Citation Nr: 21003893 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 17-04 718A DATE: January 25, 2021 ORDER Entitlement to a compensable rating for residual scars previously scars, removal of swollen lymph nodes is denied. Entitlement to a 10 percent rating for chronic headaches prior to January 24, 2020 is granted. Entitlement to a rating higher than 50 percent for chronic headaches from January 24, 2020 is denied. Entitlement to a compensable rating for relapse fever, previously fever, night sweats, prior to January 24, 2020, is denied. Entitlement to a compensable rating for carpal tunnel syndrome of the right hand prior to January 24, 2020 is granted. Entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the right hand from January 24, 2020 is denied. Entitlement to a compensable rating for carpal tunnel syndrome of the left hand prior to January 24, 2020 is granted. Entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the left hand from January 24, 2020 is denied. Entitlement to a rating higher than 10 percent for multiple joint pain prior to January 24, 2020 is denied. Entitlement to a 20 percent rating for multiple joint pain from January 24, 2020 is granted. Entitlement to a rating higher than 30 percent for idiopathic pulmonary fibrosis prior to January 24, 2020 is denied. Entitlement to a rating higher than 60 percent for idiopathic pulmonary fibrosis from January 24, 2020 is denied. REMANDED ISSUE Entitlement to a rating higher than 30 percent for blurred vision and twitching of the left eye due to an undiagnosed illness, left eye cataract, status post cataract extraction and right eye cataract is remanded. FINDINGS OF FACT 1. The Veteran’s residual scars associated with a lymph node resection show only slight disfigurement without any of the characteristics of disfigurement; residual scars are not deep or nonlinear; there is no evidence residual scars are associated with underlying soft tissue damage; nor are residual scars unstable or painful and do not affect an area sufficient for VA purposes; nor is there functional impairment associated with the Veteran’s residual scars. 2. Prior to January 24, 2020, the Veteran's service-connected headaches more nearly approximated a headache disability with frequent occurrences, commensurate to characteristic prostrating attacks averaging one in 2 months over the last several months. 3. From January 24, 2020, the preponderance of the evidence shows that the Veteran's headaches are manifested by no more than very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 4. Prior to January 24, 2020 the Veteran’s relapse fever was inactive, asymptomatic and did not result in residual disability. 5. Resolving doubt in the Veteran’s favor, for the period prior to January 24, 2020 his right and left carpal tunnel syndrome was manifested by mild incomplete paralysis of the median nerve. 6. From January 24, 2020 the Veteran’s right and left carpal tunnel syndrome has been manifested by no more than mild incomplete paralysis of the median nerve. 7. Prior to January 24, 2020 the Veteran's multiple joint pain was not manifested by exacerbations often precipitated by environmental or emotional stress or by overexertion. 8. From January 24, 2020 the Veteran’s multiple joint pain was manifested by episodic widespread musculoskeletal pain with symptoms precipitated by overexertion. 9. Prior to January 24, 2020 the evidence of record establishes that the Veteran’s idiopathic pulmonary fibrosis do not result in respiratory functional impairment of Forced Expiratory Volume in one second (FEV-1) of 40- to 55-percent predicted, or; Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 40 to 55 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). 10. From January 24, 2020 the probative evidence of record does not establish that the Veteran's idiopathic pulmonary fibrosis is manifest by any of the criteria contemplated by a 100 percent rating under Diagnostic Code (Code) 6600. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for residual scars previously scars, removal of swollen lymph nodes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Codes (Codes) 7800-7804. 2. The criteria for entitlement to a 10 percent rating for chronic headaches prior to January 24, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.124a, Code 8100. 3. The criteria for entitlement to a rating higher than 50 percent for chronic headaches from January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.124a, Code 8100. 4. The criteria for entitlement to a compensable rating for relapse fever, previously fever, night sweats prior to January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.31, 4.88b, Code 6308. 5. The criteria for a 10 percent rating for carpal tunnel syndrome of the right hand prior to January 24, 2020 have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.7, 4.124, Code 8515. 6. The criteria for entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the right hand from January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.124, Code 8515. 7. The criteria for a 10 percent rating for carpal tunnel syndrome of the left hand prior to January 24, 2020 have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.7, 4.124, Code 8515. 8. The criteria for entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the left hand from January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.124, Code 8515. 9. The criteria for entitlement to a rating higher than 10 percent for multiple joint pain have not been met prior to January 24, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Codes 8850 - 5025. 10. The criteria for a 20 percent rating for multiple joint pain have been met as of January 24, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Codes 8850 - 5025. 11. The criteria for entitlement to a rating higher than 30 percent for idiopathic pulmonary fibrosis prior to January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.97, Codes 6699-6600. 12. The criteria for entitlement to a rating higher than 60 percent for idiopathic pulmonary fibrosis from January 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.97, Codes 6699-6600. