Citation Nr: 20032963 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 16-19 511A DATE: May 12, 2020 ORDER An initial rating in excess of 20 percent for a lumbar spine disability is denied. An initial rating in excess of 10 percent for right hand tendonitis with right index finger injury is denied. An initial compensable rating for hypertension is denied. Service connection for hair removal of the neck is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), is remanded. Entitlement to service connection for headaches is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s lumbar spine disability has not been productive of limitation of forward flexion to 30 degrees nor favorable ankylosis. 2. Throughout the appeal period, the Veteran’s right hand tendonitis with right index finger injury has resulted in painful motion. 3. Throughout the appeal period, the Veteran’s hypertension has not resulted in diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more, nor does he have a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. 4. The Veteran has already been service connected for head and neck scarring as a result of pseudofolliculitis barbae and laser hair removal treatments and is not otherwise diagnosed to have any hair removal of the neck condition associated with active service. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5237 (2018). 2. The criteria for an initial rating in excess of 10 percent for right hand tendonitis with right index finger injury have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5229 (2018). 3. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.104, DC 7101 (2018). 4. The criteria for service connection for hair removal of the neck have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from July 1992 to July 2012. These matters were previously before the Board in November 2018 at which time they were remanded for further evidentiary development. In July 2019, the Veteran requested that his claims be advanced on the docket due to financial hardship. Evidence having been received demonstrating a financial hardship, the motion is hereby granted pursuant to 38 U.S.C. § 7107(a)(2) (2012); 38 C.F.R. § 20.900(c) (2018). The Board notes that in October 2019, the Veteran submitted a Supplemental Claim listing the issues currently on appeal. However, in a November 2019 communication, he indicated that he had not intended to submit a new claim and was only submitting evidence in support of the previously remanded claims. The Agency of Original Jurisdiction (AOJ) sent the Veteran a letter in December 2019 confirming the withdrawal of the Supplemental Claim. The Veteran was given 30 days to notify the AOJ that he did not intend to withdraw the claim. No response was received. As such, the Board concludes that the Veteran has withdrawn the Supplemental Claim and has opted to continue his appeals in the legacy system rather than opt-in to the modernized review system. The Veteran submitted a letter in October 2019 entitled, “request to ‘continue my appeal’ to the Board of Veterans Appeals with video hearing if applicable.” In his May 2016 Substantive Appeal (VA Form 9) the Veteran indicated that he did not want any type of Board hearing regarding the issues on appeal. He has not otherwise indicated that he desires a hearing and he has sought to advance his appeal on the docket. Nowhere in the substance of the letter did the Veteran suggest that he desired a hearing and the words “if applicable” do not appear to indicate that he is requesting a hearing. The Board finds that the title of the letter alone without more does not constitute a request for a hearing. As a final matter, the Board has considered the holding of the Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), regarding an inferred entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) in increased ratings claims. The Veteran has submitted statements indicating that he is limited in his ability to engage in employment and that he has adjusted his work hours and duties to be able to meet his employer’s needs. However, it appears from a review of the claims file that the Veteran is still fully employed. As such, entitlement to TDIU will not be addressed herein. 1. Increased Ratings 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. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner’s assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Painful motion is entitled to a minimum 10 percent rating, per joint, even if there is no actual limitation of motion. Mitchell v. Shinseki, supra. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. (a.) Lumbar Spine Disability The Veteran’s lumbar spine disability has been rated 20 percent disabling under 38 C.F.R. § 4.71a, DC 5237. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides for assignment of a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating requires that forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating requires unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, DC 5242, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine at Note (2); see also 38 C.F.R. § 4.71a, Plate V. