Citation Nr: 20021980 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 16-37 274 DATE: March 30, 2020 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for migraines claimed as headaches due to exposure to Gulf War environmental hazards is denied. Entitlement to an increase rating in excess of 30 percent for asthma prior to November 16, 2016 is denied. Entitlement to a rating of 60 percent for asthma from November 16, 2016 is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor his tinnitus began during active service with a continuity of symptoms after service. 2. Headaches were not manifest during service and are not caused by any aspect of service 3. Prior to November 16, 2016 the Veteran used inhalant’s daily but did not have an FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. 4. From November 16, 2016, the Veteran experienced frequent asthma attacks warranting courses of oral corticosteroids (at least three per year), daily use of an inhaled steroid medication (not systemic), and night use of oxygen. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107(b (2012); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a) (2019). 2. Headaches were not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5013, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2019). 3. Prior to November 16, 2016, the criteria for a rating greater than 30 percent for asthma have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.97, Diagnostic Code (DC) 6602 (2019). 4. From November 16, 2016, the criteria for a rating of 60 percent, but not higher, for asthma have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.97, DC 6602 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty service in the United States Navy from August 1986 to July 1992. This matter comes before the Board of Veterans’ Appeals on appeal from a December 2013 and January 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a Veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Tinnitus A complete review of the Veteran’s service treatment records (STRs) was conducted, which are associated with the claims file. The Veteran’s STRs were silent for any symptoms, complaints or diagnosis made for tinnitus while the Veteran was in-service. In a November 1990 service treatment record (STR) medical surveillance questionnaire, it was indicated that due to the Veteran’s job as a nuclear power student, and time working at a plant, he was exposed to noise and was given ear protection. See August 2013 STR-Medical, p.17. During a June 1992 report of medical separation examination, the clinical evaluation revealed the Veteran’s ears and drums were normal. See August 2013 STR-Medical, p.31. The Veteran also indicated that he was in excellent health and not taking any medication. However, in the “Have You Ever Had or Have You Now” section the Veteran reported that he had hearing loss but denied ever wearing a hearing aid. See August 2013 STR-Medical, p. 35. However, the examiner evaluated the report and noted that the Veteran had no history of a hearing acuity threshold shift. There was no mention of tinnitus. In October 2013, the Veteran was afforded a hearing and tinnitus VA examination. The examiner indicated that the Veteran had a current disability of recurrent tinnitus. The Veteran reported that he had a long history of tinnitus but gave no onset of the condition. The examiner noted that it was less likely than not that the that the Veteran’s tinnitus was caused by or the result of his military noise exposure. The rationale given was that the Veteran was around noise as a machinist mate working in engine rooms near turbines and reduction gear for 12-18 hours a day but made use of hearing protection, including his own. The examiner’s reasoning also was that the Veteran had several Puretone audiometric test during service, including at separation and both ears at all frequencies came back normal; and there were no significant changes between the Veteran’s enlistment and separation examinations. The examiner also noted that there were no complaints of tinnitus while in-service. Also, the examiner noted that after service the Veteran worked in an auto body shop, but he had administrative duties and was not around significant noise. Also, the Veteran indicated that tinnitus impacted his ordinary conditions of daily life and ability to work. The Veteran indicated that it was worse at times, and that he had to consciously tune it out. During a November 2019 Board hearing, the Veteran indicated that after a classroom school, he was a student at nuclear power prototype plant. The Veteran further indicated that he had noise exposure while he was on active duty working as a machinist’s mate requiring him to work in an engine room with turbine generators, main production gears and steam generating equipment. The Veteran reported that he was given standard flight deck or engine room hearing protectors. The Veteran further noted he worked watches from 4-6 hours a day and when working in the engine room he worked 16-18 hours a day. However, the Veteran indicated that he did not think the hearing protection was effective; because the seal around the ear cups were hard and they were never replaced. The Veteran further indicated that he experienced a lot of noise leaking through his hearing