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1988 to March 1996. These matters were previously before the Board of Veterans’ Appeals (Board) in December 2019 and remanded to a Department of Veterans Affairs (VA) Regional Office (RO) for additional development. In an interim August 2020 rating decision the RO granted service connection for hypertension, and assigned a 0 percent rating effective February 28, 2013. As this was a full grant of the benefit sought on appeal, that matter is no longer before the Board for appellate consideration. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. See 38 C.F.R. § 4.31. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, staged ratings may be appropriate in an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a compensable rating for residual scars previously scars, removal of swollen lymph nodes The Veteran contends he is entitled to a compensable rating for his service-connected residual scars previously scars, removal of swollen lymph nodes. The scars are currently rated under Code 7800, applicable to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. The Board notes that on July 13, 2018, VA published a final rule amending its regulations on skin disabilities. 83 FR 32592 (July 13, 2018). The effective date of the final rule is August 13, 2018. However, for this final rule, VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. As the Veteran filed his claim before the August 13, 2018 effective date, the Board will consider whether he is entitled to an increased rating under either the old or new rating criteria. Code 7800 was not revised by the recent regulatory amendments. Under Code 7800, a 10 percent rating is warranted for a scar with one characteristic of disfigurement. A 30 percent rating is warranted for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is warranted for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. There are eight characteristics of disfigurement, including: a scar 5 or more inches (13 or more cm. [centimeter]) in length, scar at least one-quarter inch (0.6 cm.) wide at its widest part, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, skin hypo-or hyperpigmented in an area exceeding six square inches (39 sq. cm), skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, underlying soft tissue missing in an area exceeding six square inches, and skin indurated and inflexible in an area exceeding six square inches. See 38 C.F.R. § 4.118, Code 7800, Note (1). The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that rating. Id., Note (5). The Veteran underwent a VA scars/disfigurement examination in December 2013. The examiner diagnosed residual scar of lymph node resection. The Veteran reported severe pain from the residual scar of his lymph node resection, located on his trunk, when he pressed on it. The examiner noted that there was no clinical objective evidence to support the Veteran’s subjective complaints of painful scars. The scars on his trunk were not unstable with frequent loss of covering of skin over the scar. The scars were not painful or unstable or due to burns. On physical examination, the affected scars were located on the anterior trunk. Scar number one was on the left lateral torso; scar number two was below the left lateral torso scar; and scar number three was on the left abdomen. The scars were linear measuring 9.0 cm., 4.0 cm. and 4.0 cm., respectively. There were no affected posterior trunk scars; or superficial or deep nonlinear scars. Neither did the scars impact the Veteran’s ability to work. Based on the December 2013 VA scars/disfigurement examination, the RO continued the Veteran’s 0 percent rating under Code 7800. The evidence supported a non-compensable rating for slight disfigurement only without any of the 8 characteristics of disfigurement. On January 2020 VA-contract scars/disfigurement examination, the Veteran reported that all the scars are painful and bother him. It was noted that he did not have scars on the trunk or extremities that were painful, or unstable or due to burns. On examination, the location of the scars were on the right upper extremity. The size of the scar on his arm was 3 cm x 0.2 cm and on his thumb was 1.5 cm x 0.1 cm. The left upper extremity was not affected. None of the scars resulted in limitation of function. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with any scar. The diagnoses were scar due to lipoma removal right upper and left upper quadrant, and scar due to muscle biopsy. The scars did not impact the ability to work. In considering the evidence of record, the Board finds the Veteran is not entitled to a compensable rating for his service-connected residual scars. Here, there is slight disfigurement without any of the 8 characteristics of disfigurement necessary to warrant a compensable rating under Code 7800. The Board has considered whether a compensable rating is warranted under Codes 7801, 7802, 7804 and 7805 and find the Veteran’s residual scars do not meet or approximate the criteria under any of these diagnostic codes. Code 7801 was revised with the August 2018 amendment. Prior to August 13, 2018, the pre-amended Code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. In contrast to the previous diagnostic code, the amended Code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7801. Here, pursuant to the pre-amended criteria, neither the December 2013 or January 2020 VA examiners indicated that the Veteran’s scars were “deep,” nor was there evidence that the scars are nonlinear. Further, under the amended criteria, there is no evidence that the Veteran’s scars are associated with underlying soft tissue damage. Thus, a compensable rating under Code 7801 is not warranted. Prior to August 13, 2018, the pre-amended Code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Code 7802. The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7802. Both versions state that a 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square cm.) or greater. Here, pursuant to the pre-amended criteria, there is no evidence that the Veteran’s scars are superficial and nonlinear. Further, under the amended criteria, there is no evidence that the Veteran’s scars covers 144 square inches (929 square cm.) or greater. Thus, a compensable rating under Code 7802 is not warranted. Code 7804 was not revised by the recent regulatory amendments. Under Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that if one or more scars are both unstable and painful, 10 percent should be added to the rating that is based on the total number of unstable or painful scars. Here, the evidence of record shows that the Veteran has residual scars, which are not painful or unstable. As such, the criteria for a compensable rating for residual scars are not met. The evidence does not demonstrate that the Veteran has at least one scar that is painful or unstable. Therefore, a compensable rating for residual scars is not warranted. Furthermore, there is no evidence of significant functional impairment associated with the Veteran's residual scars to warrant a compensable rating under Code 7805. 