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). Alternatively, disability involving disc disease may be rated under the Formula for Rating IVDS Based on Incapacitating Episodes. That formula provides a 10 percent disability rating for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). Turning to the evidence of record, the Veteran underwent a VA examination in December 2012. He was diagnosed with lumbago with spasms and with lumbar spondylosis by MRI. He described constant lower back pain that was sharp and aching, reaching the level of 8 to 9 out of 10. His current treatment was Percocet once daily with good relief. He had previously received facet injections with poor relief and epidural injections with fair relief. He stated he was able to walk approximately a mile before needing to sit, was able to sit 20 to 30 minutes without having to change his position, and was able to stand 20 minutes. He described daily flare-ups lasting for 30 minutes in which he was not able to function. The flare-ups were alleviated by time, rest, and medication. He stated that some days were worse than others. The Veteran’s range of motion was measured at forward flexion to 80 degrees with pain at 70 degrees; extension to 0 degrees with pain at 0 degrees; right lateral flexion to 20 degrees with pain at 20 degrees; left lateral flexion to 10 degrees with pain at 10 degrees; and right and left lateral rotation to 30 degrees or more with no pain. Repetitive-use testing resulted in forward flexion to 60 degrees, extension to 0 degrees, right lateral flexion to 20 degrees, left lateral flexion to 10 degrees, and right and left lateral rotation to 30 degrees or more. Functional loss was noted to be less movement than normal and pain on movement. The Veteran experienced pain on palpation and guarding or muscle spasm resulting in abnormal gait. Muscle strength was normal with no muscle atrophy, and reflex and sensory testing yielded normal results. The examiner indicated that the Veteran did not have IVDS and did not use assistive devices. Although he was not currently employed, the Veteran did not miss any work in the 12 months prior to his military retirement due to his back disability. Private treatment records indicated that the Veteran underwent a lumbar radiofrequency ablation at the L2-3, L3-4, L4-5, and L5-S1 vertebrae in October 2013. An MRI in October 2018 revealed multilevel degenerative disc disease (DDD) of the lumbar spine, most severe at the L4-5 and L5-S1 levels. Disc contact was present at L4-5. Multilevel endplate hypertrophy of the lumbar spine was also noted. The Veteran sought treatment for low back pain with a private provider in November 2018. He reported a severity level of 7 and stated that the pain occurred persistently in the lower back, radiating to the bilateral thighs. He described aching, piercing, sharp, shooting, stabbing, and throbbing pain. He stated that his symptoms were aggravated by ascending stairs, changing positions, daily activities, descending stairs, lifting, sitting, standing, and walking. His symptoms were minimally reduced by injections. The Veteran completed a health assessment questionnaire, indicating that he had “much difficulty” dressing himself, including shoe laces and buttons; he had “some difficulty” with standing up from a straight chair, getting in and out of bed, walking outdoors on flat ground, climbing up five steps, washing and drying his body, taking a tub bath, getting on and off the toilet, reaching and getting down a 5-pound object from overhead, bending down to pick up clothing from the floor, opening car doors, opening previously-opened jars, turning faucets on and off, running errands and shopping, getting in and out of a car, and doing chores such as vacuuming or yard work; and he had “no difficulty” with cutting his own meat, lifting a full cup or glass to his mouth, and opening a new milk carton. The Veteran determined that he was moderately able to carry out every day physical activities such as walking, climbing stairs, carrying groceries, or moving a chair. He stated that his pain in the last week was a 70 out of 100. In describing his overall health, he stated it was a 100 out of 100. Upon observation, the Veteran displayed mild pain with motion and there was paravertebral tenderness to the lumbar spine. Lumbar epidural steroid injections were administered in December 2018 and January 2019. Later in January 2019, the Veteran underwent a medial branch block bilaterally at the L3-4, L4-5, and L5-S1 vertebrae. At the time, he stated that the procedure relieved 85 percent of his left-sided pain and 100 percent of his right-sided pain. At a follow-up, he reported 80 percent of relief overall. The Veteran’s private treating clinician completed a back Disability Benefits Questionnaire (DBQ) in January 2019. He diagnosed facet joint arthropathy (degenerative joint disease (DJD)) of the lumbosacral spine, DDD, and radiculopathy. Forward flexion was to 80 degrees with pain, extension was to 10 degrees with pain, right and left lateral flexion were noted to be “ok,” and right and left lateral rotation were to 20 degrees with pain. Repetitive-use testing was not performed but the reason for this was not indicated. The clinician stated that the Veteran had pain on active and passive motion, with repetitive use, and with weight-bearing and nonweight-bearing, contributing to a functional loss. Tenderness to palpation was noted in the paravertebral region. The functional impact included pain on movement, interference with prolonged sitting and standing, and hyperflexion of the lumbar spine. It was noted