protection on one of his travels during service. In addition, the Veteran reported that he tried ear foam plugs, but they irritated his ears, so he bought his own hearing protection. However, he indicated that when he was not on watch duty, he did not use hearing protections; and since he was near flight operations, he stated sometimes aircraft landings or catapult operations would cause temporary loss of hearing for 20 or 30 seconds. In addition, the Veteran reported he had ringing in his ears that was high pitch, and he still had the same high pitch frequency from the reduction gears. See November 2019 Hearing Transcript, p.6-7. During the Board hearing, the Veteran indicated at discharge he was not sure what hearing loss met on the separation examination; so, he denied hearing loss and then crossed it out and indicated yes, he had hearing loss, due to the ringing in his ears. However, the examiners comments did not mention ringing in the ears. The Veteran reported that his post-service occupation involving gardening and the environment was quiet. He testified that he had not had noise exposure since service. If he was trimming weeds or cutting plywood, he would wear hearing protection. However, the Veteran did say he worked in a body shop in a primarily administrative position. The Veteran noted that the grinding started getting into the painful area, so he had to stay away until the grinding was done. The Veteran noted that it affected his ability to work. See November 2019 Hearing Transcript, p.10. Furthermore, the Veteran’s spouse testified that that the Veteran complained about high pitched noise when they met in 1993. See November 2019 Hearing Transcript. Tinnitus is a condition capable of lay observation and diagnosis. See Charles v. Principi, 16 Vet. App. 370, 374 (observing that "ringing in the ears is capable of lay observation.") Moreover, to the extent that tinnitus is capable of lay observation, the Veteran is competent to report his symptoms. Therefore, his assertions regarding in-service onset and continuing symptoms thereinafter are both competent and probative. The Board concludes that the Veteran has a current diagnosis of tinnitus that began during active service. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Lay statements and treatment records note the Veteran has a current diagnosis of tinnitus. The Veteran credibly reported noise exposure as nuclear power student and as a machinist mate. The Veteran indicated that the position required him to work in an engine room with turbine generators, main production gears and steam generating equipment exposing him to loud noise. The Veteran credibly testified that he began experiencing ringing in his ears after being exposed to loud noises in service during training and while performing his duties as a machinist mate. The Board finds the Veteran's statements to be competent and credible as to the onset of his current tinnitus, ongoing symptoms and noise exposure in service. The Veteran was afforded a VA examination in October 2013. The VA examiner noted recurrent tinnitus. The examiner concluded that it was less likely than not that the that the Veteran’s tinnitus was caused by or the result of his military noise exposure. The rationale was the Veteran was around noise as a machine mate working around engine rooms, turbines and reduction gear for 12-18 hours a day with the use of hearing protection, including his own. The examiner’s reasoning also was that the Veteran had several Puretone audiometric tests including at separation and hearing acuity in both ears at all frequencies was normal; and there were no significant changes between the Veteran’s enlistment and separation examinations. And there were no complaints of tinnitus while in-service. Based on the evidence of record the Board finds that the evidence is in relative equipoise as to the onset of his tinnitus and resolves reasonable doubt in the Veteran's favor as to the onset of tinnitus in-service. There is both favorable and unfavorable evidence regarding the onset of the Veteran's tinnitus, the Board finds the Veteran's reports of his symptoms of developing tinnitus in service with continuing symptoms since service to be credible. The examiner’s reasoning also was that there were no significant threshold changes between the Veteran’s enlistment and separation examinations; and that there were no complaints of tinnitus while in-service. Thus, resolving reasonable doubt in the Veteran's favor the Board finds that it is at least as likely as not that the Veteran's tinnitus had onset in-service with continuous symptoms since that time. As such service connection for tinnitus is warranted. Headaches 38 C.F.R. § 3.317(a) provides that VA will pay compensation to a Persian Gulf Veteran who exhibits objective indications of a "qualifying chronic disability" that becomes manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2016. See also 38 U.S.C. § 1117 (2012). A qualifying chronic disability is defined as: (A) an undiagnosed illness; or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; or (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a) (2019). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, as follows: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317(b). The Veteran contends his headaches are due to his time in service in the Persian Gulf. The Veteran's service treatment records are silent as to any complaints, treatment or diagnosis for chronic headaches. During a June 1992 report of medical separation examination, the clinical evaluation revealed that the Veterans head, face, neck and scalp; upper extremities and neurologic system were normal. See August 2013 STR-Medical, p.31. The Veteran denied that he ever had frequent or severe headaches or dizziness or fainting spells. See August 2013 STR-Medical, p.35. In an October 2011 primary care note, the Veteran denied having headaches. See July 2013 Capri, p.1. In December 2013, the Veteran was afforded a compensation and pension examination. The Veteran reported he had headaches as a result of being exposed to Gulf War environmental hazards. The examiner noted that there was no evidence of chronic headaches and that there had been no diagnosis of headaches. The examiner found that it was less likely as not that headaches were related to an exposure to Gulf War environmental hazards. In January 2014, the Veteran underwent a headaches VA examination. The examiner indicated that the Veteran had a diagnosis of migraines. The Veteran reported onset in 1997-1998, which was 4-5 years after service. The Veteran indicated that the headaches were located frontally then at his temples. The Veteran reported that dark rooms were more comfortable than rooms with light. At the time the Veteran was not prescribed medication but had been taking an over the counter drug. The Veteran reported symptoms of throbbing head pain, pain on both sides of his head, sensitivity to light, and sharp stabbing pain. The examiner concluded that the Veteran’s headaches were less likely as not related to the Veteran’s headache problems while in-service in Southwest Asia. The rationale given was that no chronic headache condition was identified as treated or diagnosed in the Veteran’s records. Also, that there are many things that could have caused the Veteran’s headaches such as genetics and depression. The examiner also noted that migraines affect 12 percent of the population and can be triggered by stress, weather changes, sleep disturbances, odors, exercise, sex, neck pain and several other factors. In addition, the examiner indicated that the Veteran described his onset as 1997-1998 which was 5 years after service. See January 2014 Capri, p.3-6. In an October 2014 VA treatment record, the Veteran indicated that his headaches were further behind his eyes. The Veteran indicated he had photo sensitivity but denied nausea. The Veteran indicated that at that time that he had 3-4 headaches within that year. The Veteran also reported that he started noticing headaches in 1997. Also, at that time the Veteran had been diagnosed with glaucoma 10-11 months prior to this visit. See November 2015 capri, p.9. In December 2014, the Veteran submitted a statement regarding his headaches. The Veteran indicated himself that he did not have regular headaches that were severe while in-service. The Veteran reported that it was not until 1995 that he started to occasionally have headaches. The Veteran went on to say that he did not associate the cause to an event and thought it was just a part of life. See December 2014 Correspondence, p.1. During a September 2015 VA treatment visit, the Veteran complained of eye strain headaches; further reporting that he had been on the computer 80 percent of his time. However, he did report also having other kinds of headaches. See November 2015 Capri, p.2. In a November 2018 VA Radiology report, the Veteran underwent magnetic resonance imaging (MRI) of the brain because his headaches increased in frequency and severity. The impression given by the physician was that there was a normal noncontrast MRI appearance of the brain. See January 2020 Medical Treatment Record- Government Facility, P.114-115. In April 2019, a private physician (referred from VA) noted that the Veteran complained of having headaches for several years, located on the top of his head and temples. The Veteran indicated he experienced throbbing, nausea, visual changes and episodes occurring 9-10 days a month. The physician noted that the Veteran started on the medication amitriptyline which helped his headaches, but he still continued to have headaches. See January 2020 Medical Treatment Record-Government Facility, p.105. During the November 2019 hearing, the Veteran testified that his migraines affected the top part of his head. The Veteran indicated that he never had auras and had no family history of migraines. The Veteran testified before service he “did not have migraines but very rarely”. The Veteran noted that he was on migraine medication and when they are severe, he had light sensitivity. See November 2019 Hearing Transcript, p. 11-12. In light of all the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's headaches are related to his active service on a direct basis. There is no evidence of headaches in the service treatment records. The Veteran specifically denied experiencing frequent headaches on his June 1992 separation report of medical history. Also, in the Veteran’s December 2014 statement, he indicated that he did not notice an onset of headaches until around 1997, which was 5 years after