Citation Nr: 20043572 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 18-20 664 DATE: June 29, 2020 ORDER Entitlement to an earlier effective date prior to February 8, 2018 for the grant of a 30 percent rating for peripheral neuropathy of the right upper extremity is dismissed. Entitlement to an earlier effective date prior to February 8, 2018 for the grant of a 20 percent rating for peripheral neuropathy of the left upper extremity is dismissed. Entitlement to an earlier effective date prior to February 8, 2018 for the grant of a 20 percent rating for peripheral neuropathy of the right lower extremity is dismissed. Entitlement to an earlier effective date prior to February 8, 2018 for the grant of a 20 percent rating for peripheral neuropathy of the left lower extremity is dismissed. As new and material evidence sufficient to reopen a claim of service connection for a right knee disorder has not been received, the petition to reopen is denied. As new and material evidence sufficient to reopen a claim of service connection for a left knee disorder has not been received, the petition to reopen is denied. Entitlement to an increased rating in excess of 30 percent from February 8, 2018 for peripheral neuropathy of the right upper extremity is denied. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the left upper extremity is denied. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the right lower extremity is denied. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the left lower extremity is denied. Entitlement to an increased rating of 40 percent effective June 16, 2017, but no earlier, for diabetes mellitus is granted. Entitlement to an increased rating in excess of 40 percent for diabetes mellitus is denied. Entitlement to a compensable rating for hypertension prior to February 8, 2018, is denied. Entitlement to a 10 percent rating for tinea versicolor from September 23, 2014, is granted. Entitlement to a rating in excess of 10 percent for tinea versicolor is denied. Entitlement to a compensable rating for peripheral artery disease of the right lower extremity prior to February 8, 2018 and in excess of 40 percent thereafter is denied. Entitlement to an increased rating in excess of 10 percent for gastroesophageal reflux disease (GERD) with hiatal hernia is denied. REMANDED Entitlement to an increased rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating for individual unemployability prior to February 8, 2018 is remanded.   REFERRED ISSUE In March 2018, service connection was granted for renal impairment and a 30 percent rating, including a 10 percent rating for hypertension was established effective February 8, 2018. The Veteran and his representative have appealed this effective date. The matter has not bee fully considered by the Originating Agency, and is referred for appropriate consideration. The issue of a compensable rating for hypertension prior to February 8, 2018, is properly before the Board as part of this appeal. FINDINGS OF FACT 1. In an April 2020 written statement, the Veteran withdrew his appeal of entitlement to an earlier effective date for a 30 percent rating for peripheral neuropathy of the right upper extremity. 2. In an April 2020 written statement, the Veteran withdrew his appeal of entitlement to an earlier effective date for a 20 percent rating for peripheral neuropathy of the left upper extremity. 3. In an April 2020 written statement, the Veteran withdrew his appeal of entitlement to an earlier effective date for a 20 percent rating for peripheral neuropathy of the right lower extremity. 4. In an April 2020 written statement, the Veteran withdrew his appeal of entitlement to an earlier effective date for a 20 percent rating for peripheral neuropathy of the left lower extremity. 5. A November 2007 rating decision denied service connection for right and left knee disorders. The Veteran received notice of this decision and did not appeal or file new and material evidence within one year. 6. The evidence received since the November 2007 rating decision is not new and material and does not related to an unestablished fact necessary to substantiate the Veteran's claims of service connection for right and left knee disorders. 7. From February 8, 2018, the Veteran's peripheral neuropathy of the right upper extremity manifests as moderate incomplete paralysis of the radial nerve. The Veteran is right handed. 8. From February 8, 2018, the Veteran’s peripheral neuropathy of the left upper extremity manifests as moderate incomplete paralysis of the radial nerve. 9. From February 8, 2018, the Veteran’s peripheral neuropathy of the right lower extremity manifests as moderate incomplete paralysis of the femoral nerve. 10. From February 8, 2018, the Veteran’s peripheral neuropathy of the left lower extremity manifests as moderate incomplete paralysis of the femoral nerve. 11. Prior to June 16, 2017, the Veteran's diabetes required insulin and a restricted diet but did not require regulation of activities. 12. From June 16, 2017, the Veteran’s diabetes required insulin, a restricted diet, and regulation of activities. 13. Prior to February 8, 2018, the Veteran's hypertension does not reflect a diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 14. With resolution of the doubt in favor of the Veteran, the Veteran’s tinea versicolor involves 10 percent of his entire body but does not require systemic therapy from the date of claim, September 8, 2018. 