect on the immediate area related to the brace. See e.g. August 2019 VA treatment record. Therefore, the Veteran is not prejudiced by the Board adjudicating the claim. Even considering the Veteran’s report during the March 2015 VA examination, that his dermatitis resulted in bumps all over his hands, sides of his chest and abdomen, and the bumps sometimes itched, as well as constant tinea pedis of the feet, the March 2015 VA examiner determined that the Veteran’s dermatitis covered less than 5 percent of the Veteran’s entire body and none of his exposed areas. Such percentage of coverage does not warrant a compensable rating under Diagnostic Code 7806 under the former code or the amended code. Further, the Veteran denied using any oral or topical treatment for the skin disorder. See March 2015 VA examination report. He has not subsequently reported any change. Thus, a higher rating is not warranted for the same. VA treatment records do not indicate worse symptoms than those reported during the March 2015 VA examination. The Board has considered whether any other diagnostic code would provide for a higher rating but finds that other diagnostic codes are not applicable. Specifically, the Board reiterates its finding that the Veteran’s tinea pedis is more akin to dermatitis than a scar as it is a recurring skin condition and not a permanent mark on the skin. The Board acknowledges the Veteran’s belief that his skin disability is worse than that reflected by the currently-assigned rating; however, the Veteran’s lay evidence regarding his symptoms are outweighed by the competent and credible medical evidence that evaluates the true extent of impairment due to the skin disability based on objective data coupled with the lay complaints. Based on the foregoing, a compensable rating for the skin disability is not warranted. In reaching this conclusion, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against a compensable rating, since March 23, 2015. Therefore, the benefit of the doubt doctrine is not applicable and the claim for higher rating must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a rating greater than 30 percent for depression. VA treatment records added to the file since the most recent VA examination in March 2015 indicate that the Veteran’s depression disability may have worsened. In this regard, the November 2017 VA treatment record noted the Veteran’s reported flashbacks. The Veteran did not report flashbacks during the March 2015 VA examination. Thus, to ensure that the record includes sufficient medical evidence to properly evaluate the disability under consideration, the Board finds that a more contemporaneous examination is needed. See 38 C.F.R. § 5103A; 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination). Further, in a March 2015 phone call to VA, the Veteran reported that he had been taken to a private mental hospital. Any outstanding private treatment records should be obtained. 2. Entitlement to a rating greater than 10 percent for a right knee disability. The March 2015 VA examination report is inadequate with respect to the examiner’s notation that she was unable to say without speculation whether pain, weakness, fatigability or incoordination of the Veteran’s right knee significantly limit functional ability with repeated use over a period of time. The examiner explained that it would be speculative to report whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during prolonged use without objective evidence in the record or when the reported symptoms are incongruent to findings on imaging and clinical examination. Significantly, the examiner did not explain what the Veteran’s reported symptoms were regarding functional effect of repeated use of the right knee over time, or why they were incongruent to findings on imaging and clinical examination. As such, another VA examination is required. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to a compensable rating for a disability of the right hand little finger. A December 2019 VA hand examination was added to the record since the case was certified to the Board in May 2018. This report has not yet been reviewed by the AOJ in connection with the claim, and as of this date there is no indication that the Veteran waives initial AOJ review. As such, the appeal is remanded for initial review by the AOJ of pertinent evidence for this claim on appeal. 4. Entitlement to a TDIU. The Veteran’s claim for TDIU may be affected by the outcome of the claims remanded herein for higher ratings. As such, the Board finds that the claim for TDIU is inextricably intertwined with the remanded claims. See Parker v. Brown, 7 Vet. App. 116 (1994) and Harris v. Derwinski, 1 Vet. App. 180, 183 (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran's claim for the second issue). The matters are REMANDED for the following actions: 1. Offer the Veteran the opportunity to provide any outstanding private treatment records from the mental hospital where the Veteran reported being taken prior to March 2015. Alternatively, offer the Veteran the opportunity to authorize VA to obtain the records on his behalf. If these records cannot be located, it must specifically document the attempts that were made to locate them and the Veteran must be notified. 2. Then, schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his depression. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 3. Schedule the Veteran for an examination with the March 2015 VA examiner (or another appropriate clinician) to determine the current severity of his right knee disability and to provide a supplemental opinion. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided, to include an opinion regarding the functional effects of the Veteran’s right knee disability since March 2015. 4. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, readjudicate the Veteran’s claims, to include claims for increased ratings for depression, right knee, and right little finger disabilities as well as entitlement to TDIU, based on the entirety of the evidence. If any claim remains denied, issue a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Donna D. Ebaugh, 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.