separation. The Veteran also reported this same information during his VA examination in January 2014. There is simply no credible evidence that the Veteran's headaches had their onset in service or are otherwise related to his active service on a direct basis. Furthermore, while the Veteran did allege his headaches are due to being exposed to gulf war environmental hazards; the Veteran did indicate that he did not realize the headaches were related to service and admitted he did not have regular and severe headaches while in-service. Also, the Board notes that such a prolonged period without any complaints from the time of separation to in 1992 to noticing the headaches in 1997 (5 years) weighs heavily against the assertion that the condition had its onset in service or is otherwise related to his active service. See Maxson v. Gober, 230 F.3d 1330, 1333 (2000). The Board finds the January 2014 VA examiner's opinion to be the most probative in this regard. The records and the examination report show that the Veteran’s recurrent episodes of headaches are a clearly diagnosed disorder and not an undiagnosed illness. The headaches do not constitute a medically unexplained chronic multisymptom illness as they have at least a partially understood etiology including genetics and depression and can be triggered by stress, weather changes, sleep disturbances, odors, exercise, sex, neck pain and several other factors. The examiner ruled out causation by the Veteran’s service in Southwest Asia. The examiner provided an adequate rationale for his opinion. As shown above, the VA examiner noted that the Veteran had a known diagnosis, but there was no evidence indicating that the headaches were related to the Veteran’s time in-service or due to exposure to a hazardous environment while in the Gulf War. To the extent the Veteran himself, as a lay person, opines that his headaches are caused by his active service or are due to exposure to a hazardous environment while serving in the Gulf War, the Board finds that the Veteran's opinion carries no probative weight because it is not supported by any basis or evidence. In summary, the Board concludes that service connection for headaches, is not warranted; as a preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2019). Separate diagnostic codes (DCs) identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2019). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2019). VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. Asthma The Veteran's service-connected asthma is rated under Diagnostic Code (DC) 6602. 38 C.F.R. § 4.97, DC 6602. DC 6602 provides ratings for asthma, in part using the results of pulmonary function tests (FFTs). Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy, is rated 10 percent disabling. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication, is rated 30 percent disabling. FEV-1 of 40-to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids, is rated 60 percent disabling. FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications, is rated 100 percent disabling. A Note to DC 6602 provides that, in the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97. In addition, the Board notes that, when evaluating based on PFTs, VA is to use post-bronchodilator results unless the post-bronchodilator results were poorer than pre-bronchodilator results, in which case the latter should be used instead. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs (e.g., FEV-1, FVC, or FEV-1/FVC) such that the evaluation would be different depending on which test was used, the Board must use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(6). The Board finds that the rating criteria do contemplate the use of medications as they are cited in the regulations and recognize the effects of bronchodilators and inhalational therapy. In an October 2011 primary care note, the clinician indicated that the Veteran was taking daily medications: albuterol and mometasone furoate inhalers for his asthma, as well as a nasal spray. See July 2013 Capri, p.1. In November 2012, the Veteran was given a pulmonary function test. The clinician concluded that the test showed a mild obstructive ventilatory defect with response to bronchodilators. See December 2013 VA Examination, p.2. In a September 2013 VA treatment note, the Veteran indicated that he had problems breathing in the autumn and was using an albuterol inhaler up to 5 times a day. See October 2013 Capri, p.1. In a November 2013 VA treatment record, a pulmonary function test was given with an FEV1 80 percent and a post-bronchodilator result of FEV-1/FVC of (84%). See December 2013 Capri, p.7. In December 2013, the Veteran was afforded a respiratory conditions examination. The examiner indicated that the Veteran’s condition did not require the use of oral or parenteral corticosteroid medication but required the use of inhaled medications intermittently. The examiner also indicated there was no required use of oral bronchodilators or antibiotics, or outpatient oxygen therapy. The Veteran’s pulmonary functioning test post-bronchodilator reading was FEV-1 at 80 percent and an FEV-1/FVC at 84 percent. The examiner indicated that the Veteran did not have multiple respiratory issues. In December 2015, the Veteran was afforded another VA examination. The