15. Prior to February 8, 2018, the Veteran's right lower extremity peripheral artery disease was not productive of claudication on walking more than 100 yards or an ankle/brachial of .9 or less. 16. From February 8, 2018, the Veteran's right lower extremity peripheral artery disease was productive of claudication on walking between 25 and 100 yards and the Veteran experienced persistent coldness. 17. Throughout the pendency of the appeal, the Veteran’s GERD with hiatal hernia has been manifested by pyrosis, reflux, and regurgitation. It has not been manifested by material weight loss, dysphagia, anemia, or any other symptoms productive of considerable or severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal for an earlier effective date for a 30 percent rating for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205 (2019). 2. The criteria for withdrawal of an appeal for an earlier effective date for a 20 percent rating for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205 (2019). 3. The criteria for withdrawal of an appeal for an earlier effective date for a 20 percent rating for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205 (2019). 4. The criteria for withdrawal of an appeal for an earlier effective date for a 20 percent rating for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205 (2019). 5. New and material evidence has not been received to reopen the finally denied claim of entitlement to service connection for a right knee disorder and the petition to reopen is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2019). 6. New and material evidence has not been received to reopen the finally denied claim of entitlement to service connection for a left knee disorder and the petition to reopen is denied. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2019). 7. The criteria for entitlement to an increased rating in excess of 30 percent for peripheral neuropathy of the right upper extremity from February 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8514 (2019). 8. The criteria for entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the left upper extremity from February 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8514 (2019). 9. The criteria for entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the right lower extremity from February 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526 (2019). 10. The criteria for entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the left lower extremity from February 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526 (2019). 11. Prior to June 16, 2017, but no earlier, the criteria for entitlement to an increased rating of 40 percent for diabetes mellitus are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2019). 12. From June 16, 2017, the criteria for entitlement to an increased rating in excess of 40 percent for diabetes mellitus are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2019). 13. The criteria for a compensable rating for hypertension prior to February 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2019). 14. With resolution of reasonable doubt in the Veteran’s favor, as of September 23, 2014, but no earlier, the criteria for a 10 percent rating for tinea versicolor are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7806 (2019). 15. During the entire period on appeal, the criteria for a rating in excess of 10 percent for tinea versicolor have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7806 (2019). 16. The criteria for a compensable disability rating for right lower extremity peripheral artery disease prior to February 8, 2018 have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7114 (2019). 17. The criteria for a disability rating in excess of 40 percent for right lower extremity peripheral artery disease from February 8, 2018 have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7114 (2019). 18. The criteria for a rating higher than 10 percent for GERD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.10, 4.120, 4.21, 4.114, Code 7346 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from April 1987 to October 2007. Withdrawal 1. Entitlement to an increased rating in excess of 30 percent for peripheral neuropathy of the right upper extremity 2. Entitlement to an increased rating in excess of 30 percent for peripheral neuropathy of the right lower extremity is remanded. 3. Entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the left upper extremity 4. Entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the left lower extremity The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, In an April 2020 statement, the Veteran has withdrawn his appeal on these claims and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeals on these issues and they are dismissed. New and Material Evidence Claims 5. Whether new and material evidence sufficient to reopen a claim of service connection for a right knee disorder has been received 6. Whether new and material evidence sufficient to reopen a claim of service connection for a left knee disorder has been received A final rating decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. §§ 5108, 7105. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. Knightly v. Brown, 6 Vet. App. 200 (1994). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). Finally, for the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). A rating decision in November 2007 denied service connection for right and left knee disorder. The RO found that although there was evidence of treatment for bilateral knee complaints in service, there was no evidence of a present disorder. The Veteran filed a petition to reopen his claim in September 2014. Since the November 2007 rating decision, the new evidence consists of updated treatment records. However, the Veteran has not submitted any evidence to show a diagnosis of a right or left knee disorder. Although the evidence contains complaints or knee and joint pain in association with his fibromyalgia, no specifically pathology of a knee disorder is shown. Therefore, the Board finds it that no new and material evidence has been submitted as the new records do not raise a reasonable possibility of substantiating the claims of service connection for bilateral knee disorder and his petition to reopen the claims of service connection is denied. Increased Rating Claims Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, VA must evaluate the veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where an appeal has been ongoing for a lengthy period of time, and because the level of a Veteran's disability may fluctuate over time, the VA is required to consider the level of the veteran's impairment throughout the entire period. In this respect, staged ratings are a sensible mechanism for allowing the assignment of the most precise disability rating-one that accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When assessing the present level of disability for the period on appeal, staged ratings are appropriate when the facts show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received, if it is factually ascertainable that an increase in disability had occurred within that timeframe. 38 U.S.C. § 5110; see also Hart, 21 Vet. App. at 509. 7. Entitlement to an increased rating in excess of 30 percent from February 8, 2018 for peripheral neuropathy of the right upper extremity 8. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the left upper extremity 9. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the right lower extremity 10. Entitlement to an increased rating in excess of 20 percent from February 8, 2018 for peripheral neuropathy of the left lower extremity The Veteran's peripheral neuropathies of his right and left upper extremities are in receipt of 30 and 20 percent ratings, respectively, under Diagnostic Code 8514. Paralysis of the radial nerves are evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Codes 8514. Under these criteria, mild incomplete paralysis of the radial nerve is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. The Veteran's diabetic peripheral neuropathy of the bilateral lower extremities are each evaluated as 20 percent disabling for the left and 20 percent disabling for the right, under Diagnostic Code 8526. Under Diagnostic Code 8526, in pertinent part, moderate incomplete paralysis is rated 20 percent disabling; severe incomplete paralysis is rated 30 percent disabling; and a 40 percent rating, the maximum available, is warranted for complete paralysis of the quadriceps extensor muscles. For VA purposes, the term "incomplete paralysis," with diseases of the peripheral nerves and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. See 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The Veteran underwent a VA examination in February 2018. Regarding symptoms, the examiner noted moderate pain, paresthesias, and numbers of the bilateral upper and lower extremities. Muscle strength testing was less than normal for all extremities. Deep tendon reflexes were normal and light touch/monofilament testing showed decreased sensation to the bilateral hands and fingers and ankles and feet. Position sense, vibration sensation, and cold sensation were decreased in all extremities. The Veteran did not have muscle atrophy or trophic changes. The examiner diagnosed a diabetic peripheral neuropathy causing moderate incomplete paralysis of the bilateral radial nerves and femoral nerves. Upon review of the record, the Board finds that the radial and femoral peripheral neuropathies are most accurately described as moderate based on the symptoms outlined above. The Board has reviewed the Veteran's VA treatment records and finds no indication of increased severity. Accordingly, the criteria for increase for radiculopathy are not met. These claims are being denied. The preponderance of the evidence is unfavorable, hence VA's benefit-of-the-doubt doctrine not for application. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. 11. Entitlement to an increased rating in excess of 20 percent for diabetes mellitus prior to February 8, 2018 12. Entitlement to an increased rating in excess of 40 percent for diabetes mellitus from February 8, 2018 Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran’s diabetes mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Veteran filed a claim for an increased rating for his diabetes in September 2014. In a December 2014 VA examination, the examiner noted the Veteran had a diagnosis of diabetes that was managed by a restricted diet and prescribed oral hypoglycemic agents, specifically more than one injection a day of insulin. The Veteran did not require regulation of activities as part of medical management of his diabetes. The Veteran saw his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than twice a month and was not hospitalized over the prior 12 months. He did not have loss of strength or weight. His complications included diabetic peripheral neuropathy, renal dysfunction, and hypertension. In a January 2015 mental health treatment record, the clinician noted that the Veteran understood the need to participate in physical activity to improve his diabetes. A March 2015 rating decision continued the Veteran's 20 percent evaluation for his diabetes. Separate 10 percent ratings were granted for peripheral neuropathies