Citation Nr: 21001253 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 10-43 605 DATE: January 7, 2021 ORDER Entitlement to an initial 10 percent evaluation for hypertension is granted. Entitlement to an initial evaluation in excess of 10 percent for dysphasia and gastroesophageal reflux is denied. Entitlement to an initial evaluation in excess of 30 percent prior to February 25, 2020 and 50 percent thereafter for migraine headaches is denied. Entitlement to an initial compensable evaluation for acne and rosacea is denied. Entitlement to an initial compensable evaluation for hemorrhoids is denied. REMANDED Entitlement to an initial compensable evaluation for eczematous seborrheic dermatitis is remanded. FINDINGS OF FACT 1. For the entire initial rating period, the Veteran’s hypertension has required medication for control and has been controlled by medication, without any intervals of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more, with a history of hypertension which would likely have included blood pressure predominantly 100 or more but for antihypertensive medication. 2. For the entire initial rating period, the Veteran has had less severe symptoms of epigastric distress, pyrosis, or regurgitation, or substernal arm or shoulder pain, without associated impaired functioning and without associated impairment of health. 3. For the entire initial rating period, the Veteran’s migraine headaches have not been more severe than migraines with characteristic prostrating attacks occurring on average once per month prior to February 25, 2020. Thereafter, the Veteran is rated at the maximum disability evaluation under the applicable criteria. 4. For the entire initial rating period, the Veteran’s acne and rosacea has been superficial and not disfiguring. 5. For the entire initial rating period, the Veteran’s hemorrhoids have been mild to moderate. CONCLUSIONS OF LAW 1. The criteria for a 10 percent evaluation, but no more, for hypertension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7101. 2. The criteria for an initial evaluation in excess of 10 percent for dysphasia and gastroesophageal reflux have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, DC 7346. 3. The criteria for an initial evaluation in excess of 30 percent prior to February 25, 2020, and in excess of 50 percent thereafter for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8100. 4. The criteria for an initial compensable evaluation for acne and rosacea have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DC 7828. 5. The criteria for an initial compensable evaluation for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, DC 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1986 to March 2009. The Department of Veterans Affairs (VA) is grateful for his service. The initial rating claims the subject of appeal pertain to the initial ratings assignable beginning from April 1, 2009. The Board of Veterans’ Appeals (Board) previously remanded the appealed claims in October 2015 and July 2019. They now return to the Board for further review. Increased Rating Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Because varying, distinct degrees of disability may have been experienced over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Id. at 505. Also, separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability over the rating period in question. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self- interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996). 1. Entitlement to a compensable initial rating for hypertension The Veteran contends, in effect, that his service-connected hypertension is more severe than reflected by the noncompensable rating. The Veteran’s hypertension is rated under DC 7101, which pertains to hypertensive vascular disease, to include hypertension and isolated systolic hypertension. 38 C.F.R. § 4.104. DC 7101 provides that a 60 percent rating is warranted if the diastolic pressure is predominantly 130 or more. A 40 percent rating is assigned if the diastolic pressure is predominantly 120 or more. A 20 percent rating is warranted when the diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 10 percent rating is assigned if the diastolic pressure is predominantly 100 or more, systolic pressure is 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. In several submitted statements the Veteran addressed both the severity of his hypertension while in service and conditions which he contended were a result of uncontrolled hypertension while in service. Other claimed conditions or disabilities as secondary to hypertension have been separately addressed in other adjudicated claims and are not the subject of this appeal. The severity of the Veteran’s hypertension while in service is also not at issue here except to establish that prior elevated blood pressure resulted in the Veteran requiring medication for control of hypertension, which is part of the basis of the Board’s grant herein of a 10 percent disability rating for hypertension. Upon pre-separation examination in December 2008, the Veteran provided a history of being diagnosed with hypertension in 2005, being tried on several different medications which he did not tolerate, and currently taking Terazosin which he tolerated and which resulted in his hypertension being usually well-controlled. Blood pressure readings were 140/89, 138/82, and 134/83. Cardiovascular examination revealed regular cardiac rate and rhythm with no murmurs, rubs, or gallops, no jugular venous distention, and peripheral pulses symmetrical and intact. The examiner diagnosed essential hypertension which was controlled. Upon VA examination in April 2015, the examiner noted the extenuating circumstance of the Veteran being