38 C.F.R. § 4.118, Code 7805. Thus, in applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to a compensable disability rating for his service-connected residual scars under Code 7805. In consideration of the evidence of record, the Board finds that the weight of the evidence is against entitlement to a compensable rating for residual scars under any potentially applicable diagnostic code, and the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 38 U.S.C. § 5107(b). 2. Entitlement to a compensable rating for chronic headaches prior to January 24, 2020 3. Entitlement to a rating higher than 50 percent for chronic headaches from January 24, 2020 The Veteran contends he is entitled to a compensable rating for his service-connected headaches prior to January 24, 2020 and a rating higher than 50 percent from that date. The Veteran’s headaches are currently rated under Code 8100, applicable to migraine. 38 C.F.R. § 4.124a. Under Code 8100 a 0 percent rating is warranted for migraines with less frequent attacks. A 10 percent rating is provided for migraine with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is provided for migraine with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is provided for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The rating criteria do not define "prostrating." "Prostration" is defined as extreme exhaustion or powerlessness. See Dorland's Illustrated Medical Dictionary at 1531 (32nd ed. 2012). In addition, the phrase "productive of severe economic adaptability" has not been clearly defined by regulations or by case law. "Productive of" can either have the meaning of "producing" or "capable of producing." See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually produce severe economic inadaptability to warrant the 50 percent rating. See Id. at 445-46. "Economic inadaptability" also does not mean unemployability, as such would undermine the purpose of regulations pertaining to individual unemployability. See Id. at 446; 38 C.F.R. § 4.16. The Board notes, however, that migraines must be, at a minimum, capable of producing severe economic inadaptability. Notably, the Veteran is competent to report symptoms of headaches that require medication, including pain, frequency of episodes of migraine headaches, and the severity of the migraines as these symptoms are observable and within the realm of his personal knowledge. In addition, he is competent to report the number of days he has missed work due to the symptomatology of his migraine headaches. In this instance, the Board finds no reason to doubt the credibility of the Veteran’s statements in that regard. Prior to January 24, 2020 On December 2013 VA headaches examination, the Veteran reported that he experiences 2 or more headaches per week. The headaches are severe and may start in the afternoon and continue to at least 2:00 a.m. He stated he can do nothing when he has a severe headache. For less severe headaches he is able to take 2 to 4 Tylenols, which alleviate the pain. At the onset of a headache, he will take 2 to 4 Tylenol and if that does not abort the pain in an hour, he will take more Tylenol and if that does not abort the headache, he know he will have a severe headache. He experiences blurry vision with the severe headaches. He is unsure what prompts the headaches. He related that his headaches have become more frequent since returning from the Gulf War. His treatment plan includes taking medication for his headaches. His symptoms include pulsating or throbbing head pain. Non-headache symptoms associated with his headaches include occasional blurry vision with severe headaches. The duration of typical head pain is approximately 3 hours. The headaches start at the back of the head then encompass the entire head. The Veteran does not have characteristic prostrating attacks of migraine headache pain or of non-migraine headache pain. The diagnosis was tension headaches. The Veteran’s headache disability does impact his ability to work in that he has had to leave work secondary to headache pain. On review of the evidence, the Board finds the Veteran's headaches have not been productive of characteristic prostrating attacks. However, the pan described by the Veteran and the loss of work noted is commensurate to this level of disability, though not more. Accordingly, a 10 percent evaluation, but not higher, is warranted prior to January 24, 2020. To this extent, the appeal is granted. From January 24, 2020 On January 2020 VA-contract headaches examination, the Veteran complained of having daily headaches. The headaches are usually in the back of his head but occasionally he wakes up at night and has temporal throbbing. He does not have nausea, vomiting, photophobia, or phonophobia. He takes 6 to 8 Tylenols per day, and the usual level of his headaches is 6/10. Currently he experiences 2 or more headaches per week. He stated that severe headaches may start in the afternoon and continue to at least 2:00 a.m. He can do nothing when he has a severe headache. For less severe headache he is able to take 2 to 4 Tylenols which alleviates the pain, and if that does not abort the pain, he will take more Tylenol and if that does not abort the headache, he knows he will have a severe one. He can experience blurry vision with the severe headaches. He is unsure what prompts the headaches. His headaches