of the bilateral upper and lower extremities. In a June 2017 letter, the Veteran's physician stated that he was treating his uncontrolled Type II diabetes with insulin. He also stated that the Veteran's “uncontrolled diabetes requires a restricted diet and avoidance of strenuous occupational and recreational activities.” In February 2018, the Veteran underwent a VA examination for his diabetes. The examiner noted that the Veteran had a diagnosis of diabetes that was managed by a restricted diet, prescribed oral hypoglycemic agents, specifically more than one injection a day of insulin. The Veteran required regulation of activities as part of medical management of his diabetes, specifically avoiding strenuous occupational and recreational activities that would raise his stress levels to adversely affect blood sugars or increase chance of hypoglycemic episodes. The Veteran saw his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than twice a month and was not hospitalized over the prior 12 months. He did not have loss of strength or weight. A March 2018 rating decision increased the Veteran's rating for diabetes to 40 percent, effective February 8, 2018. Upon review of the record, the Board finds that a 40 percent rating is warranted for the Veteran's diabetes, effective June 16, 2017, the date the records reflect the Veteran's diabetes required regulation of activities. Therefore, an increased rating is granted from that date, but no earlier. As noted, this was the first evidence showing that the Veteran met the criteria for a higher rating. From June 16, 2017, the Board finds that a rating in excess of 40 percent is not warranted. The Veteran did not have episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. The Veteran is competent to report his symptoms and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that his diabetes mellitus required twice a month visits or one or more hospitalizations per year. The Board notes that the evidence of record shows that the Veteran has complications of diabetes; however, these complications are assigned separate ratings. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 40 percent from June 16, 2017. 13. Entitlement to compensable rating for hypertension prior to February 8, 2018 Hypertension is evaluated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is warranted for hypertensive vascular disease with diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for hypertensive vascular disease with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A rating of 40 percent is assigned with diastolic pressure predominantly 120 or more. A rating of 60 percent is assigned diastolic pressure predominantly 130 or more. The Veteran filed a claim for an increased rating for his hypertension in September 2014. In October 2014, the Veteran's treatment records show readings of 134/84 and 148/81. In a December 2014 VA examination, the examiner noted a diagnosis of hypertension that requires continuous medication for treatment. His readings were 147/84, 126/56, and 122/75. A March 2015 rating decision continued the Veteran’s noncompensable evaluation for his hypertension. In 2016 and 2017, his blood pressure readings were 160/78, 138/70, 152/87, 119/73, 139/87, 154/94, 199/114, 153/87, 144/94, 131/91, 146/99, 116/62, and 113/77. The Veteran consistently reported that his readings at home were within normal range. See September 26, 2016 treatment record. February 2018 treatment records showed readings of 183/109 and 158/84. In February 2018, the Veteran underwent a VA examination for his hypertension. The examiner noted that the Veteran takes continuous medication for his hypertension. His readings were 162/91, 174/92, and 168/89. The Veteran did not have a history of a diastolic BP elevation to predominantly 100 or more. The impact of the hypertension or isolated systolic hypertension on the claimant’s ability to work is generalized fatigue with exertion. Based on the above, a compensable rating for the Veteran's hypertension is not warranted. Although the Veteran is required to continuously take medication for hypertension, the Veteran's diastolic blood pressure is not predominantly 100 or more, nor does he have a history of such prior to February 8, 2018. Further, the Veteran's systolic blood pressure is not predominantly 160. The Board notes approximately six readings of systolic blood pressure at 160 or higher, but approximately 20 readings where it is under 160 during the pendency of the claim. As such, a 10 percent rating is not warranted and the Veteran's claim for a compensable rating for hypertension is denied. 14. Entitlement to a compensable rating percent for tinea versicolor prior to February 8, 2018 15. Entitlement to a rating in excess of 10 percent for tinea versicolor from February 8, 2018 The Veteran’s tinea versicolor is rated under Diagnostic Code 7806. Under Diagnostic Code 7806 for dermatitis or eczema, a 10 percent evaluation is warranted if 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; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted if the skin condition covers 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted if the skin condition covers 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. § 4118, Diagnostic Code 7806. The Veteran filed a claim for an increased rating for his tinea versicolor on September 23, 2014. In a December 2014 VA examination, the examiner noted that the Veteran had discoloration of the hands. He had no scarring of the head, face, or neck, no benign or malignant neoplasm, and no systemic manifestations due to skin disease. The