treated beginning in service with the antihypertensive medication terazosin for benign prostatic hypertrophy (BPH), and that this continuing medication likely had the added effect of reducing his blood pressure. The examiner noted that despite this treatment there were some service readings of elevated blood pressure. The examiner accordingly concluded that it was at least as likely as not that the Veteran had hypertension controlled by medication despite the absence of a past formal finding of hypertension dating from service. Blood pressure readings in February 2015 were 136/80, 134/77, and 134/74. Physical findings included no jugular venous distention, no bruit, heart reflecting regular rate and rhythm without gallop, no dependent edema, and pulses symmetric. The Veteran denied a history of adverse cardiac events, and the examiner noted that “his latest diagnostic data revealed no target organ damage due to poorly-controlled [hypertension].” The Veteran’s drug therapy for hypertension was noted to be “well-tolerated and without treatment emergent adverse effect.” The Veteran was noted by the April 2015 examiner to be continued on antihypertensive medication. The examiner diagnosed benign, essential hypertension, and assessed that this was incurred in service. In statements submitted in April and July of 2015, the Veteran asserted that the VA examiner in April 2015 never examined him for hypertension and accordingly created a false record. However, the Veteran then conceded that the April 2015 examiner had then examined him for other conditions, that a technician had obtained blood pressure readings prior to the physician examining him, and that the examiner reviewed past records in the examination report. While the Veteran took issue with the examiner’s findings and objects, in effect, that the physician did not ask him directly and explicitly about hypertension and did not explicitly consider past medical records which the Veteran deemed to be relevant, the Board does not find substantial evidence that an examination was not conducted or that an examination report was falsified. The examiner may certainly have visually examined the Veteran and performed clinical tests without the Veteran being cognizant that these were for assessment related to hypertension. While the Veteran has made apparent his objection with the examination findings, the Veteran’s assertions appear to be substantially unfounded. Additionally, the record contains other examination reports which are substantially consistent with findings and conclusion of the April 2015 examiner, including the more recent VA examination in February 2020. (Regarding the Veteran’s assertions of other cardiac conditions which the Veteran perceived the April 2015 examiner to have erroneously discounted, such other cardiac conditions are beyond the scope of evaluating hypertension for rating purposes, and hence beyond the scope of the Board’s adjudication herein. The Board notes that the Veteran was granted service connection for left ventricular hypertrophy (LVH) by a February 2015 rating action as secondary to hypertension, and this service-connected LVH was subsequently recharacterized by the RO in a December 2015 rating action as coronary artery disease (CAD). VA benefits based on the grant of service-connected for LVH and then CAD were granted notwithstanding the opinions of the April 2015 VA examiner that there was no evidence of end-organ damage due to uncontrolled hypertension. If the Veteran wishes to file additional claims for other cardiac or non-cardiac conditions, he may do so at the RO level.) Upon a VA examination in February 2020, the Veteran’s hypertension was noted to be controlled by medication. Blood pressure readings at the examination were 136/72, 147/66, and 141/76. The examiner found that the Veteran did not have persistent diastolic blood pressure predominantly 100 or more, and did not have other physical findings, complications, conditions, signs, or symptoms related to his hypertension. The examiner found that the Veteran’s hypertension did not impact his work capacity. The examiner additionally found that no change was warranted in the diagnosis of hypertension. The February 2020 examiner did not find a history of diastolic blood pressure predominantly 100 or more but did note a history in 1988 of the Veteran feeling flush in the face, neck, and ears, with dizziness, fatigue, and chest pains, for which he was treated with Terazosin. The Veteran was prescribed more exercise while in the Air Force in 1990, and he was treated with hypertension medication beginning in 2002, with mediation changed in 2007 due to ineffectiveness. Current symptoms included episodes of low blood pressure and dizziness. The Veteran’s current treatment consisted of blood pressure medication. Reportedly, occupational stress and strenuous activities increased the Veteran’s symptoms. The February 2020 examiner’s findings are consistent with and supported by the balance of findings over the claim period reflecting absence of uncontrolled or elevated blood pressure with diastolic predominantly 100 or more or systolic predominantly 160 or more during the claim period. The examination findings are consistent with the balance of the record as reflecting blood pressure controlled by continuous medication. Based on likely control of otherwise elevated blood pressure beginning in service with prescribed Terazosin for BPH, with hypertension controlled by medication since that time, a 10 percent rating is warranted. DC 7101. The weight of the evidence is against the Veteran’s hypertension warranting a 20 percent rating at any time during the claim period, based on the absence of a showing of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. Accordingly, staged ratings are not warranted. Hart, 21 Vet. App. at 509-10. 