have become more frequent since returning from deployment in the Persian Gulf. The Veteran described symptoms of pain on both sides of the head and constant pain with an increase in pulsating-like symptoms during severe headaches. He experiences non-headache symptoms associated with headaches as nausea, sensitivity to light, sensitivity to sound, changes in vision, and watery eyes. The duration of typical head pain is 1 to 2 days. He has characteristic prostrating attacks of migraine/non-migraine headache pain more frequently than once per month. Such attacks of migraines/non-migraine pain are productive of severe economic inadaptability. The diagnoses were migraine including migraine variants and tension headaches. The Veteran’s headaches disability impact his ability to work as his headaches are constant and associated with light sensitivity and sound; he is also constantly tired due to headaches in the morning and his efficiency is limited. Therefore, these produce a severe economic inadaptability and impact his ability to work. As noted above, Code 8100 provides a maximum 50 percent rating for migraine headaches when there is evidence of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The January 2020 VA examination report reveals the Veteran has characteristic prostrating attacks of migraine/non-migraine headache pain more frequently than once per month; and such attacks are productive of severe economic inadaptability. Therefore, the 50 percent rating already assigned compensates the Veteran for his very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability and is the maximum schedular rating available under Code 8100. There is no legal basis upon which to award a higher schedular rating for headaches under Code 8100, and the appeal must be denied. 4. Entitlement to a compensable rating for relapse fever, previously fever, night sweats prior to January 24, 2020 The Veteran contends that a compensable rating for relapse fever is warranted prior to January 24, 2020. His service-connected relapse fever is rated pursuant to Code 6308, relapsing fever. Under Code 6308, a 100 percent rating for relapsing fever is assigned when there is an active disease process. Thereafter, rate under the appropriate body system any residual disability of infection, which includes, but is not limited to, liver or spleen damage, iritis, uveitis, or central nervous system involvement. Effective August 11, 2019, the schedule for rating infectious diseases, immune disorders, and nutritional deficiencies was amended. See Final Rule, Schedule for Rating Disabilities; Infectious Diseases, Immune Disorders, and Nutritional Deficiencies, 84 Fed. Reg. 28227 (June 18, 2019). Under the revised rating criteria, effective August 11, 2019, relapsing fever is to be evaluated under the General Rating Formula for Infectious Diseases (General Rating Formula). This states that for an active disease, evaluate as 100 percent; and after an active disease has resolved, rate at 0 percent for infection. It also states to rate any residual disability of infection within the appropriate body system. See 38 C.F.R. § 4.124a, Code 6308. On his December 2013 VA infectious diseases examination, the Veteran reported that his symptoms begin with flushing in his face that leads to night sweats and a fever. When he awakes, he is damp and his temperature ranges from 94 to 103 degrees. These episodes would occur at least 20 times a year or more. He stated he had no other illness going on when he experienced these symptoms. On examination there was no information provided regarding symptoms or residuals attributable to relapsing fever. There were no significant diagnostic test findings and/or results. The diagnosis was relapsing fever. The Veteran’s infectious disease disability did not impact his ability to work. The examiner noted the Veteran had a normal physical examination with normal vital signs and temperature. There was no objective evidence to support the Veteran’s subjective claim. At the October 2019 hearing, the Veteran testified that he still has relapse fevers. He stated that most of the time he does not notice them because he is already asleep, but his wife has told him that he is “sweating and stuff like that.” He stated that he wakes up sweaty. His highest temperature has been 101 degrees; most times his temperature is 99 degrees. The night sweats occur 6 or 7 times a month. The Veteran’s wife testified that the Veteran has had fevers more often than he realizes because he sweats a lot at night and because he is on pain medication, which manages it. On January 2020 VA-contract infectious diseases examination, the Veteran reported a worsening of his disability. He stated he still suffers fever at night. The examiner noted the Veteran has active disease with symptoms of fever during the night associated with night sweats. The diagnosis was relapse fever/night sweats. His relapse fever, however, did not impact his ability to work. By rating decision dated in August 2020, the Veteran’s service-connected relapse fever was increased to 100 percent effective January 24, 2020 based on him having active disease. 100 percent is the maximum assignable rating for relapsing fever. On review for the earlier period on appeal, the Veteran was not found to have active disease on examination in December 2013. He had a normal physical examination with normal vital signs and temperature. Further, there was no impact on his ability to work. The Board acknowledges the Veteran’s and his wife’s testimony proffered at the hearing and find they are competent to report his symptoms of fevers and night sweats, but do not have the expertise to diagnose relapse fever or any residuals of relapse fever. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The competent medical evidence addressing this claim is the December 2013 VA examination, which shows no active disease, and no residuals. Accordingly, the Board finds that prior to January 24, 2020 the Veteran did not meet the criteria for a compensable rating under the old criteria or the new criteria (effective Aug. 11, 2019). Specifically, there is no competent evidence of active symptoms. There is also no clinical evidence demonstrating that residuals of relapse fever could be rated under the appropriate bodily system. The Board finds that the Veteran's symptoms most nearly approximated a noncompensable rating. Therefore, the Veteran's claim for a compensable rating for relapse fever is denied for this period. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is inapplicable. 38 U.S.C. § 5107(b). 5. Entitlement to a compensable rating for carpal tunnel syndrome of the right hand prior to January 24, 2020 6. Entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the right hand from January 24, 2020 7. Entitlement to a compensable rating for carpal tunnel syndrome of the left hand prior to January 24, 2020 8. Entitlement to a rating higher than 10 percent for carpal tunnel syndrome of the left hand from January 24, 2020 The Veteran asserts entitlement to a compensable rating for bilateral carpal tunnel syndrome (CTS) prior to January 24, 2020 and higher than 10 percent from that date. The Veteran’s CTS is rated under 38 C.F.R. § 4.124a, Code 8515. Code 8515 provides ratings for complete and incomplete paralysis of both the "major" and the "minor" extremities. The Veteran is dominant on the left side. Under Code 8515, evidence of mild incomplete paralysis warrants a 10 percent rating for the major or minor extremity. Evidence of moderate incomplete paralysis warrants a 30 percent rating for the major extremity and a 20 percent for the minor extremity. Evidence of severe incomplete paralysis warrants a 50 percent rating for the major extremity, and a 40 percent rating for the minor extremity. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The Board also observes that the words "mild," "moderate," and "severe," as used in Code 8515, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions will be "equitable and just." 38 C.F.R. § 4.6. Prior to January 24, 2020 On December 2013 VA peripheral nerves conditions examination, the Veteran reported that he experiences near constant tingling in his hands aggravated by unknown etiology. He sleeps in bilateral CTS braces with severe symptoms. He has not had surgery. He is left hand dominant. He reported having symptoms of moderate to severe tingling of his hands, bilaterally. He also reported moderate to severe painful cramping of the hands, bilaterally. On physical examination, his muscle strength and reflexes were normal. There was no muscle atrophy present. He did have decreased sensation to pin prick of all fingers, both hands. He had a normal soft touch sensation of all fingers of both hands. Phalen’s and Tinel’s signs tests for median nerve were negative. He reported wearing bilateral wrist braces on a near constant basis when he sleeps. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis (functions of the upper extremity including grasping, manipulation, etc.). The examiner reported normal results of an EMG [electromyograph] study performed in November 2001. The diagnosis was bilateral CTS. The Veteran stated his hands cannot hold an object for more than 10 minutes without dropping the item which interferes with his job, chores and activities. The examiner noted there was no objective evidence of CTS on clinical examination. Based on the above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's symptoms more nearly approximate mild incomplete paralysis of the median nerve prior to January 24, 2020. Thus, the Board finds that a 10 percent rating is warranted for that period. Specifically, the VA examiner noted there was no objective evidence of CTS on clinical examination; however it appears the examiner did not adequately consider the reported symptoms of tingling of his hands with examination findings of decreased sensation to pin prick of all fingers of both hands, which indicates mild impairment as contemplated by the 10 percent rating. Thus, a 10 percent rating each for the period prior to January 24, 2020 for the service-connected right and left CTS is granted. A rating higher than 10 percent for that same period is not warranted, as the objective clinical findings do not reveal any moderate impairment of coordination deficits, muscle atrophy, sensory disturbances, loss of muscle strength, or loss of reflexes to warrant a higher rating. Specifically, the December 2013 VA examination report shows normal clinical findings as it pertains to muscle strength, reflexes and light touch sensation. From January 24, 2020 On January 2020 VA-contract peripheral nerves conditions examination, the Veteran reported an increase in severity of his bilateral CTS. He reported near-constant tingling in his hands aggravated by unknown etiology. He stated he sleeps in bilateral CTS braces when symptoms are severe. He also experiences sharp pain on his right and left hands associated with swelling. He stated that if he is cutting wire his hand “is going to be cramped.” He is left hand dominant. He described constant mild pain and mild paresthesias and/or dysesthesias in his right and left upper extremities; and intermittent moderate pain and moderate numbness in his right and left upper extremities. Muscle strength testing revealed all normal findings. There was no muscle atrophy. His reflex examination was normal. His sensory examination was primarily normal with the exception of decreased sensation for light touch of the right and left hands/fingers. Tests for median nerve were positive, bilaterally. On evaluation for upper extremity nerves affected, the Veteran’s radial, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group, and middle radicular group, and lower radicular group nerves bilaterally were normal. There was mild incomplete paralysis of the right and left medial nerves. The Veteran uses a brace regularly for his bilateral CTS. The diagnoses were left-side and right-side CTS. He related that his CTS impairs his ability to hold an object for more than 10 minutes without dropping it due to decreased sensation, which impacts his ability to work. Here, the Board finds that from January 24, 2020, a rating higher than 10 percent is not warranted for the Veteran's bilateral CTS. The January 2020 VA examination report reflects normal muscle strength testing and reflex were normal. There was no muscle atrophy. His sensory