that weight-bearing and hyperextension caused increased pain. There was no guarding or muscle spasm, and the Veteran had normal gait and spinal contour. Muscle strength testing was normal with no muscle atrophy and no ankylosis was present. The clinician indicated that he did not have IVDS with incapacitating episodes. The Veteran’s description of his symptoms was identical to that given to the clinician at the November 2018 appointment. The clinician stated that during flare-ups or after repeated use, the Veteran’s forward flexion would still be to 80 degrees but likely limited due to pain and extension would still be to 10 degrees but aggravated by weight-bearing and limited by pain. There was no functional impact due to the disability. The Veteran underwent lumbar radiofrequency ablation again at the L3-4, L4-5, and L5-S1 vertebrae in February 2019. At a follow-up, he reported that he received 75 to 80 percent relief of symptoms as a result of the procedure. Another VA examination was conducted in September 2019. The examiner diagnosed lumbar spondylosis, DDD, and IVDS. He stated that this reflected a new diagnosis as although the Veteran was previously diagnosed with spondylosis, he also had degenerative disease of the intervertebral discs as well as the soft tissues of the spine. The Veteran described current symptoms of pain and stiffness in the lower back radiating down the back of the legs. Treatment included the procedures outlined above, physical therapy, ibuprofen, Percocet, Flexeril, and Tylenol. He did not report flare-ups. He described functional impairments with walking, standing, lifting, and sitting. He noted that his back symptoms affected almost everything. Forward flexion was to 90 degrees, extension was to 5 degrees, right lateral flexion was to 10 degrees, left lateral flexion was to 15 degrees, right lateral rotation was to 15 degrees, and left lateral rotation was to 10 degrees with pain noted on all planes of motion except forward flexion. There was also pain with weight-bearing and nonweight-bearing. Testing on passive motion was not conducted as it was medically inappropriate. Range of motion was noted to contribute to functional loss in that the Veteran was unable to lift heavy objects or perform repetitive tasks with the lower spine. There was moderate pain on palpation in the paralumbar and midline spine. The Veteran was able to perform repetitive-use testing with additional loss of range of motion. Range of motion with repetitive-use testing and with repeated use over time included forward flexion to 80 degrees, extension to 5 degrees, right lateral flexion to 10 degrees, left lateral flexion to 5 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 5 degrees. Factors contributing to functional loss with repetitive use and with repeated use over time included pain, fatigue, weakness, lack of endurance, and incoordination. The Veteran demonstrated muscle spasm including tight muscular banding in the paralumbar area not resulting in abnormal gait or abnormal spinal contour. The examiner found that the Veteran had IVDS with episodes of bed rest having a total duration of at least 6 weeks during the past 12 months. In support of this notation, he stated that the medical history demonstrating these episodes were facet injections and physical therapy in 2019. The functional impact was determined to be that the Veteran could not lift more than 20 pounds in a single lift or more than 5 pounds repetitively; he was unable to sit/walk/stand for prolonged periods of time; and he was not able to work as a police officer, commercial truck driver, construction worker, school teacher, or any other occupation that required acceptable levels of attendance at work and/or strenuous or vigorous activity and/or prolonged sitting, standing, or walking. In an October 2019 lay statement, the Veteran reported a long history of medical documentation of injections, surgeries, therapy sessions, and multiple missed days from work. He stated that measuring his level of disability on one single day (the day of a VA examination) did not reflect his true degree of impairment because he had good and bad days. He stated that he has not received the required “bed rest” from physicians because he has not chosen to undergo surgery because of a need to stay employed. At the outset, the Board finds that the VA examination and private DBQ results of record are adequate reflections of the Veteran’s disability and comply with the requirements of DeLuca, Correia, and Sharp. Although the December 2012 VA examination did not determine whether there was pain with nonweight-bearing or estimate the additional functional loss during flare-ups in terms of range of motion, the Veteran’s descriptions of his limitations provided sufficient information to determine those impairments. He stated that he could undergo nonweight-bearing activity such as sitting for 20 to 30 minutes without having to change his position, suggesting pain occurred with prolonged nonweight-bearing activity. He noted that he was unable to function during his daily 30-minute flare-ups, suggesting that he avoided any range of motion during that timeframe. The examinations included the Veteran’s statements regarding the extent and severity of his disability including with repeated use and during flare-ups. They were conducted by both qualified VA examiners and the