2. Entitlement to an initial rating greater than 10 percent for dysphasia and gastroesophageal reflux The Veteran contends, in effect, that his service-connected esophageal dysphagia and gastroesophageal reflux are more severe than is reflected by the assigned 10 percent rating and that a higher evaluation is warranted. The Veteran’s esophageal dysphagia and gastroesophageal reflux are appropriately rated under 38 C.F.R. § 4.115a, DC 7346, under hiatal hernia, because the anatomical location of disability, symptoms, and impacts on functioning are in this case equivalent. 38 C.F.R. § 4.20. Under DC 7346, a 60 percent evaluation contemplates a level of impairment which includes symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation is warranted when there are two or more symptoms of the 30 percent rating of less severity. 38 C.F.R. § 4.114, DC 7346. In a September 2014 statement, regarding symptoms during the claim period, the Veteran provided the following: GERD conditions cause me to experience extreme upper stomach pain after eating 10 times per month. Vomiting has occurred 2 times per month and is relieved sometimes with nausea medication. Nausea is more frequent, at 4 times per week, sometimes uncontrolled leading to vomiting. Records show esophageal dilation has been performed to relieve “lump” in the throat feeling. I use medication to control these “spasms”. I do have to leave work during reflux attacks, driving is impaired and I have to change my lifestyle to account for these conditions. I have had to take time off work during episodes. I can’t eat spicy, acidic, or heavy sauced food, to include chocolates. I must eat 4 hours before bedtime to allow time for digestion or I’m up until 1 am, dealing with gastric pains. The Veteran then added that he had “stomach pains, sternum to left arm pain daily.” Upon pre-separation examination in December 2008, the Veteran reported a history of pyrosis and reflux, with the reflux continuing until he was started on Nexium, with the reflux virtually resolved since that time. The Veteran denied having any nausea, vomiting, or hematemesis. He reported good results with Nexium, and a history of a normal upper GI examination. A history of esophageal dilation in 2008 was noted, with the Veteran reporting some ongoing dysphagia symptoms. The examiner reviewed recent upper GI and barium swallow examinations which were normal. The examiner assessed dysphagia status post esophageal dilation without objective evidence of gastroesophageal reflux disease or hiatal hernia. Upon VA examination in March 2015, past diagnoses of GERD and hiatal hernia were noted. Past treatment in 2008 with esophageal dilation was noted, as well as proton pump inhibitor (PPI) therapy, with a follow-up study in 2011 revealing only mild chronic gastritis. The Veteran reported ongoing heartburn largely relieved by daily PPI use, and he denied odynophagia or dysphagia currently. The examiner noted that there was no evidence of weight loss; rather, the evidence reflected weight gain. The Veteran stated that after his breakfast, usually of cereal and milk, he experienced bloating and nausea for which he took antispasmodic and antiemetic medications. The Veteran denied a history of hematemesis or melena. He had no history of upper GI surgery. Physical examination was benign. The examiner noted that past upper gastrointestinal examinations had shown esophageal spasm during examination and had shown hiatal hernia and gastritis, but revealed no rings, strictures, or other anatomic obstructive lesions of the esophagus. The March 2015 examiner assessed that the Veteran’s symptoms included persistently recurrent epigastric distress, pyrosis, reflux, and nausea, with four or more episodes of nausea per year and average duration of nausea of less than one day. The examiner concluded that the Veteran’s GERD was effectively treated with daily antacid therapy, and that the Veteran did not have nutritional deficiency or anemia or other complication. The examiner also concluded that the Veteran’s esophageal dysphagia and gastroesophageal reflux “would not hinder employability.” Responsive to a statement by the Veteran in March 2015 that he experienced “severe pain in the stomach and under the sternum to the left shoulder to arm pain” daily, the examiner noted that with the Veteran’s prescribed daily PPI therapy, which the Veteran had reported was tolerated and efficacious, these symptoms would be alleviated. The examiner further noted that the Veteran had not reported these pain symptoms to his treating gastroenterologist. In a March 2015 submitted statement, the Veteran reported numerous symptoms which he attributed to hiatal hernia and GERD with dysphagia, including nausea at many and varied times during the day; spasms, tightness, and pain in his esophagus; cramping and burning in the stomach area; abdominal pain; and “cramping, which is the pain in my sternum, chest.” The Veteran made several objections to the March 2015 examination, including particularly objecting to the examiner’s statements to the Veteran (not noted on the examination report) that the Veteran may be lactose intolerant and this may be contributing to his intestinal symptoms associated with his daily breakfast. The Veteran also expressed that his symptoms were more severe than the examiner reflected on the examination report. In a November 2015 statement, the Veteran informed that his dysphagia and reflux resulted in permanent discomfort which required diet changes and daily medication, and which altered his sleep. Upon VA examination in March 2020, the examiner diagnosed dysphagia as a residual of esophageal dilation. The