examination was primarily normal with the exception of decreased sensation for light touch of the right and left hands/fingers. Moderate pain and numbness were noted, but the Veteran’s radial, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group, and middle radicular group, and lower radicular group nerves bilaterally were normal. There was mild incomplete paralysis of the right and left medial nerves. Accordingly, the Board finds that for the period from January 24, 2020, the Veteran's level of impairment is most analogous to mild incomplete paralysis. A rating higher than 10 percent for this period is not warranted, as the objective clinical findings do not reveal moderate impairment of the median nerve. The Board has also considered other potentially applicable diagnostic codes. However, for the periods prior to and from January 24, 2020, there is no evidence showing other diagnostic codes would provide a higher rating or that separate ratings are warranted. In making the above determinations, the Board has carefully considered the Veteran's contentions with respect to the nature and severity of his service-connected bilateral CTS, and notes that his lay statements are competent to describe certain symptoms associated with this disability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability ratings for which the Veteran has been found entitled by the Board. Moreover, the Board finds that the competent medical evidence, which offers detailed specific findings pertinent to the rating criteria, is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's statements regarding matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the Veteran's bilateral CTS. Accordingly, the Board finds that the Veteran is entitled to increased ratings to 10 percent each, but no higher, for his bilateral CTS prior to January 24, 2020. The Board also finds that the preponderance of the evidence is against a rating higher than 10 percent from January 24, 2020. 38 U.S.C. § 5107. 9. Entitlement to a rating higher than 10 percent for multiple joint pain prior to January 24, 2020 10. Entitlement to a 20 percent rating for multiple joint pain from January 24, 2020 In a December 2013 rating decision, the RO continued a 10 percent rating for the service-connected multiple joint pain due to undiagnosed illness under 38 C.F.R. § 4.71a, Codes 8850 - 5025 for fibromyalgia. Code 8850 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War Veteran by analogy to one of the musculoskeletal diseases found in VA's Rating Schedule and Code 5025 is the rating code for fibromyalgia. Under Code 5025 for fibromyalgia (fibrositis, primary fibromyalgia syndrome) a rating of 10 percent is assigned whenever there is widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms that require continuous medication for control; at 20 percent when symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but are present more than one-third of the time. A 40 percent rating, the maximum available, is warranted when symptoms are constant or nearly constant and refractory to therapy. 38 C.F.R. § 4.71a, Code 5025. For VA purposes, "widespread pain" means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. Id. at Note. The Board notes that the Veteran is separately rated for headaches, irritable bowel syndrome, lumbar spine, bilateral shoulder, and bilateral CTS, and such service-connected disabilities cannot be considered for purposes of evaluating his multiple joint pain under Code 5025 for fibromyalgia. See 38 C.F.R. § 4.14 (the evaluation of the same manifestation or disability under different diagnoses is to be avoided). Prior to January 24, 2020 In December 2013 the Veteran underwent a VA fibromyalgia examination to address his claim for an increase for his service-connected multiple joint pain. He reported his multiple joint pain was due to Gulf War exposure. He stated he had constant pain that is aggravated by carrying firewood and bending over. He also related that his multiple joint pain impacted his ability to work in that he has missed at least 7 days of work over the past 6 months for symptoms and doctor’s appointments for the symptoms. He stated that these symptoms also interfere with his chores/activities around his home. He stated that if he becomes exhausted, he is unable to finish his chores. He reported signs and symptoms of widespread musculoskeletal pain and fatigue. He stated that based on his stress or activity level he has “shakes” in his hands, feet and legs; when he lays in bed his arms/legs will spasm, he has muscle cramps, leg cramps and cramps on the side of his torso. The diagnosis was fibromyalgia. Diagnostic testing was not clinically indicated. The examiner noted there was no objective evidence of fibromyalgia on clinical examination. A February 2016 VA outpatient clinic note shows the Veteran was seen at the clinic with complaints of right shoulder pain, right hand pain and left foot pain. It was noted that his x-rays show degenerative disease that is somewhat better with medication twice daily. In reflecting his current clinical situation, it was noted that he does not take any medication for fibromyalgia. The assessment was right shoulder, right hand and left foot pain. At the October 2019 hearing, the Veteran testified that his multiple joint pain felt like a big nail is going in his shoulders and knees. He stated that the pain is all over his body. He stated that he also has a tingling sensation, which is the carpal tunnel in his hands and feet. He stated he also has swelling, the last episode being about two days ago. He experiences cramps that causes distortion of the fingers and toes and when his left leg cramps, it goes up toward his back. He also has stiffness. He is treated for his multiple joint pain at a VA clinic and takes medication for it. The preponderance of the evidence is against the assignment of a rating higher than 10 percent for the Veteran’s service-connected multiple joint pain for the period prior to January 24, 2020. Although the Veteran has reported pain affecting mostly the shoulders, arms, feet, hands, and legs, the medical evidence notes the pain was managed with medication during this period. He stated he had constant pain