Veteran’s own treating clinician, as well. Based on the entirety of the record, the Veteran’s lumbar spine disability warrants a 20 percent rating throughout the entire appeal period. His range of motion has not been limited to 30 degrees of forward flexion during any of the examinations and the VA and private examiners determined that additional loss of function with repeated use or during flare-ups would not be so limited as to only result in 30 degrees of forward flexion. Based on the clinical testing results and taking into account the Veteran’s statements regarding his limitations in activities of daily life (i.e. only “some difficulty” with bending down to pick things off the floor, getting in and out of a car, vacuuming, doing yard work), it does not appear as though his disability results, even at worst, in forward flexion limited to 30 degrees. Further, there is no evidence throughout the appeal period of favorable ankylosis. As such, a rating in excess of 20 percent is not warranted under the General Rating Formula for Diseases and Injuries of the Spine. The Board acknowledges the Veteran’s concern that range of motion testing on an examination day might not reflect the entirety of a lumbar spine disability. However, the Veteran was not initially awarded a 20 percent rating based on range of motion testing but instead upon evidence of guarding or muscle spasm resulting in abnormal gait. Both VA and private examiners conducted clinical testing and, taking into account the Veteran’s lay statements, were able to determine the reduced range of motion that would result from repetitive use and during flare-ups, representing the most severe effects of his lumbar spine disability. As such, the Board’s decision reflects a consideration of the entirety of his symptomology, including limited range of motion both on days of clinical testing and on medical professionals’ determinations of the increased severity in terms of range of motion on his worst days. The Board also finds that an increased rating is not warranted based on the criteria of the Formula for Rating IVDS Based on Incapacitating Episodes. Although the most recent VA examination diagnosed the Veteran with IVDS and stated that he experienced incapacitating episodes lasting at least six weeks, there is no evidence of any incapacitating episodes in the Veteran’s medical history. The examiner listed facet injections and physical therapy in 2019 as the relevant medical history demonstrating incapacitating episodes. However, there is nothing to suggest that the Veteran was prescribed bed rest by clinicians in association with the facet injections, which were conducted to relieve pain and increase function and which had a high degree of pain relief immediately after treatment, or with physical therapy, which by its very nature suggests active movement rather than bed rest. Nothing in the claims file supports the indication that he has had any incapacitating episodes due to his lumbar spine disability. Indeed, the Veteran himself said in his October lay statement that he did not meet the criteria of bed rest because he had not yet opted to have surgery. As such, a rating in excess of 20 percent based on incapacitating episodes is not established. Based on the foregoing, a rating in excess of 20 percent for the Veteran’s lumbar spine disability is not warranted. The preponderance of the evidence is against the claim; therefore, the benefit of the doubt rule is not for application. (b.) Right Index Finger Disability The Veteran’s right hand tendonitis with right index finger injury has been rated 10 percent disabling under 38 C.F.R. § 4371a, DC 5229. He is right-hand dominant. Under DC 5229, limitation of motion of the 2nd digit (index finger) and 3rd digit (long finger) are rated. For the major and minor extremity, a noncompensable disability evaluation is assigned for limitation of motion of the index or long finger with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by no more than 30 degrees. A maximum schedular 10 percent disability evaluation is assigned where there is limitation of motion of the index or long finger with a gap of one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by more than 30 degrees. Other diagnostic codes relevant to the Veteran’s disability include DC 5126 through DC 5156 pertaining to amputation of single or multiple digits; DC 5216 through DC 5219 pertaining to unfavorable ankylosis of multiple digits; DC 5220 through DC 5223 pertaining to favorable ankylosis of multiple digits; and DC 5224 through DC 5227 pertaining to ankylosis of individual digits. The Veteran underwent a VA examination in December 2012 at which right index finger tenosynovitis was diagnosed. He stated that he had difficulty with fine motor movements due to pain. He noted that opening a bottle of soda would cause pain. He stated that he experienced flare-ups in which he was unable to use his hands. He treated his pain with Motrin with poor effect. Upon observation, there was a gap less than 1 inch between the index finger and the proximal transverse crease of the palm and the ring finger and the proximal transverse crease of the palm. There was no objective evidence of painful motion of the index finger and no limitation of extension. The Veteran was able to perform repetitive-use testing with identical results. There was no pain on palpation, muscle