Citation Nr: 21002515 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 13-06 600A DATE: January 13, 2021 ORDER A rating in excess of 20 percent for diabetes mellitus is denied. A rating in excess of 10 percent for lumbar strain with degenerative changes for the period prior to April 10, 2012 is denied. A rating of 40 percent, but no higher, for lumbar strain with degenerative changes from April 10, 2012 is granted. Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae is denied. FINDINGS OF FACT 1. Throughout the entire period on appeal, the Veteran’s type 2 diabetes mellitus (DM) has been manifested by more than one daily injection of insulin, oral hypoglycemic agents, and restricted diet, but does not require regulation of activities. 2. Prior to April 10, 2012, the Veteran’s lumbar strain was manifested by forward flexion to 80 degrees at worst, and a combined range of motion of 190 degrees at worst; but not by abnormal gait or spinal contour, forward flexion to 60 degrees or less, a combined ranged of motion of 120 degrees or less, ankylosis or incapacitating episodes. 3. From April 10, 2012, the Veteran’s lumbar strain was manifested by forward flexion to 10 degrees at worst (on repetitive use), and a combined range of motion of 60 degrees; but not by unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes. 4. Throughout the entire period on appeal, the Veteran’s pseudofolliculitis barbae (PFB) affects less than 20 percent of his exposed skin and does not require systemic therapy. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for type 2 diabetes mellitus (DM) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.20, 4.31, 4.115, 4.119, Diagnostic Code 7913 (2017). 2. Prior to April 10, 2012, the criteria for a rating in excess of 10 percent for lumbar strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. From April 10, 2012, the criteria for a 40 percent rating, but no higher, for lumbar strain, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 4. The criteria for a rating in excess of 10 percent for PFB have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes (DC) 7813-7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 1999 to October 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In a December 2020 motion, the Veteran requested that his case be advanced on the docket due to financial hardship, with the submission of evidence of eviction. The motion to advance the case on the docket is granted. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). In a March 2013 rating decision, the RO granted a higher 40 percent rating for lumbar strain with degenerative changes, effective January 3, 2013. However, as that award did not represent a total grant of the benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In April 2017 the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board previously remanded these matters in July 2017 for additional development. As the actions specified in the remand have been substantially completed, these matters have been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Duties to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. The Veteran has not advanced any procedural arguments in relation to VA's duty to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Increased Rating Claims Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. § Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability determinations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the current level of disability that is of primary concern, and VA must only address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in such cases, when the factual findings show distinct time periods during which the veteran exhibits symptoms of the disability at issue, and such symptoms warrant different disability ratings, staged ratings may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus (DM) The Veteran has claimed entitlement to a higher rating for his service-connected type 2 diabetes mellitus (DM), which is currently rated as 20 percent disabling effective February 21, 2006. The Veteran contends that he is entitled to a higher rating because his DM and its associated symptoms are more severe than contemplated by his currently assigned rating. The Veteran's DM is rated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus that requires insulin and restricted diet, or; oral hypoglycemic agents and restricted diet. A 40 percent rating is warranted for diabetes mellitus that requires insulin, restricted diet, and regulation of activities. Id. A 60 percent rating is assigned where the Veteran requires insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or weekly visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. A 100 percent rating is assigned when the Veteran requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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. Id. The rating criteria for diabetes are successive. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). "Successive" rating criteria is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Id. Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). As the Veteran is currently in receipt of separate ratings for diabetic complications of neuropathy of the bilateral extremities, and erectile dysfunction, the symptoms related to those disabilities cannot be considered in evaluating the level of disability due to DM. See 38 C.F.R. § 4.14 (pyramiding, or rating the same manifestation under different diagnoses, is to be avoided). The Veteran was afforded VA examinations to assess the severity of his DM in June 2009, March 2010, December 2012, and June 2018. The June 2009 examiner reported that the Veteran's DM is managed by a restricted diet, and more than one insulin injection per day. The Veteran does not require regulation of activities as part of medical management of his DM. The Veteran was noted to have denied hospitalization or surgery, pancreatic trauma, pancreatic neoplasm, and episodes of hypoglycemia reaction or ketoacidosis. The examiner noted the Veteran’s history of treatment for hypertension, listing January 2009 as the date of the Veteran’s hypertension diagnosis. The March 2010 and December 2012 examiners reported that the Veteran's DM is managed by more than one insulin injection per day. The examiners noted no activity or diet restrictions as part of medical management of the Veteran’s DM. The examiners noted no hospitalizations for ketoacidosis or hypoglycemia. During his April 2017 hearing, the Veteran stated that he is on a restricted diet and takes multiple injections of insulin each day. The Veteran testified that he was hospitalized in a VA facility “this past August,” for 3-4 days. The Veteran testified that his blood sugar “got kinda high.” The Veteran testified that while he meets with diabetes counselors and tries to eat the right things, that it doesn’t always work out for him. The Veteran testified that a lot of this has to do with his “lack of being able to be doing a lot of physical activity.” The Veteran testified to his feeling that if his back “wasn’t the way that it was,” that he could be active and “go to the gym three or four times a week.” The Veteran reported that he has not been restricted from activities, and apart from the August 2016 hospitalization, testified to no other hospitalizations or ER visits due to his DM. The Veteran testified that he sought treatment from his VA primary care provider once a quarter and from the VA diabetic clinic every few months. While the Veteran reported hospitalization in August 2016, such is not support by the medical evidence of record. In a December 2018 VA examination report, the VA the examiner reported that the Veteran’s DM is managed by prescribed oral hypoglycemic agents and more than one insulin injection per day. The examiner noted no regulation of activities on file and no report of weight loss. The examiner noted one five-day hospitalization in January 2018 for diabetic ketoacidosis. While the examiner noted this hospitalization, such is not supported by the medical evidence of record. The examiner also recorded a two-day hospitalization in October 2017 due to hyperglycemia. A March 2019 VAMC record reflects the Veteran’s hospitalization from March 30, 2019 – April 2, 2019 for diabetic ketoacidosis (DKA). A treatment note on admission reflects that the Veteran presented with three days of nausea, vomiting and loose stools, and was found to have blood glucose in the 600s. The record further reflects that the Veteran had not taken his insulin for the prior three days. During an April 2020 visit with a VA diabetic clinic, the Veteran reported that he has “had some scares over the past few months.” Specifically, the Veteran reported that he received help by paramedics in February because he was “unresponsive and bloods sugars low.” The Veteran reported that paramedics had to come help because the Veteran lives alone. A September 2020 letter from the Veteran’s VA provider reflects one hospitalization and three emergency room (ER) visits. The provider noted the April 2019 hospitalization was for diabetic ketoacidosis and three ER visits during which the Veteran was found to have hyperglycemia. An October 2020 VA treatment record reflects the Veteran’s admission to the ER. The Veteran presented with elevated blood sugars and reportedly stated that he did not take his insulin the day prior. The Veteran was noted to have self-increased his dose to 16 units on the morning of his admission to the ER when his glucometer read “high.” The Veteran was discharged the same day. During his April 2017 hearing, the Veteran stated that he is on a restricted diet and takes multiple injections of insulin each day. The Veteran testified that he was hospitalized in a VA facility “this past August,” for 3-4 days. The Veteran testified that his blood sugar “got kinda high.” The Veteran testified that while he meets with diabetes counselors and tries to eat the right things, that it doesn’t always work out for him. The Veteran testified that a lot of this has to do with his “lack of being able to be doing a lot of physical activity.” The Veteran testified to his feeling that if his back “wasn’t the way that it was,” that he could be active and “go to the gym three or four times a week.” The Veteran reported that he has not been restricted from activities, and