Veteran did not treat with oral or topical medications. He had no debilitating or non-debilitating episodes. A physical examination showed less than 5 percent of his total body area and exposed body area was affected by eczema. A March 2015 rating decision continued the Veteran’s noncompensable evaluation for his tinea versicolor. In February 2018, the Veteran underwent a VA examination for his tinea versicolor. The examiner noted that tinea versicolor began in service and the Veteran reported that it worsened since that time. He had no scarring of the head, face, or neck, no benign or malignant neoplasm, and no systemic manifestations due to skin disease. The Veteran did not treat with oral or topical medications. He had no debilitating or non-debilitating episodes. The examiner noted fungal infections of the chest and bilateral hands that cover 10 percent of total body area and less than 5 percent of exposed body area. In April 2020, the Veteran and his wife submitted lay statements in which they testified that the Veteran had discoloration on his hands, forearms, and upper arms since service and it has remained the same, neither getting better nor worse. Upon review of the record and with resolution of the doubt in favor of the Veteran, the Board finds that a 10 percent rating is warranted for the entire period on appeal from September 23, 2014. The Veteran’s tinea versicolor is observable to lay witnesses and the Veteran and his wife are competent to testify as to their observations and the Board finds them to be credible. Both stated that the tinea versicolor had been consistently present on his hands, forearms, and upper arms since service. Therefore, the Board finds that a compensable rating is warranted from September 23, 2014, but no earlier However, as neither the lay evidence nor the observations of the VA examiner show that the Veteran's skin disorder affects more than 20 percent of the body or exposed areas and the Veteran does not treat with systemic therapy, the criteria for a higher, 30 percent rating are not met. Therefore, a rating in excess of 10 percent is denied. The Board finds that the Veteran’s tinea versicolor is appropriately rated under Code 7806. The record does not show scarring due to tinea versicolor (and the service-connected tinea versicolor does not affect the face, head, or neck). Accordingly, Codes 7800, 7801, 7802, 7804, and 7805 are not for consideration. 16. Entitlement to a compensable rating peripheral artery disease prior to February 8, 2018 17. Entitlement to a rating in excess of 40 percent for peripheral artery disease from February 8, 2018 The Veteran's peripheral artery disease is currently evaluated as 0 percent for the right lower extremity prior to February 8, 2018 and 40 percent thereafter, in accordance with the General Rating Formula for the Cardiovascular System under the disability criteria set forth at 38 C.F.R. § 4.104, Diagnostic Code 7114. Under those criteria, a 20 percent evaluation is assigned for claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. A 40 percent evaluation is warranted for claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less. A 60 percent evaluation is warranted for claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. A 100 percent evaluation is warranted for ischemic limb pain at rest, and; either deep ischemic ulcers or ankle/brachial index of 0.4 or less. Diagnostic Code 7114 also notes that, the ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. Note 1. These evaluations are for involvement of a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under §4.25), using the bilateral factor (§4.26), if applicable. Note 3. In a December 2014 VA examination, the examiner noted that the Veteran did not have and never had a vascular disease. The Veteran had no history of peripheral artery disease, no varicose veins or post-phlebitic syndrome, no peripheral vascular disease, no aortic aneurysm or aneurysm of a small artery, no Raynaud’s syndrome, and no arteriovenous (AV) fistula, angioneurotic edema or erythromelalgia. No diagnostic testing was conducted. The examiner remarked that “For the VA established diagnosis of peripheral artery disease, right lower extremity, the diagnosis is changed; as there is no evidence of peripheral artery disease, right lower extremity. Review of clinical record and examination show no evidence of this condition.” The Veteran also underwent a VA examination in December 2014 to assess the severity of his diabetic peripheral neuropathies. That examiner found the Veteran had trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to diabetic peripheral neuropathy which are described as loss of extremity hair with smooth skin. A March 2015 rating decision continued the Veteran’s noncompensable evaluation for his peripheral artery disease. In February 2018, the Veteran underwent a VA examination for his peripheral artery disease. The examiner noted a diagnosis of peripheral artery disease, right lower extremity. The Veteran reported an onset in 2005 and that the condition began spontaneously during service as a result of weight gain. He alleged that it had worsened since that time. Upon examination, the examiner noted that it caused claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour and that it caused persistent coldness of the extremity. The Veteran required constant use of a cane. The right ankle/brachial index was 1.40. The impact of the vascular condition on the Veteran's ability to work is pain, stiffness, limited range of motion, difficulty with heavy lifting, prolonged standing, walking, jogging, or