that is aggravated by carrying firewood and bending over. He also related he has missed at least 7 days of work over the past 6 months for symptoms of his multiple joint pain and doctor’s appointments for the symptoms. The symptoms interfere with his chores/activities. Here, the evidence does not more nearly approximate symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion but are present more than one-third of the time. The Board finds the medical evidence to be more probative than the Veteran’s assertions as to the severity of symptomatology. Accordingly, the preponderance of the evidence is against a rating higher than 10 percent for multiple joint pain prior to January 24, 2020, and the claim is denied. From January 24, 2020 On January 2020 VA-contract muscle injuries examination, the Veteran reported that his bilateral joint pain disability is worse. He reported that his body aches and he is unable to carry objects. He stated he started experiencing bilateral tingling pain and weakness in his feet. He also has bilateral knee, shoulder, and lower back pain. He reports currently his foot, knee, shoulder, and lower back pain is constant. He is unable to distinguish between muscle or joint pain. His main areas of discomfort are his feet and shoulders. He states that there has been a gradual increase in pain that is chronic, and it has not been helped with medication with the exception of narcotics, which he is uncomfortable with taking on a chronic basis. His knee pain is worse with activity, but as the day progresses his knees “do well.” He has no sensation of locking, but states that his knees have given out twice in general. He localized his pain to the area of the pes bursa and medial joint line. There was no history of fracture, dislocation, or subluxation involving his knees. He stated he used to run 10 miles a day and now he is unable to run at all due to pain and stiffness. He does not require the use of a cane or walker. His muscle strength testing was normal. The diagnosis was multiple joint disease, bilaterally. His multiple joint disability causes constant pain on his shoulder, and knees. He has associated stiffness and tiredness that interferes with his chores/activities around the home. He experiences exhaustion and is unable to perform tasks at home, which impacts his ability to work. Based on the foregoing, the evidence shows that the Veteran's multiple joint pain symptoms are present more than one-third of the time with pain precipitated by overexertion, as found on VA examination in January 2020. He reported constant pain, including in his feet and knees. He localized his pain to the area of the pes bursa and medial joint line. He experiences exhaustion and is unable to perform task at home. As such, the Board finds a 20 percent disability rating is warranted for the period from January 24, 2020. To this extent, the appeal is granted. Although the evidence demonstrates that the Veteran has experienced a gradual increase in pain that is chronic and has not been helped with medication with the exception of narcotics, which he is uncomfortable taking on a chronic basis, his multiple joint pain was not refractory to therapy. Without this, the next higher 40 percent rating is not more nearly approximated and therefore not warranted. Accordingly, the Board finds that the preponderance of the evidence is against a rating higher than 10 percent for multiple joint pain prior to January 24, 2020. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. The Board also finds that the Veteran is entitled to an increased rating to 20 percent, but not higher, for his multiple joint pain from January 24, 2020. 11. Entitlement to a rating higher than 30 percent for idiopathic pulmonary fibrosis prior to January 24, 2020 12. Entitlement to a rating higher than 60 percent for idiopathic pulmonary fibrosis from January 24, 2020 The Veteran's service-connected idiopathic pulmonary fibrosis is currently rated 30 percent prior to January 24, 2020 and 60 percent from that date pursuant to 38 C.F.R. § 4.97, Codes 6699-6600. A diagnostic code ending in "99" and followed by a hyphen connotes a disability which does not exist in the rating schedule and instead has been rated as analogous to a different disability which does exist in the rating schedule. 38 C.F.R. § 4.20. In this instance, the RO determined that the Veteran's service-connected idiopathic pulmonary fibrosis was most closely analogous to Code 6600, for impairment resulting from chronic bronchitis. The Board notes the Veteran is not service connected for bronchitis under Code 6600 and there is no indication that the Veteran has a diagnosis of bronchitis. Neither the Veteran nor his representative have challenged the use of Code 6600 to rate his service-connected disability, and the Board finds that diagnostic code is appropriate for analogous rating because it measures respiratory functioning. The Veteran asserts entitlement to a higher rating for his idiopathic pulmonary fibrosis due to decreased respiratory functioning. Respiratory disorders are rated under Codes 6600 through 6817 and 6822 through 6847. Ratings under those diagnostic codes will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96(a). Code 6600 provides ratings based on the results of pulmonary function tests. FEV-1 of 56- to 70-percent predicted value, or; the ratio of FEV-1/FVC of 56 to 70 percent or; DLCO (SB) of 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97, Code 6600. Prior to January 24, 2020 On December 2013 VA respiratory conditions examination, the Veteran reported that his daily activities have decreased because he is exhausted. He has shortness of breath and becomes exhausted when climbing less than one flight of stairs or carrying groceries into the house. He has gone to the emergency room for breathing difficulties two times over the past year and treated with steroids and antibiotics. His respiratory disability requires intermittent courses or bursts of systemic corticosteroids. He has had two courses or bursts in the past 12 months. His respiratory disability requires use of an inhalational bronchodilatory therapy, and inhalational anti-inflammatory medication daily. He also uses a