strength was normal, and there was no ankylosis. The examiner stated that there was no functional loss from the disability. As noted above, the Veteran completed a self-assessment of his ability to engage in the activities of daily living in November 2018. He stated that he had “some difficulty” with his grip, including with opening car doors, opening previously-opened jars, and turning faucets on and off. Another VA examination was conducted in September 2019. The examiner diagnosed right hand tendonitis status post injury to the right index finger and De Quervain’s tenosynovitis of the right thumb, status-post surgery. The Veteran stated that his condition had progressed since its onset in service and currently resulted in pain and intermittent swelling. He treated his symptoms with Motrin, rest, and ice packs. He did not report flare-ups or any functional impairment. Range of motion testing yielded entirely normal results with no limitation of extension or flexion in the right index finger or any other digits. There was no gap between the pad of the thumb and the fingers or between the fingers and the proximal transverse crease of the hand on maximal finger flexion. Pain was elicited on finger flexion, opposition with thumb, and finger extension. Pain was exhibited on range of motion of all fingers of the right hand. There was no evidence of pain with nonweight-bearing and passive motion elicited the same results as active motion. There was evidence of pain with use of the hand and objective evidence of mild localized tenderness or pain on palpation at the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joint of the right index finger. The examiner stated that pain, fatigue, weakness, and lack of endurance would limit function with repeated use over a period of time, however range of motion would remain normal. The examiner determined that the functional impact was that the Veteran was unable to perform repetitive or strenuous activity with his right, dominant hand and fingers. He was unable to work as a construction worker, mechanic, receptionist, typist, calligrapher, postal worker, policeman, or other occupation requiring full use of his right hand and fingers. In an October 2019 lay statement, the Veteran disagreed with the criteria of the Rating Schedule, noting that range of motion testing did not fully encompass the actual usage of his right hand. He stated that he found it difficult to compete simple tasks such as opening soda bottles. He continued that he understood the system and therefore regrettably accepted the final outcome of a denial of his increased rating claim. The Board finds that an initial rating in excess of 10 percent for the Veteran’s right hand tendonitis with right index finger injury is not warranted. Range of motion testing throughout the appeal period did not meet the criteria of a compensable rating. However, the Veteran demonstrated painful motion, thus meeting the criteria for a 10 percent evaluation. 38 C.F.R. § 4.59. A 10 percent rating also demonstrates the maximum schedular rating available for disabilities of the index finger under DC 5229. There is no evidence of favorable or unfavorable ankylosis of the index finger or any other digit and none of the Veteran’s fingers have been amputated or have approximated amputation. As such, a rating in excess of 10 percent is not warranted. The Board acknowledges the Veteran’s statements regarding the adequacy of the Rating Schedule criteria to measure the extent of his disability. Indeed, the VA examiner stated that even with repetitive use, the Veteran’s range of motion would not be affected, however, his functional ability would be limited. The Board has contemplated whether extraschedular consideration may be indicated. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Veteran has largely described his functional limitations in terms of fine motor skills such as being able to open soda bottles. However, this type of movement is contemplated by the schedular criteria, as the ability to grip and handle objects is largely determined by the index finger’s ability to flex towards the palm, which is exactly what is measured in DC 5229. The pain elicited by such movements is contemplated in the 10 percent rating under DC 5229. See 38 C.F.R. § 4.59. As the Veteran’s symptomology is contemplated by the schedular criteria, extraschedular consideration is not warranted. An initial rating in excess of 10 percent for right hand tendonitis with right index finger injury is not merited. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. (c.) Hypertension The Veteran’s hypertension has been rated at a noncompensable rate under 38 C.F.R. § 4.104, DC 7101. Under DC 7101, a 10 percent disability rating requires diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or that an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent disability rating requires diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent disability rating requires diastolic pressure predominantly 120 or more. A 60 percent disability rating requires diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104. In every instance in which the Rating Schedule does not provide a zero percent disability rating for a diagnostic code, a zero percent shall be assigned when the requirements for a compensable disability rating are not met. 38 C.F.R. § 4.31 (2018). During