Veteran reported a history of a lump and burning in the throat, regurgitation after meals, and pain at the top of the stomach with severe heartburn lasting days. This was noted to be treated with a nausea medication. Current continuous medication consisted of Dexlansoprazole, Mylan, and Prilosec. At the examination, the Veteran endorsed the presence of symptoms including dysphagia (difficulty swallowing), reflux, regurgitation, and substernal pain. The Veteran also endorsed nausea present four or more times per day. The examiner noted that the Veteran’s esophageal condition had been amenable to dilation, with balloon dilation performed in November 2008. The examiner also noted that esophagogastroduodenoscopy (EGD) revealed only mild esophageal narrowing status post dilation. CBC testing in February 2020 showed hemoglobin 14.3, hematocrit 42.3, white blood cell count 6.5, and platelets 182. Neither hematologic nor nutritional deficiencies were identified. The examiner found no impact of the Veteran’s condition on his ability to work. Humana Military / TRICARE treatment records obtained in August 2020 generally reflect good control of the Veteran’s dysphagia and esophageal reflux, with the Veteran denying significant symptoms, contrary to the Veteran’s assertions in submitted statements and at VA examinations. At an August 2015 treatment visit for angina, the Veteran did not report any esophageal or abdominal-related pain and reported good appetite. At a June 2016 general treatment visit, the Veteran reported feeling well with no issues; regarding gastrointestinal conditions, the Veteran denied heartburn, nausea, and vomiting. At a January 2017 pulmonary clinic visit for complained-of shortness of breath and dry cough, the clinician noted that a December 2015 EGD resulted in a diagnosis of mild to moderate reflux esophagitis and cricoarytenoid inflammation from likely laryngopharyngeal reflux. However, at the January 2017 visit the Veteran denied symptoms of abdominal pain, nausea, or vomiting. At an April 2019 treatment, the Veteran was noted to have gastroesophageal reflux disease (GERD) without esophagitis. At a December 2019 treatment visit for chronic GERD, the Veteran reported that his condition was well-controlled on current medication. At a March 2020 annual physical, the Veteran’s history of esophageal reflux was noted, but the Veteran denied having nausea, vomiting, or abdominal pain. The Veteran was then noted to be well-appearing, well-developed, and well-nourished. Keesler Air Force Base (AFB) records obtained in October 2016 also generally reflect good control of his dysphagia and esophageal reflux, with the Veteran denying significant symptoms. At October 2014 and December 2014 medical care visits, the Veteran reported that in general he felt well and in good health; at both visits he denied nausea, vomiting, and abdominal pain. Other, earlier care at military facilities also reflect good control of dysphagia and esophageal reflux, without report of recurrent upper gastrointestinal discomfort, nausea, regurgitation, or vomiting. A VA intake medical record dated in September 2016 and reflecting care received at military facilities from April 2009 to September 2016 listed active problems, which did not include dysphagia or esophageal reflux or GERD. Only a single instance of vomiting, in February 2011, is documented to have occurred, with the cause not reported. The Board finds that the Veteran’s statements when receiving care at military facilities are more credible than those made to VA in furtherance of his VA benefits claims, due to greater motivation for frankness in the course of care in order to receive accurate treatment and greater motivation for exaggeration of symptoms when making statements to VA in furtherance of his claim. Caluza, 7 Vet. App. at 511-512. Hence, affording greater weight to the Veteran’s statements in the course of care at military facilities, the Board concludes that over the claim period it is more likely that the Veteran had limited symptoms of his dysphagia and gastroesophageal reflux, without significant nausea or vomiting, significant pyrosis, or significant distress, and without any impact on general health or functioning. The Veteran’s self-reports at VA examinations and in submitted statements have reflected symptoms of esophageal dysphagia and gastroesophageal reflux including nausea, pain, reflux, regurgitation, and dysphagia, with continuous medication. The Veteran’s endorsed symptoms at the March 2020 examination and previously during the claim period include several symptoms which would be consistent with a 30 percent rating, but without resulting considerable impairment of health. 38 C.F.R. § 4.114, DC 7346. The Veteran’s reporting of severe symptoms upon VA examinations are noted to reflect more and more severe symptoms than have been reported by the Veteran at treatment visits. The record does not reflect any impairment of health associated with the Veteran’s dysphagia and gastroesophageal reflux, with no associated weight loss or reduced nutrition reflected in the record. The Board concludes that notwithstanding the Veteran’s reporting of considerable symptoms in furtherance of his claim, the weight of the evidence – inclusive of the Veteran’s own statements to care providers and objective findings upon examinations as well as absence of any identified impairment of health associated with the Veteran’s dysphagia and gastroesophageal reflux – is against the Veteran’s dysphagia and esophageal reflux meeting the criteria for a 30 percent evaluation. 