nebulizer approximately 2 to 3 times a week or when he runs out of the inhalers. He requires use of antibiotics and claims 1 to 2 courses of antibiotics for 14 days each over the past 12 months for respiratory infection. Chest x-rays showed no acute cardiopulmonary disease. There were no pulmonary function test results, as the Veteran cancelled the test for this claim. The diagnosis was idiopathic pulmonary fibrosis. The Veteran stated that his ability to work is impacted because he has shortness of breath when walking into the parking lot into the building where he works. He also experienced shortness of breath with activities and chores around his home. Based on the foregoing, the Veteran’s service-connected idiopathic pulmonary fibrosis had not resulted in respiratory impairment showing FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). As such, the Veteran is not entitled to the next higher 60 percent rating under Code 6600 for the period prior to January 24, 2020, and his appeal for such is denied. From January 24, 2020 On January 2020 VA-contract respiratory conditions examination, the Veteran reports that his idiopathic pulmonary fibrosis disability had gotten worse. He reported that he becomes short of breath and exhausted when climbing less than one floor, carrying groceries into the house. He stated he went to the emergency room for breathing difficulties 4 times over the past year resulting in dose pack steroids and antibiotics. His respiratory condition requires the use of oral or parenteral corticosteroid medications. He has undergone 4 or more intermittent courses of system corticosteroids in the past 12 months. He requires daily inhalational bronchodilator therapy and inhalational anti-inflammatory medication. His idiopathic pulmonary fibrosis disability does not require the use of oral bronchodilators, antibiotics, or outpatient oxygen therapy. January 2020 chest x-rays show clear lungs. Heart and pulmonary vascularity within normal limits. Osseous structures were unremarkable. The impression was no acute intrathoracic findings. His January 2020 pulmonary function test results revealed FEV-1 of 47 percent pre-bronchodilator predicted, FEV-1/FVC of 70 percent pre-bronchodilator predicted value, and DLCO 63 percent pre-bronchodilator predicted; FEV1 of 53 percent post- bronchodilator predicted, FEV-1/FVC of 71 percent post-bronchodilator predicted value. The FEV-1 percent predicted results most accurately reflect the Veteran’s level of disability. The diagnosis was idiopathic pulmonary fibrosis. The Veteran did not have multiple respiratory conditions. His moderated obstructive ventilatory defect impairs him from walking long distances, exercising, and performing activities/chores at home. He becomes easily short of breath; thus, idiopathic pulmonary fibrosis disability impacts his ability to work. A January 2020 pulmonary function report reveals spirometry demonstrates good cooperation from the Veteran for interpretation of these curves. The forced vital capacity and FEV-1 were moderately reduced. Maximum expiratory flow rates are moderately reduced. Mid maximum expiratory flow rates are severely reduced. There is minimal, but consistent improvement following the use of inhaled albuterol. The single breath diffusing capacity corrected for the volume is mildly reduced. Room air arterial oxygen saturation was normal at 92 percent. The impression was moderate obstructive ventilatory defect consistent with both chronic bronchitis and emphysema. In this instance, the January 2020 VA-contract respiratory conditions examination revealed FEV-1 of 47 percent pre-bronchodilator predicted, supporting the current 60 percent evaluation. Notably, these findings do not meet any of the criteria warranting a 100 percent rating, as delineated above specifically from January 24, 2020. Thus, the Board finds that, from January 24, 2020, the probative evidence of record does not establish that the Veteran's respiratory condition manifested in any of the criteria contemplated by a 100 percent rating under Code 6600. As such, entitlement to a rating higher than 60 percent from January 24, 2020 is denied. Other Considerations The Veteran is assigned a combined total rating from January 24, 2020. Prior to January 2020 his combined schedular rating was less than total. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a total disability rating based on individual unemployability (TDIU) is considered part and parcel of an increased rating claim when the issue of unemployability is raised by the record. In this case, for the period prior to January 24, 2020 the Board finds that the issue of individual unemployability has neither been raised by the Veteran, nor by the record. It appears that during that period, the Veteran was employed. In an August 2015 VA outpatient physician’s note, the Veteran related that he stays active in a full-time job as a computer analyst. When he was seen at the St. Louis VA Medical Center in September 2018, he indicated he was currently working in another state. Thus, consideration of TDIU prior to January 24, 2020 is not warranted. The Veteran has not raised any other issues, to include entitlement to an extraschedular rating for these disabilities, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). REASONS FOR REMAND 13. Entitlement to a rating higher than 30 percent for blurred vision and twitching of the left eye due to an undiagnosed illness, left eye cataract, status post cataract extraction and right eye cataract Regrettably, the Veteran’s January 2020 VA examination does not reflect visual field testing. Given that this is a rating factor for visual impairment, this is a deficiency that must be corrected upon remand. Accordingly, the case is REMANDED for the following action: Afford the Veteran a VA eye examination to address his blurred vision of the left eye and left eye cataract. The examiner must review the claims file and perform all necessary testing, including both visual field and central visual acuity testing. All results must be included in a typewritten report, with all opinions supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Young, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.