service, the Veteran’s diastolic blood pressure was measured 100 or more on three occasions (December 2010, March 2011, February 2012). All other readings were normal or elevated, but under the 100 mark for diastolic pressure. The Veteran underwent a VA examination in December 2012 which reflected a current diagnosis of hypertension. It was noted that the Veteran was prescribed Lisinopril 20 mg which he took daily. Blood pressure readings were 134/80, 134/64, and 130/72. Another VA examination was conducted in September 2019. The Veteran stated that his condition had stayed about the same since its onset and that he was still currently taking Lisinopril to control his hypertension. Blood pressure readings were 132/86, 136/88, and 134/84. The examiner determined that the Veteran’s disability resulted in no functional impact. In an October 2019 lay statement, the Veteran reported that to achieve a compensable rating for his hypertension, he would have to not take his prescribed medications which would be dangerous and against medical advice. He requested that more than one-day readings be used to determine the severity of his condition. Post-service treatment records contained normal blood pressure readings with none having a diastolic pressure of 100 or more. The Board finds that an initial compensable rating for hypertension is not warranted. During the appeal period, the Veteran’s blood pressure readings have not included diastolic pressure of 100 or more nor have they contained systolic pressures of 160 or more. In the hundreds of blood pressure readings conducted during service and post-service, there were only three instances of diastolic pressure of 100 or more. The Board finds that so few 100 or more results among many does not constitute a history of diastolic pressure predominantly 100 or more. As such, the criteria for a compensable rating have not been met. The Board acknowledges the Veteran’s comments that to achieve a higher rating he would need to forgo his prescribed medication and that readings on one day should not be used to rate his disability. However, the 10 percent criteria under DC 7101 specifically contemplates the effect of medication on hypertension. It is apparent that the Veteran’s hypertension is currently well-controlled through medication. However, the criterion acknowledges the palliative effects of medication by providing for a 10 percent rating for a history of more severe symptoms that are now controlled through use of medication. Further, the Board’s determination is not based merely on the readings taken at VA examinations, but includes a review of the Veteran’s entire medical history, including the timeframe prior to the appeal period. The entirety of the evidence demonstrates that the criteria for a compensable rating have not been met. Additionally, the Veteran has not contended, and the evidence does not suggest, any additional symptomology related to his hypertension that is not contemplated by the provisions of DC 7101 other than suggesting a secondary disability of headaches, which is addressed below. Based on the foregoing, an initial compensable rating for hypertension is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. 2. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2018). During service, the Veteran was diagnosed with pseudofolliculitis barbae and underwent laser hair removal numerous times. There are no other diagnoses of any skin or hair removal conditions of the neck during service or anytime thereafter. Over the course of the appeal, he was provided VA skin and scar examinations which diagnosed pseudofolliculitis barbae and associated scarring. He was subsequently service-connected for scars of the head and neck associated with pseudofolliculitis barbae in an October 2019 rating decision at 30 percent disabling under 38 C.F.R. § 4.118, DC 7800 (2018). Pseudofolliculitis barbae is rated by analogy to 38 C.F.R. § 4.118, DC 7806, pertaining to dermatitis or eczema. It is evaluated under the General Rating Formula for the Skin, which provides that the disability can be rated by area of the body affected or rated as disfigurement of the head, face, or neck, depending upon the predominant disability. The AOJ, based on the results of the VA examination, determined that the predominant disability was the scarring of the head and neck which was the result of pseudofolliculitis barbae. As such, the condition of pseudofolliculitis barbae and its residuals (the head and neck scars) have already been service-connected and the Veteran is currently receiving compensation therefor. The Veteran underwent laser hair removal in service as a course of treatment for pseudofolliculitis barbae. There is no indication in the record that the treatment resulted in another disability other than the already-compensated scarring. As such, there is no basis for an award of service connection for hair removal of the neck that would not constitute undue pyramiding. 