apart from the August 2016 hospitalization, testified to no other hospitalizations or ER visits due to his DM. The Veteran testified that he sought treatment from his VA primary care provider once a quarter and from the VA diabetic clinic every few months. While the Veteran reported hospitalization in August 2016, such is not support by the medical evidence of record. Based on the medical evidence of record, the Board finds that the Veteran's DM does not warrant a higher 40 percent rating. The Veteran requires insulin, oral hypoglycemic agents, and a restricted diet, but does not require regulation of activities. While the Board acknowledges the Veteran’s hearing testimony that his physical activity is limited due to back pain, the Veteran’s activities are not regulated as a result of his DM. Therefore, there is no basis under the rating criteria upon which to award the Veteran a higher rating as the Veteran's DM is no more than 20 percent disabling. Treatment records reflect the Veteran’s March 30, 2019 through April 2, 2019 hospitalization for DKA. An October 2020 VA treatment record reflects the Veteran’s admission to the ER for elevated blood sugar however, he did not require hospitalization and was discharged the same day. Moreover, as noted above, the Veteran was seen in the ER on three occasions in June 2019, January 2020, and June 2020, and found to have hyperglycemia. However, throughout the entire period on appeal, the Veteran’s activities have not been regulated as part of medical management of his DM. In light of this, and given that the successive nature of the DM rating criteria, the Veteran does not satisfy the requirements for an even higher rating of 60 percent or 100 percent for his service-connected DM. See 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board finds the foregoing VA examinations adequate and highly probative both as to the Veteran’s subjective reports and the resulting objective findings. Specifically, the examiners interviewed the Veteran, reviewed his claims file, and conducted physical examinations. Moreover, the examiners had the requisite medical expertise and sufficient facts and data on which to base their conclusions. As such, the Board accords the VA examination opinions great probative weight. In reaching the above conclusion, the Board acknowledges that the Veteran sincerely believes his symptoms to be more severe than contemplated by his currently-assigned 20 percent disability rating. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of symptomatology. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, he is not competent to identify a specific level of disability under the appropriate diagnostic codes. Determining whether the Veteran meets the criteria for a higher rating requires diagnostic testing and clinical findings made in conjunction with an examination. The medical findings of record provided in the VA examination reports directly address the criteria under which the Veteran's DM is rated. The Board has considered the Veteran's lay assertions and given them appropriate weight where they are consistent with the objective medical evidence of record. However, the Board has accorded greater weight to the findings of the VA examiners who have the training or expertise required for this complex medical determination, and the most probative medical evidence has shown that the Veteran's DM is no more than 20 percent disabling during the period on appeal. Accordingly, the Board finds that the preponderance of the evidence is against finding that a rating in excess of 20 percent for DM is warranted. Therefore, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an increased rating for lumbar strain When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40; see DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. The Veteran's low back disability is currently-rated as 10 percent disabling prior to January 3, 2013 and 40 percent thereafter, under Diagnostic Code 5237. All spine disabilities covered by Diagnostic Codes 5235 to 5242 are rated according to the General Rating Formula for Diseases and Injuries of the Spine (General Formula) based on limitation of motion. 38 C.F.R. § 4.71a, General Formula. Under the General Formula, the spine is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. Under the General Formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, muscle spasm, guarding or localized tenderness not resulting in abnormal gain or spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, General Formula. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Concerning disabilities affecting the spine, any associated objective neurologic abnormalities are evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Id. at Note 2. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation, with the normal combined range of motion of the thoracolumbar spine being 240 degrees. Id. Unfavorable ankylosis is a condition in which the entire thoracolumbar spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Id. at Note 5. Fixation of a spinal segment in neutral position always represents favorable ankylosis. Id. The Veteran was provided with VA spine examinations in June 2009, March 2010, April 2012 and June 2018. On examination in June 2009, the Veteran was capable of forward flexion to 80 degrees, extension to 20 degrees, bilateral flexion to 30 degrees, left lateral rotation to 0 degrees and right lateral rotation to 30 degrees. The examiner noted objective evidence of pain following repetitive range of motion testing, but no additional limitations. The examiner noted that there was no evidence of guarding or muscle spasms, and that the tenderness did not result in abnormal spinal contour. Pursuant to this exam, the Veteran also had imaging of his lumbar spine. Imaging showed mild arthritic changes with narrowing of the disk space. The examiner noted no fracture and that pedicles were intact. The examiner’s impression was some narrowing of the L5-S1 disk space. In March 2010, on examination the Veteran was capable of forward flexion to 80 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees and right and left lateral rotation 30 to 40 degrees. The examiner noted no flare-ups, pain, weakness, fatigability, decreased endurance, incoordination, or instability. No pain was present after repetitive testing. The examiner noted no current treatment except occasional stretching exercises and icing. The examiner noted that the Veteran does not use a back brace and that the Veteran’s condition is not incapacitating. In April 2012, the Veteran reported regular back spasms and sharp, shooting pain below his thighs up to knees. which starts from the back and shoots up to mid and upper back. The Veteran reported no specific trigger for the shooting pain. The Veteran also reported no low back surgeries and reported his pain level as 10 of 10. The Veteran reported that walking more than one block, heavy lifting, and rainy weather can all result in severe back pain. The Veteran reported flare-ups that limit his ability to do certain activities like bending over to tie shoes, and any activity requiring bending or lifting. The examiner noted that the Veteran was unsure what helps alleviate his low back pain. The examiner noted tingling in the bilateral extremities, with no numbness. On examination the Veteran was capable of forward flexion to 15 degrees, extension to 5 degrees, right lateral flexion to 5 degrees, left lateral flexion to 15 degrees, right lateral rotation to 15 degrees, and left lateral rotation to 5 degrees. The examiner diagnosed the Veteran with arthritis pursuant to the results of a September 2012 MRI. The examiner noted objective evidence of pain following repetitive range of motion testing, with additional loss of forward flexion to 10 degrees. Following repetitive testing, the Veteran experienced functional loss caused by less movement than normal and pain on movement. The examiner noted that there was evidence of mild tenderness or palpation. The examiner noted that there was no evidence of guarding or muscle spasms of the thoracolumbar spine, no intervertebral disc syndrome, and no finding of ankylosis reported. In June 2018, the Veteran reported his condition as worsening and symptoms of throbbing, aching, and shooting pain. The Veteran experiencing flare-ups of his low back disability, with it worsening when the weather is damp and that if he sits, he can’t get up again. On examination the Veteran was capable of forward flexion to 80 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. The Veteran experienced pain on forward flexion, and bilateral rotation. The examiner noted no tenderness or pain on palpation but noted pain with weightbearing. The examiner observed no pain on non-weightbearing, and passive range of motion measurements were the same active range of motion testing. The examiner noted that the Veteran had muscle spasms not resulting in abnormal gait or abnormal spinal contour. Finally, there was no evidence of ankylosis. There is no evidence that the above examiners were either not competent or credible. Further, all examiners based their assessments of the Veteran's disability on the Veteran's own account of his symptoms and their own objective evaluations. As such, the Board finds that each examination report is entitled to significant probative weight as to the severity of the Veteran's low back disability during the period on appeal. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA treatment records generally reflect on-going reports of and treatment for low back pain and radiculopathy, but no further range of motion testing is of record. Throughout treatment from the period on appeal, the Veteran was noted to have a normal gait. In April 2017, the Veteran testified that his low back disability has gotten worse over the years, reporting “good days and bad days,” but noted that the bad days seem to outweigh the good these days. The Veteran testified to being limited in his activities, like being able to play with his daughter, due to his low back disability. Based on the foregoing, the preponderance of the evidence is against a finding that an increased rating in excess of 10 percent prior to April 10, 2012 is warranted. During the period prior to April 10, 2012, the evidence clearly reflects that Veteran was capable of forward flexion well in