climbing stairs. A March 2018 rating decision increased the Veteran’s rating for peripheral artery disease to 40 percent, effective February 8, 2018. The Veteran and his wife filed lay statements in April 2020. They testified that the Veteran's right leg had been having cramps and was a cooler temperature than the left leg since service, specifically in 2008. The Veteran began using a cane in 2013. Upon review of the evidence, the Board finds that higher ratings in excess of those assigned are not warranted. Prior to the February 2018 VA examination, there is no evidence of peripheral artery disease, to include diminished peripheral pulses or claudication. A review of the Veteran's outpatient treatment records shows no showings of any ankle brachial index at .9 or lower, trophic changes, persistent coldness, ischemic limb pain, ischemic ulcers, or claudication at a distance of less than 100 yards of walking at that time. Therefore, a compensable rating is not warranted. From February 8, 2018, the evidence of record shows, at worst, claudication on walking between 25 and 100 yards and persistent coldness of the extremity. Trophic changes were not noted on examination and the ankle/brachial index was 1.14. Therefore, the Veteran is not entitled to a rating in excess of 40 percent. The Veteran has considered the lay statements of the Veteran and his wife and finds them to be competent and credible regarding their observations. However, the findings of the VA examiner are more probative as to the severity of the disorder when applied to the rating criteria. As the preponderance of the evidence is against a claim for a higher rating, the Veteran's claim is denied. 18. Entitlement to an increased rating in excess of 10 percent for GERD with hiatal hernia The Veteran filed a claim for an increased rating for his GERD in September 2014. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. §§ 4.14, 4.113. Ratings under Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The rating code does not contain a listing for GERD. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The Veteran’s GERD has been evaluated by analogy to a hiatal hernia. The Board had reviewed the rating schedule and is unable to find any other code that more accurately evaluates the GERD. The medical evidence shows that the diagnosis of the Veteran’s disability now includes a hiatal hernia. Therefore, the Board will continue to rate the Veteran’s GERD by analogy to the rating code for hiatal hernia. Under the rating code for a hiatal hernia, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Lastly, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Code 7346. In a December 2014 VA examination, the Veteran reported having acid reflux with substernal pain. Further evaluation showed that he had a hernia. He was treated with acid medication that has helped. Additional symptoms include pyrosis. There was no esophageal stricture, spasm, or acquired diverticulum. A March 2015 rating decision continued the Veteran’s 10 percent evaluation for his GERD. In February 2018, the Veteran underwent a VA examination for his GERD. The examiner noted GERD and hiatal hernia. The Veteran takes continuous medication for this condition. His symptoms include pyrosis, reflux, and regurgitation. There was no esophageal stricture, spasm, or acquired diverticulum. Based on a review of the evidence of record the Board finds that a rating in excess of 10 percent is not warranted. The Veteran pyrosis, reflux, and regurgitation, which are all contemplated by the current 10 percent rating. The Board does not find that the Veteran has exhibited persistently recurrent symptoms of epigastric distress productive of considerable impairment in health to warrant an increased 30 percent rating. The examiner noted no impact on the Veteran’s ability to work. There is no indication that the Veteran’s symptoms have been productive of considerable impairment of health. In conclusion, all potentially applicable diagnostic codes have been considered for this period, and there is no basis to assign an evaluation in excess of the rating assigned herein for the Veteran’s GERD. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). As the preponderance of the evidence is against the Veteran's claim, it is denied. REASONS FOR REMAND 1. Entitlement to an increased rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. 2. Entitlement to a TDIU is remanded. Following the issuance of a March 2018 statement of the case, and after the certification of this appeal to the Board, the Veteran was afforded a VA examination for his PTSD in May 2020. This new evidence pertinent to his increased rating claim was added to the record and was not considered by the RO or reported in any subsequent supplemental statement of the case. On remand, the Ro should readjudicate the claim and issue a supplemental statement of the case which considers the additional evidence of record received since the March 2018 statement of the case, as appropriate. Additionally, the May 2020 VA examination report notes that the Veteran has been employed as a facility manager at Hanscom Air Force Base at the medical clinic. Therefore, the Board finds it relevant to the Veteran's claim of TDIU. Therefore, the claims are inextricably intertwined and must be remanded pending the issuance of a SSOC. The matters are REMANDED for the following action: Review the May 2020 VA examination. Then, complete any other development as may be indicated and the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shana Z. Siesser, 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.