38 C.F.R. § 4.14. Accordingly, service connection for hair removal of the neck is not warranted. REASONS FOR REMAND 1. Psychiatric Disability The Veteran initially submitted a claim for PTSD, identifying a stressor event of a fellow soldier being killed by an improvised explosive device (IED) under his command while riding in the passenger seat of a vehicle which the Veteran typically occupied. His claim has been expanded to consider all possible acquired psychiatric disorders. The service treatment records (STRs) do not contain diagnosis or treatment of any psychiatric disorder. The Veteran indicated on a post-deployment assessment that increased irritability was a deployment-related issue. However, the examining clinician did not indicate PTSD symptoms or other mental health conditions were concerns. On a February 2012 report of medical history, the Veteran stated that he had previously received counseling but denied any current relevant complaints. He also noted that he needed a PTSD follow-up. At two VA examinations and on a private DBQ, the Veteran noted that he had received counseling during his active service while stationed in Beaufort, South Carolina. On the private DBQ it was noted that he was diagnosed with PTSD during such counseling. Although there are medical records in the STRs from Beaufort, they address only medical issues and do not discuss any psychiatric symptomology or counseling. As the Veteran has identified outstanding relevant records of in-service treatment, the Board finds that remand is needed to attempt to locate such records. Additionally, the Veteran identified and submitted a general release for private psychiatric treatment records from Baytree Behavioral Health. The records were sought in August 2019 and September 2019 by successful fax and letter requests. The Veteran was informed in a September 2019 letter that the records had been sought and that it was his responsibility to see that VA received the records. He subsequently submitted a letter several days later noting that he had gone to Baytree Behavioral Health facilities to request any relevant documents. He specifically stated that any outstanding records would “NOT include any additional information that is or was not previously annotated on the DBQ,” referring to a DBQ that was completed previously by a Baytree clinician and included in the claims file. He also noted that the provider stated that it would take a significant amount of time to obtain the identified records and the Veteran suggested that if he had a lawyer, he might have more success getting his records. Despite the fact that the Veteran noted that no additional information would be contained in the records, on remand he should be afforded the opportunity to submit the Baytree records or any other relevant records of private psychiatric treatment or counseling. There are differing opinions of record as to whether the Veteran has a current psychiatric disorder. Two VA examiners found that he did not meet the criteria for PTSD. A November 2012 examiner diagnosed bereavement based on the Veteran’s identified stressor and his only symptoms of grief and sadness. A September 2019 examiner found that the Veteran did not meet the criteria for any psychiatric disorder and that he did not have any relevant symptomology. Both assessments reflected the fact that the Veteran spoke of his military career in very positive terms and that although the identified stressor was adequate to support a diagnosis of PTSD and was related to a fear of hostile military or terrorist activity, he did not meet the Criteria B through F to establish a PTSD diagnosis. In contrast, the Baytree clinician submitted a DBQ in February 2019 in which he diagnosed PTSD and identified a multitude of symptoms not previously identified by the Veteran to treating clinicians or in lay statements contained in the claims file. However, given the contrast between the history set out in this report, and the remainder of the file, further clarification is indicated. Also, the Veteran’s claim is based on a fear of hostile military or terrorist activity, and as such, a VA or VA-contracted psychologist or psychiatrist must determine that such a stressor is related to a PTSD diagnosis. See 38 C.F.R. § 3.304(f)(3) (2018). As there are significant discrepancies as to whether the Veteran has a current psychiatric disorder, the Board finds that a new examination and opinion are needed to reconcile the differing opinions. 2. Headaches The Veteran has asserted that a headache disability had its onset during active service due to trauma to the head or that it was proximately caused or aggravated by his service-connected hypertension. The STRs contain the report of an incident in August 1993 in which the Veteran was hit in the head with a metal pipe, resulting in a laceration to the left side of the forehead. He had no loss of consciousness or vomiting at the time. He has been service-connected for the resulting scar. In July 1995, he reported a headache associated with congestion, nausea, and dizziness. The symptoms appeared to resolve as there were no further relevant notations. On a July 2007 post-deployment assessment, the Veteran marked headaches as a deployment-related concern. In February 2012, he indicated that he had missed duty for longer than three days due to head trauma. He also noted that he had various headaches for which he had not sought treatment. On a February 2012 report of medical history, he indicated that he had frequent or severe headaches and suggested that he had headaches either from pre-hypertension or an injury. He stated the same on a June 2012 report and said he had a history of frequent headaches but no diagnosis of migraines and he treated the headaches with BC powder. A VA examiner in December 