examiner indicated that the Veteran was using an inhaler daily but was not using any antibiotics or oxygen. The Veteran had no asthma attacks in the past 12 months. Also, the Veteran was given a pulmonary functions test that only gave a reading for pre-bronchodilator. The Veteran’s FEV-1 was at 81 percent. During the period of 2016 to the present, the Veteran began seeing a physician for his respiratory condition, consistently on a monthly basis and eventually on a weekly basis. In October 2016, a clinician noted that the Veteran had chronic respiratory failure. See Medical Treatment Record-Government Facility, p.5. In November 2016, a clinician indicated that the Veteran was taking Symbicort and albuterol. See Medical Treatment Record-Government Facility, p.28. Also, during the same month a clinician noted that the Veteran had an FEV1 of 78 percent and his FEV1/FVC was at 90 percent. See Medical Treatment Record-Government Facility, p.31. In another November 2016 private treatment record, the clinician noted that treatment for asthma exacerbation was prescribed. The medication prescribed was prednisone tablets for 12 days with 10mg, 60mgnfor 2 days, 50mg for 2 days, 40mg for 2 days, 30mg for 2 days, 20mg for 2 days, 10mg for 2 days. The Veteran was also prescribed Symbicort an inhalation for 30 days to be used twice a day and was given 3 refills. The Veteran was started on a home nebulizer with one refill; and prescribed another inhalation medication to be taken 4 times a day for 30 days and was given 3 refills. The clinician also noted that the Veteran was given the option of going to the emergency room to be admitted for more aggressive treatment for his asthma, but he did not want to go. Also, the Veteran’s Symbicort dosage was increased to 160/4.5 with two puffs twice daily. The physician noted that the reason for the Veteran’s appointment was chronic respiratory failure. See January 2020 Medical Treatment Record-Government Facility, p. 62-64. In March and April 2017, the Veteran was prescribed prednisone tablets at 10mg with 6 tablets for 2 days, 5 tablets for 2 days, 4 tablets for 2 days, 3 tablets for 2 days, 2 tablets for 2 days, 1 tablet for 2 days. Also, the medication was prescribed to take orally, once a day for 12 days with 0 refills, and the Veteran was prescribed a prednisone taper at 80mg. See January 2020 Medical Treatment Record-Government Facility, p. 51. In May 2017, a doctor indicated that the Veteran had acute exacerbation of moderate and persistent asthma, which had improved. The Veteran was also using 2 liters of oxygen by nasal cannula at night since December 2016 but had started on 2.5-3.5 liters of oxygen full time in October 2016. The doctor also noted that the Veteran had a complete course of prednisone. See January 2020 Medical Treatment Record-Government Facility, p.44. Also, during the same month the clinician prescribed prednisone tablets, 10 mg for 6 tablets for 2 days, 5 tablets for 2 days, 4 tablets for 2 days, 3 tablets for 2 days, 2 tablets for 2 days, 1 tablet for 2 days; and orally once a day for 12 days, 4, 42 total tablets with no refills. The Veteran was also prescribed Spiriva Respimat aerosol solution which is an inhaler that was to be used once a day for 30 days. The clinician gave the Veteran 3 refills, with a follow up visit one week later. See January 2020 Medical Treatment Record-Government Facility, p. 42; 47. In November 2017, the Veteran was given a pulmonary function test; his FEV1 was 75 percent pre-bronchodilator and 89 percent post- bronchodilator; and his FEV1/FVC post- bronchodilator. The clinician indicated that the Veteran was taking Duoneb, albuterol, Spiriva and Symbicort. See January 2020 Medical Treatment Record-Government Facility, p.18 med. In August 2019, the Veteran was given a pulmonary functions test; and his post FEV1/FVC was at 82 percent. See January 2020 Medical Treatment Record-Government Facility, Medical, p.17. In October 2019, a clinician noted that the Veteran was still taking Symbicort daily. The clinician further indicated the Veteran had taken prednisone for 7 months and had not been on it since May 2017. Also, the clinician indicated that the Veteran was taking oxygen at night. See January 2020 Medical Treatment Record-Government Facility, p.71. During the November 2019 hearing, the Veteran revealed that he had to go to the emergency room in October 2016; because he woke up with a pounding headache and his oxygen was at 88 percent. The Veteran indicated that he had to be walked around the emergency room with a pulse oximeter and his oxygen rate dropped to 83 percent. The emergency room doctor stated he did not understand how the Veteran could be in good shape but appeared to have respiratory failure. The Veteran also stated in November 2016, he went to a doctor who indicated his condition was getting worse, and the Veteran was on oxygen 24/7. Furthermore, the Veteran indicated that he was taking three courses a year of corticosteroids in late 2016. In all he indicated he had 5 courses of steroids in 2016. The Veteran indicated that he was at that time on oxygen 12 hours a day, did sleep studies and prescribed CPAP. Also, the Veteran reported that his doctor did an experiment taking him off oxygen and he would wake up with headaches and would wake