38 C.F.R. § 4.114, DC 7346. The Board finds the disability has more nearly approximated the criteria for a 10 percent rating throughout the initial rating period, with less severe symptoms of epigastric distress, dysphagia, pyrosis, regurgitation, or substernal arm or shoulder pain, without associated impairment of functioning, and without impairment of health. Id. The Board finds no interval during which the disability was of greater severity so as to more nearly approximate the criteria for a 30 percent rating, and hence staged ratings are not warranted. Hart, 21 Vet. App. at 509-10. 3. Entitlement to higher initial ratings for migraine headaches, currently evaluated as 30 percent disabling prior to February 25, 2020, and 50 percent disabling thereafter. The Veteran’s disability has been rated under DC 8100, which rates headaches, provides a 10 percent rating for prostrating attacks averaging one in two months over several months. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. The maximum schedular disability rating of 50 percent is warranted for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. 4.124a, DC 8100. The rating criteria do not define “prostrating,” nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to WEBSTER’S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” Upon pre-separation examination in December 2008, the Veteran reported being diagnosed with migraines in 2003 and usually having two migraine headaches per month which may last for several hours and which were usually preceded by an aura. He related headache pain. He reported that during significantly severe migraines he experienced nausea but with no vomiting, photophobia, and noise intolerance, adding that he had a severe headache approximately three to four times per year, when he would be incapacitated and had to lie down in a dark, quiet room. The examiner assessed migraine headaches which were well-controlled with current medication. Upon VA examination in February 2015, the Veteran reported having migraines three times per month. However, the examiner stated that there was no evidence to suggest that the Veteran’s migraines were very frequent, completely prostrating, or prolonged, or that they would cause severe economic inadaptability. In a statement submitted in October 2014 and again in February 2015 with additional comments, the Veteran reported that he had headaches which occurred three times per month and were always associated with “photophobia and phonophobia” and “severe sensitivity to light,” with his migraines having worsened in intensity and duration so that “they last at least 2 days now.” The Veteran further reported that due to his photophobia and phonophobia he had to stay in his bedroom closet “to get away from prostrating onset of attacks.” He also reported having to leave work during prostrating attacks and that his driving was impaired. In a March 2015 submitted statement, the Veteran reiterated many prior statements including that he had recurrent migraine attacks lasting two days and asserted, “During migraine attack, I’m not able to do anything by lay down and breathe.” In a November 2015 statement the Veteran reported having one to two migraines monthly and that he required continued medication. Post-service Keesler Air Force Base (AFB) records generally reflect well-controlled migraines. The Veteran was seen in March 2015 for a complaint of a migraine for the past two days for which he had taken Imitrex without relief. This single treatment is notable because it is the only record reflecting care for a migraine of this duration, and treatment records do not reflect that the Veteran reported having other migraine episodes of that duration at on other occasions. Also notably, at that treatment the Veteran did not report any associated vomiting or inability to do anything but lie down or retreat to a dark closet, and did not report any difficulty venturing to the medical appointment, which would all appear contrary to his assertions regarding severe migraines in support of his claim. A June 2016 VA treatment record indicates that the Veteran’s migraines were well-controlled with current regiment. At a December 2019 treatment, the Veteran reported that he had been experiencing migraine headaches off and on for four months and that they had been getting worse, increasing in frequency to one to two times per week. He then requested a referral to a neurologist. Humana Military / TRICARE treatment records obtained in August 2020 reflect that the Veteran had ongoing treatment of migraines with prescribed Sumatriptan. At a December 2019 treatment, the Veteran reported having migraine headaches one to two times per week. Both December 2019 and March 2020 treatment records note that the Veteran’s migraines were without aura, were not intractable, and were without status migrainosus. At a December 2019 treatment, the Veteran reported that his migraines had increased in frequency, were 5 to 8 out of 10 in severity, and were associated with sensitivity to light. A July 2020 treatment noted the Veteran’s report of increased frequency of migraines of three times per month, with a treating neurologist prescribing Fioricet. At a February 2020 VA examination the Veteran reported severe, disabling migraines monthly and missing four days of work per month due to migraines. On this basis the RO granted a 50 percent rating from February 25, 2020. Thus, the VA and TRICARE treatment records, and the February 2020 VA examination record are inconsistent in the reported frequency of migraines, their severity (particularly whether they are intractable/ debilitating), and the resulting impact on work functioning. The Board finds the treatment records to be the more reliable since the Veteran would then be motivated to receive appropriate treatment based on accurate information, and the TRICARE records more reliable than the VA records because the Veteran