excess of the 60 degrees or less contemplated by higher ratings. Further, based on the measurements in the June 2009 and March 2010 examinations the Veteran had a combined range of motion in excess of the 120 degrees or less contemplated by a 20 percent rating. Neither the June 2009, nor the March 2010 VA examination reports reflect that the Veteran's disability was manifested by ankylosis of the spine of any kind. Similarly, treatment records are silent for ankylosis. Accordingly, the Board finds that the preponderance of the evidence is against finding that a rating in excess of 10 percent for lumbar strain is warranted prior to April 10, 2012. Therefore, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Based on the findings in the April 10, 2012 VA examination report, the evidence shows that the Veteran was only capable of forward flexion of less than 30 degrees, with the April 2012 examiner noting that the Veteran was limited to flexion to 15 degrees, and 10 degrees on repetitive use. Based on the foregoing, the Board finds that an increased rating of 40 percent, but no higher, for the period of April 10, 2012 to January 2, 2013, is warranted. There was no evidence of ankylosis or IVDS or a showing of incapacitating episodes. In this regard, a rating higher than 40 percent is not warranted. In January 2013, the evidence shows that the Veteran was capable of forward flexion well in excess of the 30 degrees of limitation contemplated by the higher ratings available for the low back disability, with the June 2018 examiner noting that the Veteran was capable of flexion to 80 degrees. Further, the examiner noted that there was no evidence of ankylosis, and the Veteran's treatment records are silent for any evidence of ankylosis of any kind. Accordingly, the Board finds that the preponderance of the evidence is against finding that a rating in excess of 40 percent for the lumbar strain disability is warranted. When evaluating disabilities of the spine, any associated objective neurologic abnormalities are to be rated separately under an applicable Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. Here, service connection for the Veteran's radiculopathy of the bilateral lower extremities has already been granted, and therefore is already contemplated by its assigned ratings. No other neurologic abnormalities have been noted as being associated with the Veteran's low back disability. No other associated neurologic abnormalities are reflected in the VA examination reports or the Veteran’s treatment records. As such, additional separate compensable ratings are not warranted. Id. With respect to the possibility of assigning a higher rating under 38 C.F.R. § 4.40 and § 4.45, the Board has considered whether the Veteran has demonstrated additional functional loss attributable to pain, weakness, excess fatigability, or incoordination, to include on repetitive-use or during flare-ups, that would warrant the assignment of a higher rating. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07. Only the April 2012 examiner noted objective evidence of painful motion resulting in additional limitation of motion on examination. Although the Veteran has subjectively reported functional loss due to pain and painful motion, no additional loss of function or range of motion was objectively observed during any of the examinations of record since April 2012. Accordingly, the Board finds that the overall level of disability demonstrated by the Veteran throughout the period on appeal is not commensurate with assigning a higher schedular rating under the Deluca criteria. Although the Board acknowledges that the Veteran has reported pain that has resulted in functional loss, there is nothing in the record that suggests the pain resulted in functional loss beyond what is already contemplated by the assigned 10 and 40 percent ratings, for the respective periods. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07. The findings provided in the examination reports are adequate to decide the claim. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). In reaching the above conclusions, the Board acknowledges that the Veteran sincerely believes his symptoms to be more severe than contemplated by his currently-assigned disability ratings. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of pain and other symptomatology. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). While the Board has considered the lay statements of record, the Board has given them appropriate weight where they are consistent with the objective medical evidence of record. However, the Board has accorded greater weight to the objective evidence of record as VA clinicians and examiners have the requisite medical training and expertise and this issue involves a medical determination that is complex. Therefore, the medical evidence is more probative regarding the Veteran's claims in this case, and the most probative medical evidence has shown that only for the period beginning on April 10, 2012 is a higher rating warranted for the Veteran’s lumbar strain disability. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 36970 (2017). Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae (PFB) The Veteran has claimed entitlement to a higher rating for his service-connected PFB which is currently rated as 10 percent disabling effective August 2, 2007. The Veteran contends that he is entitled to a higher rating because his PFB and its associated symptoms are more severe than contemplated by his currently assigned rating. The Veteran’s PFB is rated as a skin disorder under 38 C.F.R. § 4.118, Diagnostic Codes 7813-7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated 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 Board notes that the criteria for rating skin disabilities have changed once during the period covered by this appeal, effective August 13, 2018. See 83 Fed. Reg. 32592 (July 13, 2018). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. Prior to August 13, 2018, Diagnostic Code 7806 provides that a noncompensable disability rating is assigned when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation will be assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed area is affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation will be assigned for dermatitis that 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. § 4.118 (2017). For the purposes of Diagnostic Code 7806 effective prior to August 31, 2018, several recent court cases have addressed the meaning of "systemic" and "topical." The Board notes that the United States Court of Appeals for Veterans Claims (CAVC) issued a decision in Johnson v. McDonald, 27 Vet. App. 497 (2016) that reversed and remanded an April 2014 decision of the Board denying an increased rating for a skin condition under 38 C.F.R. § 4.118, DC 7806. VA disagreed with the Court's decision and appealed it to the United States Court of Appeals for the Federal Circuit (Federal Circuit). In July 2017, the Federal Circuit issued an opinion that reversed the decision by the Court, noting that Diagnostic Code 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code." Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Id. As such, the Board is bound by the Federal Circuit's interpretation. Diagnostic Code 7806 also provided that the symptoms at issue could be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 780, 7802, 7804, 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. However, the clinical evidence does not show that the Veteran's PFB caused scarring or disfigurement of the head, face, or neck. Consequently, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805 do not apply. Effective August 13, 2018, skin disabilities rated under Diagnostic Code 7806 were evaluated under the General Rating Formula for the Skin. A 10 percent disability rating is warranted if there is one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent disability rating is warranted if there is one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent disability rating is warranted if there is at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. The revised General Rating Formula for the Skin also provides that skin disabilities may be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. However, the clinical evidence does not show that the Veteran's pseudofolliculitis barbae caused scarring or disfigurement of the head, face, or neck. Consequently, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805 do not apply. The Veteran was afforded VA exams in March 2010, January 2013, and June 2018. All the Veteran’s examiners agreed that the Veteran had a diagnosis of PFB. The March 2010 examiner noted that the Veteran's PFB involved the Veteran’s upper neck, an exposed area limited to less than 1% of the Veteran’s body surface area. The examiner noted that the Veteran was not under current treatment for his PFB and that the Veteran had grown a beard which “minimizes the effect.” An August 2012 VA dermatology consult note recorded the Veteran’s PFB as “controlled with beard.” The note indicates that the Veteran presented for evaluation of “scaling” in his beard area along with intermittent pruritus. The provider observed the Veteran’s beard area with significant “greasy scale and patchy erythema.” The January 2013 examiner noted multiple hyperpigmented spots from PFB in the Veteran’s beard area in addition to ingrown hairs. The Veteran did not have any systemic manifestations due to his PFB and had not been treated with oral or topical medications in the prior 12 months for any skin conditions. The examiner found that the Veteran’s PFB covered less than 5 percent of his total body and total exposed areas. The August 2015 DBQ completed at the Veteran’s request, reflects similarly that the Veteran has a diagnosis of PFB. The Veteran’s provider did not opine as to a percent of the Veteran’s total or exposed body impacted by his PFB but noted the severity as “mild.” The examiner described the Veteran’s condition as small areas of ingrown hairs on neck and face, not infected. The examiner observed no pustules and nothing obvious on the Veteran’s scalp or behind the ears. The Veteran had not been treated with oral or topical medications in the prior 12 months for any skin conditions. The Veteran did not have any systemic manifestations due to any skin