up several times during the night. The Veteran reported that the worst time of year for him was the fall and winter due to the shortness of breath, coughing and wheezing continuously. During this time, the Veteran reported that he was taking three different medications. The Veteran noted that he had three pulmonary function tests and an arterial blood gas test. The Doctor diagnosed him with severe persistent asthma with hypoxemia and shortness of breath. See November 2019 Hearing Transcript, p.12-20. The Board finds, after review of the evidence, that a rating in excess of 30 for the period prior to November 16, 2016 (beginning February 19, 2013) is not warranted. The most appropriate rating for this period is 30 percent. The Board reviewed the pulmonary function test on file. The December 2013 and the December 2015 VA examination results showed a much higher rating then an FEV-1/FVC of 56 to 70 percent, which is necessary for a 30 percent rating. However, the December 2015 examination and VA treatment records revealed that the Veteran was taking inhaler medication on a daily basis, which meets one of the components of a 30 percent rating. Nevertheless, there is no medical information of record that suggests the period prior to November 16, 2016 should be rated at a rating in excess of 30 percent because the pulmonary function tests do not meet the 60 percent criteria for that period. There is no evidence that the Veteran had courses of systemic corticosteroids or reoccurring visits to a physician for required care of exacerbations. Furthermore, the Board finds, after a careful review of all pertinent evidence in light of the above-noted criteria, that the Veteran's respiratory symptomatology more nearly approximates the severity of bronchial asthma contemplated for a 60 percent rating from November 16, 2016. In reaching this conclusion, some weight is placed to the findings from the pulmonary function test of record; as none of them fall within the prescribed ranges for a higher 60 percent rating (FEV-1 of 40-55 percent predicted or FEV-1/FVC of 40-55 percent); or fall in the prescribed ranges for a higher 100 percent rating (FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent. In fact, the results from these PFTs reveal FEV-1 and FEV-1/FVC values that are higher than the ranges required for the currently assigned 30 percent disability rating for bronchial asthma (FEV-1 of 56-70 percent predicted or FEV-1/FVC of 56-70 percent). Accordingly, the Veteran's PFT testing results alone do not warrant an increased disability rating to 60 or 100 percent. However, the significant weight is placed on the Veteran’s courses and daily use of systemic (oral or parenteral) corticosteroids and reoccurring visits to a physician for required care of exacerbations as well as prescribed use of oxygen on at least part of the day or night. With respect to medication, the record documents the Veteran's daily use of multiple medications, including an Albuterol inhaler, and other inhaled corticosteroids such as Duoneb, Spiriva, and Symbicort. There is medical evidence that the Veteran required courses of systemic (oral or parenteral) corticosteroids. As noted above, the Veteran began receiving consistent treatments for prednisone (a systemic corticosteroid), that were taken on a regular basis; more than 3 times a year. As noted in the Veteran’s file the Veteran was receiving intermittent doses of prednisone since November 2016, with courses that exceeded 3 times a year, which would warrant the Veteran’s asthma rating to be increased to the higher 60 percent rating. In addition, the Veteran’s medical records show that the Veteran was consistently seeing a physician for his condition, monthly (every 3-4 weeks), then eventually the Veteran was seeing the physician for weekly followups that included daily use of the Symbicort inhaler, a steroid medication that is a bronchodilator affecting the lungs but is not systemic. In addition, the Veteran prednisone courses were taken to the point that they were daily with high doses that ranged from a low 10mg to a high 60-80mg but during the episodic courses and not continuously on a daily basis. The Board recognizes that the Veteran’s respiratory function as shown in multiple pulmonary function tests do not justify a high rating. However, the rating criteria is clear and specifies a 60 percent rating for the previously prescribed oral steroid (Prednisone) which was taken frequently, even daily when prescribed, but daily during its prescribed course time. The Board also considered the Veteran’s need for prescribed oxygen at night. In the most recent private treatment record dated in October 2019, the attending physician described the respiratory disorder as persistent and severe. However, the pulmonary function testing shows considerable function with the use of the prescribed medication. A higher rating of 100 percent is not warranted because the use of the systemic steroid is not daily, and the daily use of inhalers and nebulizers are not systemic as they act only on the lungs. Therefore, the Board finds that the criteria for a 60 percent rating for asthma have been met effective November 16, 2016. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, Associate 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.