was receiving care for his migraines through TRICARE. The Board considers the Veteran’s reports to VA examiners for compensation purposes would be less reliable because the Veteran’s motivation would tend toward exaggeration of severity, frequency, and duration of migraines in furtherance of his benefit claims. Particularly telling are the TRICARE treatment notes from December 2019 and March 2020 informing of the absence of intractable migraines, and hence the absence of characteristic prostrating attacks which would merit compensable ratings under the rating criteria. Given the Veteran’s notably more mild symptoms and reports of well-controlled migraines to Keesler AFB and Humana/ TRICARE providers, it appears most likely that the Veteran’s more extreme statements in support of his claim, such as in February 2015 that all is migraines last at least two days and in March 2015 that during his migraine attacks he was able to do nothing but lie down and breathe, are most likely false. Medical opinions based on inaccurate factual premises are not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (per curiam). Hence, medical findings or conclusions relying on the Veteran’s exaggerated statements of the severity and duration of his migraine headaches are not probative. With due consideration of the above-noted inconsistent statements of record and resulting inconsistent medical findings, the Board relies most heavily on the TRICARE treatment records reflecting more limited migraine symptoms based on the Veteran’s statements regarding their severity which were motivated for accurate assessment and correct medical care. The Board thereby concludes that the weight of the evidence is against the Veteran’s migraines being manifested by characteristic prostrating attacks during the claim period more frequently than three or four times per year, with the migraines generally well-controlled by medication. However, treatment records do reflect that less severe migraines were of sufficient frequency beginning in approximately August 2019 to be equivalent to prostrating attacks occurring once every two months. The Veteran’s report at a July 2020 TRICARE visit of migraines increased to three times per month informs of greater frequency of migraines but still less frequency than he had reported at VA treatment and examination visits months earlier. The Board accordingly concludes that over the entire claim period the Veteran’s migraines are not more severe than an equivalence to migraines with characteristic prostrating attacks averaging one in two months. They are therefore also not more severe than migraines with characteristic prostrating attacks occurring on average once per month prior to February 25, 2020, and are not more severe than very frequent, completely prostrating attacks beginning February 25, 2020. Notably, a 50 percent rating is the maximum evaluation under this code. Hence, the Board finds the preponderance of the evidence against migraines warranting higher ratings than the 30 percent assigned prior to February 25, 2020, and 50 percent assigned thereafter. The Board has considered additional staged ratings, but finds that the weight of the evidence is against any intervals of greater severity of disability than that reflected by the ratings already assigned. Hence, staged ratings are not warranted. Hart, 21 Vet. App. at 509-10. 4. Entitlement to a compensable initial rating for acne rosacea The Veteran contends, in effect, that his acne rosacea is more severe than is reflected by the initial noncompensable rating assigned. The Board notes that during the pendency of the appeal, the criteria for evaluating certain disabilities of the skin were revised, effective August 13, 2018. See 38 C.F.R. § 4.118, (Diagnostic Codes 7801, 7802, 7805, and 7806) (2017). However, DC 7828 was unaffected by the revisions, and the Veteran’s acne rosacea is appropriately rated as acne under DC 7828. Thus, the revisions do not affect the Veteran’s claim for a higher rating under DC 7828. Under DC 7828, a noncompensable disability rating is warranted for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. The maximum 30 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. Or acne may be rated as disfigurement of the head, face or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, 7805), depending upon the predominant disability. At a December 2008 pre-separation VA examination, the Veteran was noted to have been diagnosed with acne rosacea in 2007. At the December 2008 examination, the Veteran reported that his rosacea was intermittent and that he had treated the condition with Metronidazole twice daily for the past six months. The examiner observed no significant scarring or disfigurement. There was some very mild facial erythema in the malar areas bilaterally, but no acne or chloracne was present. Upon a VA skin examination in February 2015, the Veteran reported a history of more bumps of acne under his facial skin, treated topically, and of rosacea in 2011 spreading from his nares’ creases to his cheeks, also treated topically. The examiner found no disfigurement of the head, face, or neck associated with the Veteran’s skin conditions. The Veteran used Retin-A topically for his acne. Objectively, the examiner found mild facial redness to the nares and cheeks due to rosacea, and she found a “scant amount of pimples to the upper right cheek and lower jaws.” The examiner assessed superficial acne affecting less than 40 percent of the face and neck, resulting in no functional impact on the Veteran’s ability to work. In a November 2015 statement purportedly addressing his rosacea, the Veteran informed that he had a “dry, painful, itchy, flaky” condition of the face, neck, and back which