Citation Nr: 21066174 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 15-38 744 DATE: October 28, 2021 ORDER Entitlement to an evaluation in excess of 10 percent for psoriasis form dermatitis is denied. Entitlement to an evaluation in excess of 10 percent for right knee meniscotomy is denied. Entitlement to an evaluation in excess of 30 percent for limitation of flexion of the right knee is denied. Entitlement to service connection for hypertrophic gastritis is granted. Entitlement to service connection for erectile dysfunction is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, recurrent chronic, severe is remanded. FINDINGS OF FACT 1. The Veteran's psoriasis form dermatitis is manifested by characteristic lesions involving less than 5 percent of the exposed areas and constant topical medication use. 2. The Veteran's right knee meniscotomy is rated as 10 percent disabling, which is the maximum schedular rating permitted for symptomatic removal of semilunar cartilage. 3. The Veteran's right knee degenerative joint disease is rated as 30 percent disabling, which is the maximum schedular rating permitted for limitation of flexion of the leg. 4. Resolving reasonable doubt in the Veteran's favor, his hypertrophic gastritis is at least as likely as not related to his military service. 5. The preponderance of the evidence is against finding that erectile dysfunction began during active service, or is otherwise related to an in-service injury or disease.. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for psoriasis form dermatitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7816. 2. The criteria for a rating in excess of 10 percent for right knee meniscotomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5259. 3. The criteria for a rating in excess of 30 percent for [DISABILITY] have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5010, 5260, and 5261. 4. The criteria for service connection for hypertrophic gastritis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from March 1982 to June 1982 and from February 2003 to August 2003. This case comes before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo and San Juan, Commonwealth of Puerto Rico. The Veteran's claims were previously remanded by the Board in a March 2021 decision. The Board finds that the RO has substantially complied with the March 2021 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on docket pursuant to 38 C.F.R. § 20.900 (c); 38 U.S.C. § 7107 (a)(2). The Board notes that the Veteran has been in receipt of a 100 percent disability rating effective April 19, 2018. Increased Rating 1. Entitlement to an evaluation in excess of 10 percent for psoriasis form dermatitis The Veteran contends that he is entitled to a higher rating for his psoriasis. The Veteran's psoriasis form dermatitis is rated under Diagnostic Code 7816 for psoriasis. VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least 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, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 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 rating is assigned for 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, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is psoriasis form dermatitis. In June 2021, the VA obtained an updated examination regarding the Veteran's skin condition. The examiner noted a diagnosis of psoriasiform dermatitis. The Veteran described episodes of scaling and itch on his left hand that has worsened due to increased hand washing during the pandemic. The Veteran reported he uses a prescribed cream on a daily basis because he develops fissures in his hand if not used continuously. The examiner noted the Veteran is treated with topical corticosteroids or other immunosuppressive medications with constant/near-constant use. The examiner also indicated the Veteran's dermatitis manifests as characteristic lesions over less than 5 percent of the total body area nad less than 5 percent of the exposed body area as it is contained to the proximal left palm. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under the August 13, 2018, regulations because the Veteran's psoriasis does not more nearly approximate characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. The Veteran required continuous use of a topical medication and his condition manifests as characteristic lesions on less than 5 percent of the total body area or exposed body area as it is only present on his left palm. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include worsening due to excessive handwashing, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that the Veteran's disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of a rating in excess of 10 percent for [DISABILITY]. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an evaluation in excess of 10 percent for right knee meniscotomy The Veteran contends that he is entitled to a higher rating because of the functional impairment resulting from his right knee disability. The Veteran's status post right knee meniscotomy is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. As the Veteran is in receipt of the highest schedular rating for dislocation of symptomatic removal of semilunar cartilage, there is no basis to award a higher evaluation. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg as discussed below. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for right knee meniscotomy. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an evaluation in excess of 30 percent for limitation of flexion of the right knee The Veteran contends that he is entitled to a higher rating because of the functional impairment resulting from his right knee disability. The Board notes that the Veteran is separately rated under Diagnostic Code 5257 for right knee instability at 10 percent from February 1, 2009, and at 20 percent from February 7, 2021. The Veteran's right knee degenerative joint disease with patellofemoral dysfunction is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board also notes that the Veteran's right knee disability is rated under Diagnostic Code 5010 for traumatic arthritis. As the Veteran is in receipt of the highest schedular rating for limitation of flexion of the leg, there is no basis to award a higher evaluation. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In June 2021, the Veteran was afforded a VA examination for his right knee disability. On initial range of motion testing, the Veteran had flexion limited to 105 degrees and extension limited to 10 degrees. The examiner estimated that the Veteran would have flexion limited to 90 degrees and extension limited to 15 degrees during a flare up. Thus, the Veteran's right knee disability does not meet the requirements for a compensable rating under DC 5260 or a rating greater than 30 percent under DC 5261. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for limitation of flexion of the right knee. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. SERVICE CONNECTION 4. Entitlement to service connection for hypertrophic gastritis The Veteran contends that his hypertrophic gastritis is related to his active-duty service. The Board concludes that the evidence is in equipoise regarding whether the Veteran has a current disability that began during active service or was caused by active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The April 2017 VA examination shows the Veteran has a current diagnosis of hypertrophic gastritis. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes lack of objective medical evidence from during the Veteran's active-duty service and the opinion of the April 2020 and August 2021 VA examiners. The April 2020 and August 2021 VA examiners concluded that the Veteran did not have a current diagnosis of hypertrophic gastritis without ever examining the patient. The April 2020 and August 2021 VA examiners did not adequately consider the April 2017 VA examination that concluded the Veteran had hypertrophic gastritis based on 2013 imaging. The evidence in favor of the claim includes the April 2017 VA examination, the Veteran's own lay statements, and the opinion of the July 2021 VA examiner. The July 2021 VA examiner concluded that the Veteran's hypertrophic gastritis was incurred in or caused in service. As rationale, the examiner found the Veteran's lay statements regarding the onset of his symptoms consistent with the upper endoscopy findings and his service-connected GERD. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current hypertrophic gastritis is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for hypertrophic gastritis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for erectile dysfunction The Veteran contends that his erectile dysfunction is related to his military service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of erectile dysfunction (ED), the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. In June 2021, an addendum opinion was obtained regarding the nature and etiology of the Veteran's ED. The examiner concluded that it was less likely than not (less than 50 percent probability) that the Veteran's ED was incurred in or caused by his active-duty service. As rationale, the examiner noted that the Veteran reported he began experiencing symptoms in 2014 to 2015, which correlated with the medical evidence in the Veteran's file. The examiner also noted the Veteran reported in February 2016 that his issues had been going on for the last two years. Thus, the Veteran's condition began years after his active-duty service lessening the probability of an etiological connection. The June 2021 examiner also opined that it was less likely than not that the Veteran's ED was secondary to his lumbar spine disability. As rationale, the examiner explained that for degenerative disc disease to cause or aggravate ED, there would need to be damage to T10-T11 or S2-S3 parasympathetic nerves. The examiner noted the Veteran's lumbar spine disability did not impact these anatomic levels. The examiner concluded that the etiological origin of the Veteran's ED was likely his nonservice-connected diabetes mellitus and depressive disorder. While the Veteran believes his ED is related to service, the Board reiterates that the preponderance of the evidence weighs against findings that an in-service injury, event, or disease occurred that could cause ED. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, recurrent chronic, severe is remanded. The Veteran contends that his acquired psychiatric disorder, to include major depressive disorder, is secondary to the pain associated with his service-connected disabilities. Specifically, the Veteran has contended that his depression is related to his degenerative arthritis of the lumbar spine. In December 2020, the VA obtained an addendum opinion regarding whether the Veteran's acquired psychiatric disorder was related to his service-connected degenerative arthritis of the lumbar spine. The examiner concluded that the Veteran's unspecified depressive disorder "was result of severe familial crisis, and partner relational problems, not associated or related, to any service-connected result of degenerative arthritis of the lumbar spine." The examiner continued that the conditions had "no relation one with the other." The examiner also indicated there is no temporal or causality relationship between the conditions based on the mental condition being diagnosed in 2017. The Board finds this opinion inadequate as it does not address the Veteran's statements in treatment records indicating that his physical disabilities were exacerbating his depression. Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA undertakes an examination, it must provide an adequate one). A review of the Veteran's psychiatric treatment records reveal that the Veteran presented with depressive symptoms based on multiple factors. Treatment notes from April 2017 indicate that the Veteran reported that his worsening pain is exacerbating his mood disorder. In July 2018, the Veteran again reported that his physical pain was exacerbating his depression. Cucuras v. Sec'y of Health and Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993) (finding no error in fact-finder's decision to give more weight contemporaneous medical records generated for treatment purposes than to contrary lay testimony, reasoning that "[m]edical records, in general, warrant consideration as trustworthy evidence, and that "oral testimony in conflict with contemporaneous documentary evidence deserves little weight"); Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I. 2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). The Board also notes that the December 2020 VA examiner primarily discussed an unspecified depressive disorder, but that the Veteran's April 2020 VA treatment notes indicated that he was diagnosed with major depressive disorder, recurrent, severe. The matters are REMANDED for the following action: 1. Obtain any updated VA mental health treatment records. 2. Schedule the Veteran for a VA examination with an appropriate mental health clinician for his acquired psychiatric disorder. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the acquired psychiatric disorder at least as likely as not proximately due to the Veteran's service-connected lumbar spine disability or other service-connected disabilities? Is the acquired psychiatric disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by pain or other symptoms of the Veteran's service-connected lumbar degenerative arthritis and his other service-connected disabilities? The examiner is asked to provide a rationale for the opinion that addresses the Veteran's lay statements to his treatment providers regarding his physical pain worsening his psychiatric symptoms. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.D. Taylor, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.