2012 determined that the Veteran did not have a diagnosis of a headache condition. At a September 2019 VA examination, the Veteran was given a diagnosis of migraine including migraine variants. He reported that his symptoms began in 2009 and had since worsened. The examiner concluded that the condition was not directly related to his active service as the STRs contained no records of head pain or recurrent or chronic headaches. Further, he determined that the migraine headaches were less likely than not proximately due to or the result of the Veteran’s service-connected hypertension as hypertension does not cause headaches. It can indirectly cause head pain as a result of other medical illnesses (that the Veteran did not have), however, that was not the case here. The Veteran suffered from essential hypertension which does not cause headaches and is asymptomatic. In support, he stated that this was consistent with medical school textbooks and widely-available medical literature. The examiner also concluded that the Veteran’s headaches were not aggravated by his hypertension as hypertension does not exacerbate headaches. He stated that essential hypertension is the elevation of blood pressure and is asymptomatic unless it causes end-organ disease and there was no evidence in the medical records or upon examination of any end-organ damage due to the Veteran’s well-controlled hypertension. The Board finds that remand is necessary to obtain an addendum opinion regarding the Veteran’ headache claim. The medical opinion relies on an absence of treatment or diagnosis and does not consider the Veteran’s contemporaneous lay statements that he experienced headaches during active service. Further, the Veteran’s contention that his headaches stemmed from the August 1993 incident has not been evaluated by a medical professional. Remand is necessary to obtain a more thorough opinion in which a VA clinician takes into consideration the Veteran’s contemporaneous reports and post-service lay statements regarding his headaches. The matters are REMANDED for the following action: 1. Contact the appropriate facility/facilities to request any outstanding service treatment records, specifically to include any mental health clinic counseling records from Beaufort, South Carolina. All requests and responses received from each contacted entity should be associated with the claims file. If the requested records are unavailable, issue a formal finding of unavailability and notify the Veteran to allow him the opportunity to submit any medical records in his possession. 2. Afford the Veteran the opportunity to identify and provide releases for any pertinent private treatment records, specifically to include records from Baytree Behavioral Health, and assist him in obtaining such records. All requests and responses received from each contacted entity should be associated with the claims file. 3. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of any psychiatric disorder, to include PTSD. The record should be made available and the examiner’s review of the record should be indicated. The opinion should include discussion of the Veteran’s documented medical history and assertions. The examiner is asked to determine whether it is at least as likely as not (50 percent or higher degree of probability) that any diagnosed psychiatric disability had its onset in service, or is otherwise due to an in-service disease or injury, or stressor if PTSD is diagnosed. The stressors supporting any diagnosis of PTSD should be identified. Any psychiatric disorder that may have been present, but has since resolved also should be identified. (a.) The examiner is asked to provide a rationale and to explain the reasons behind each opinion expressed and conclusion reached. Mere conclusory statements cannot form a sufficient basis for a rationale for VA benefits purposes. The examiner is asked to reconcile the differing diagnoses and medical opinions of record with the Veteran’s medical history, lay statements, and clinical testing results. 4. Obtain a VA medical opinion from an appropriate medical professional to determine the nature and etiology of any headache disability. The record should be made available and the clinician’s review should include discussion of the Veteran’s documented medical history and assertions. The need for an additional examination is left to the discretion of the clinician. (a.) The clinician is asked to determine whether it is at least as likely as not (50 percent or higher degree of probability) that any headache disability is the result of his military service, to include the August 1993 incident and his contemporaneous reports of a history of headaches (see July 2007, February 2012, and June 2012 notations). (Continued on the next page)   (b.) The clinician is asked to provide a rationale and to explain the reasons behind each opinion expressed and conclusion reached. Mere conclusory statements or reiterations of a provided opinion cannot form a sufficient basis for a rationale for VA benefits purposes. The clinician is reminded that any opinion must provide an adequate rationale which does not rely solely on a lack of evidence of treatment or diagnosis of the claimed condition during service. 5. Readjudicate the claims. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, 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.