was “not curable.” It appears from this statement that the Veteran was conflating his rosacea with his eczematous seborrheic dermatitis, since, as reflected by examination findings, the Veteran’s dry, itchy, flaky skin describes his eczematous seborrheic dermatitis, not his acne rosacea. Upon VA examination in February 2020, the examiner diagnosed acne rosacea and observed the Veteran’s condition to consist of redness and bumps to the cheeks, nose, and forehead. Reported treatment over the past 12 months included the topical retinoid tretinoin which the Veteran used constantly or near-constantly for rosacea. The Veteran also used Finacea topically constantly or near-constantly for rosacea over the past 12 months. The examiner noted that Veteran had no treatments or procedures for the condition over the past 12 months. The February 2020 examiner found that the rosacea affected less than five percent of total body area but affected from 20 to 40 percent of exposed areas. The examiner assessed that the acne rosacea affected work capacity by making the Veteran unable to tolerate sun exposure due to irritation of skin on the face. The Veteran’s acne rosacea is appropriately rated as noncompensable. While the Veteran’s rosacea is noted to affect 20 to 40 percent of exposed areas, it is superficial and not deep acne, and hence does not merit a compensable rating under DC 7828. The rosacea more nearly approximated superficial acne than deep acne. As DC 7828 indicates, superficial acne to any extent is rated as noncompensable. The record does not reflect any intervals of greater severity of acne rosacea with deep acne, and hence staged ratings are not warranted. Hart, 21 Vet. App. at 509-10. The acne rosacea has not been identified by examiners or treating clinicians as disfiguring, and hence a rating based on equivalence to disfiguring scars of the head, face, or neck is not warranted, with the preponderance of the evidence against. 38 C.F.R. § 4.118, DC 7800. 5. Entitlement to a compensable initial rating for hemorrhoids The Veteran contends, in effect, that his hemorrhoids are more severe than is reflected by the noncompensable rating assigned, and that a compensable rating is warranted. The Veteran’s hemorrhoids are appropriately rated under DC 7336, for external or internal hemorrhoids. Under DC 7336, a noncompensable rating is assigned for hemorrhoids manifested by mild or moderate symptoms. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336. At a pre-separation VA examination in December 2008, the Veteran reported onset of hemorrhoids in 1992, with conservative treatment, but developing bright blood with bowel movements in 2001 and undergoing colonoscopy in 2004 when internal and external hemorrhoids were identified. The Veteran denied fecal leakage or involuntary bowel movements. He also denied thrombosed hemorrhoids and reported no current bleeding, though he had occasional blood on his toilet paper. He used Analpram HC topically and daily added fiber in his diet. Objectively, rectal examination revealed small external hemorrhoid tags. Examination was hemoccult negative, and no fecal leakage was noted. The examiner assessed external hemorrhoids with no acute findings, and internal hemorrhoids which were noted on colonoscopy. In a March 2015 statement, the Veteran reported having blood in his stool, severe pain with bowel movement, and severe pain “randomly after sitting.” The Veteran also reported having anal pain which sometimes was throbbing and burning, which occurred at least three days per week, and which was sometimes persistent daily for weeks at a time. The Veteran also then reported that he “must use” Analpram and Anusol suppositories daily. The Veteran questioned the thoroughness of the prior VA examination in 2015, the completeness of its findings, and the accuracy of its conclusions. In a November 2015 submitted statement the Veteran reported that internal and external hemorrhoids were “continually present” with bleeding. The Veteran submitted other statements in the course of claim endorsing similarly severe symptoms. Given the Veteran’s propensity for exaggeration as discussed above in this decision with regard to other claimed disabilities, the Board relies most heavily on objective findings upon examination, which are in any case substantially the basis of assigning compensable ratings hemorrhoids. At a February 2015 VA examination (signed in March 2015 by the examining physician) the Veteran reported having worsened hemorrhoidal complaints with prolonged sitting and when straining during bowel movements. The examiner noted findings on endoscopy revealing only skin tags without thrombosed external or internal hemorrhoids. The examiner further noted that the Veteran had not undergone any ano-rectal surgery, and that the Veteran denied any history of hematochezia. The Veteran was noted to apply Analpram-HC for rectal discomfort and to use fiber supplements for avoidance of constipation and straining. The examiner noted symptoms consisting of mild to moderate internal or external hemorrhoids with associated “rectal pruritis/ burning discomfort” and pruritis ani “[s]econdary to large anal skin tag.” Physical examination revealed no external hemorrhoids but only skin tags. The examiner found no other pertinent medical conditions. A CBC conducted in March 2014 was noted with a hemoglobin of 14.1 and a hematocrit of 40.2, with no finding of anemia. The examiner found no impact of the Veteran’s hemorrhoids on his ability to work. The examiner summarized: “Veteran with service connection for hemorrhoids, no daily, continuous therapy required, physical examination without evidence of thrombosed hemorrhoid or other complication; the Veteran’s mild hemorrhoidal complaints addressed with the as[-]needed use of a topical analgesic/ anti-inflammatory medication would not hinder employability.” The 2015 examiner further noted, “The Veteran’s C-file contains a note from March 14, 2015 that states he suffers from ‘internal and external hemorrhoids’ with ‘pain and bleeding’ and ‘episodes of stool leakage.’ However, the Veteran’s endoscopic studies do not validate this claim, and he had no such complaints to his private Gastroenterologist or to this evaluator.” Thus, the examiner effectively discounted the validity of the Veteran’s assertions in March 2015. In subsequent submitted statements, the Veteran took issue with the March 2015 VA examination report, including as to whether the Veteran denied rectal bleeding at that time. However, the presence or absence of rectal bleeding is not determinative of a higher rating for hemorrhoids in the absence of secondary anemia, which is not shown in this case. Rather, the examiner specifically noted CBC results not revealing anemia. Upon VA examination in February 2020, the Veteran reported that while his hemorrhoids were treated with medication, his current symptoms included pain with bowel movements, spasms, and pain with prolonged sitting. (The Veteran also reported having a colon polyp which he apparently associated with his hemorrhoids. If the Veteran wishes to submit a claim for additional conditions, such as for a colon polyp, he may do so at the RO level.) The examiner noted symptoms of mild or moderate internal or external hemorrhoids. Physical examination revealed small or moderate external hemorrhoids, without any other pertinent physical findings, complications, conditions, signs, symptoms, or scars. CDC testing in February 2020 revealed hemoglobin 14.3, hematocrit 42.3, white blood cell count 6.5, and platelets 182. The examiner assessed as an impact on the Veteran’s ability to work inability to sit for prolonged periods of time due to hemorrhoid pain. The Board find the preponderance of the competent and credible evidence of record against the Veteran’s hemorrhoids meeting the criteria for a 10 percent rating as there have been no findings of large or thrombotic, irreducible hemorrhoids with excessive redundant tissue at any time during the claim period. Persistent bleeding with secondary anemia or fissures is also not shown at any time during the claim period so as to warrant a 20 percent rating. The Veteran’s hemorrhoids have instead consistently been found to be mild or moderate, and hence more nearly approximating the criteria for a noncompensable rating. DC 7336. The Board has considered staged ratings, but the record does not reflect any interval during the claim period when the evidence does not preponderate against the presence of findings required for higher ratings than the noncompensable rating assigned. Hence, staged ratings are not warranted. Hart, 21 Vet. App. at 509-10. Benefit of the Doubt To arrive at the above determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against entitlement to the higher evaluations than those already assigned or assigned by this decision, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND Entitlement to a compensable initial rating for eczematous seborrheic dermatitis is remanded. Upon February 2020 VA examination, the examiner diagnosed eczematous seborrheic dermatitis and observed that the Veteran’s condition consisted of dry, itching skin on the scalp and ears. However, in past submitted statements the Veteran reported that he had been treated for dermatitis also affecting his back, beginning in service. See also e.g. January 2009 VA examination report. The February 2020 examiner failed to address whether the Veteran’s eczematous seborrheic dermatitis also affected his back. Hence, the examination is potentially incomplete, warranting remand for a new examination. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file any unobtained VA and military facility and pertinent private treatment records, with the Veteran’s authorization and assistance, as appropriate. If records cannot be obtained, the Veteran should be appropriately notified. 2. Thereafter, due to the Covid-19 pandemic, if records-based examination (including examination supplemented by telephonic examination conducted with the Veteran) can satisfactorily address all questions posed in the remand instructions, then these should be accomplished. To the extent these cannot be accomplished, then in-person examination should be conducted to the extent feasible. 3. Obtain a dermatology examination to determine the nature, severity, and extent of the Veteran’s service-connected eczematous seborrheic dermatitis. All affected areas should be addressed and described in detail. The examiner should be advised that the prior VA examination in February 2020 was inadequate because past statements by the Veteran indicated dermatitis affecting the Veteran’s back but the examiner failed to address whether or not eczematous seborrheic dermatitis was present on the Veteran’s back, instead only addressing the Veteran’s face, scalp, and ears. The claims file should be reviewed, and any necessary tests or studies should be conducted. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology, including experienced skin conditions. If there is a medical basis to support or doubt the history provided by the Veteran, particularly pertaining to his description of flare-ups or recurrences of dermatitis, the examiner should provide a fully reasoned explanation. (Continued on the next page)   A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Thereafter, readjudicate the remanded issue. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechter 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.