disease, nor did he have any benign or malignant skin neoplasms. The June 2018 examiner observed lesions from PFB on the Veteran’s chin and base of his neck, noting these as the areas the Veteran shaves. The examiner observed dry patchy lesions on these areas. The examiner noted no facial inflammation or hyperpigmentation. The examiner determined that the Veteran’s PFB effected 5 percent to less than 20 percent of the Veteran’s entire body, with no systemic therapy required. The Veteran had not been treated with oral or topical medications in the prior 12 months for any skin conditions. The Veteran presented with a full beard and reported that he still gets irritated if he shaves. The Veteran did not have any systemic manifestations due to any skin disease, nor did he have any benign or malignant skin neoplasms. During the April 2017 Board hearing, the Veteran testified that he has gotten, “eczema, like patches on the back of [his] head.” The Veteran pointed out three dark spots caused by his condition. The Veteran testified that he had rough, patchy areas on his temples, neck, and behind ears. In this case, the Veteran has not demonstrated that enough exposed skin is affected to warrant an increased rating. Because throughout the entire period on appeal, the effects of the Veteran’s PFB are limited to less than 20 percent of his exposed skin, and because his skin disorder did not require treatment with systemic therapy, the Board finds that a rating in excess of 10 percent for PFB is not warranted. In order to warrant a higher rating under earlier criteria for Diagnostic Code 7806, the Veteran's skin disorder would have to be manifested by 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Here, however, the Veteran's VA exams, self-requested DBQ, VA treatment records, and the Veteran's lay statements, show that his skin disorder covers less than 20 percent of the total body area and exposed areas. Additionally, the above evidence shows that the Veteran’s PFB is not treated with oral or topical medications, nor is the Veteran’s PFB treated with systemic therapy. Accordingly, a rating in excess of 10 percent is not warranted for the Veteran's skin disorder under criteria pre-August 13, 2018 criteria under Diagnostic Code 7806. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change. Thus, it can only be applied in this matter from August 13, 2018, forward. The Board concludes that the application of the amended rating criteria does not result in a higher disability rating for the Veteran's pseudofolliculitis barbae from August 13, 2018, forward. In arriving at this conclusion, the Board acknowledges that the United States Court of Appeals for the Federal Circuit held that systemic therapy meant "treatment pertaining to or affecting the body as a whole," whereas topical therapy means "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Johnson v. Shulkin, 862 F.3d 1351, 1355 (2017). Further, in considering whether a treatment is systemic, the Board must also consider whether the treatment affects the body as a whole and whether the given treatment is like or similar to a corticosteroid or other immunosuppressive drug. See Burton v. Wilkie, 30 Vet. App. 286 (2018). In this case, the Board does not find that the Veteran uses such systemic therapy to treat his PFB. In reaching the above conclusion, the Board acknowledges that the Veteran sincerely believes his symptoms to be more severe than contemplated by his currently-assigned 10 percent disability rating. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of symptomatology. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, he is not competent to identify a specific level of disability under the appropriate diagnostic codes. Determining whether the Veteran meets the criteria for a higher rating requires diagnostic testing and clinical findings made in conjunction with an examination. The medical findings of record provided in the VA examination reports directly address the criteria under which the Veteran's PFB is rated. The Board has considered the Veteran's lay assertions and given them appropriate weight where they are consistent with the objective medical evidence of record. However, the Board has accorded greater weight to the findings of the VA examiners who have the training or expertise required for this complex medical determination, and the most probative medical evidence has shown that the Veteran's PFB is no more than 10 percent disabling during the period on appeal. There is no evidence that the examiners were either not competent or credible. Further, all examiners based their assessments of the Veteran's disability on the Veteran's own account of his symptoms and their own objective evaluations. As such, the Board finds that each examination report is entitled to significant probative weight as to the severity of the Veteran's PFB during the period on appeal. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that the preponderance of the evidence is against finding that a rating in excess of 10 percent for PFB is warranted. Therefore, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Gates 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.