Citation Nr: 21068941 Decision Date: 11/16/21 Archive Date: 11/16/21 DOCKET NO. 17-43 097 DATE: November 16, 2021 ORDER Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a 10 percent disability rating for an epidermal cyst prior to April 23, 2019 is granted. Entitlement to a disability rating in excess of 10 percent for residual status post epidermal cyst excision scar denied. Entitlement to a compensable disability rating for lichen simplex chronicus prior to October 15, 2020 and in excess of 10 percent thereafter is denied. Entitlement to a total disability rating due to individual unemployability based on service-connected disability (TDIU) is denied. REMANDED Entitlement to a disability rating in excess of 20 percent for left shoulder degenerative arthritis with impingement syndrome and partial rotator cuff tear is remanded. Entitlement to a disability rating in excess of 10 percent for left knee degenerative arthritis is remanded. FINDINGS OF FACT 1. The Veteran has not demonstrated total occupational and social impairment due to his PTSD. 2. Prior to April 23, 2019, the Veteran's epidermal cyst was tender and painful. 3. From April 23, 2019, the Veteran's scar from epidermal cyst removal is a single painful linear scar that is not unstable and measures 7 inches by 1 inch. 4. Prior to October 15, 2020, the Veteran's lichen simplex chronicus involved less than 5 percent of both the exposed area and the total area of the body and has not required the use of systemic therapy for treatment. 5. From October 15, 2020, the Veteran's lichen simplex chronicus was characterized by at least 5 percent, but less than 20 percent, of the entire body affected; and no more than topical therapy required during the past 12-month period. 6. The evidence of record does not demonstrate that the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. Prior to April 23, 2019, the criteria for a 10 percent disability rating, but no higher, for an epidermal cyst have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7819-7804. 3. From April 23, 2019, the criteria for a disability rating in excess of 10 percent for residual status post epidermal cyst excision scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7819-7804. 4. Prior to October 15, 2020, the criteria for a compensable disability rating for lichen simplex chronicus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.118, Diagnostic Code 7806. 5. From October 15, 2020, the criteria for a disability rating in excess of 10 percent for lichen simplex chronicus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.118, Diagnostic Code 7806. 6. The criteria for entitlement to TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1991 to July 1991 and from June 1994 to March 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the case in October 2019 for further development. The requested development as to the claims adjudicated below have been completed to the extent possible, and no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a disability rating in excess of 70 percent for PTSD is denied. The Veteran is seeking an increased disability rating for his service-connected PTSD. Specifically, the Veteran contends that his PTSD is more severe than reflected by his assigned disability rating. The regulations for mental disorders are found in 38 C.F.R. §§ 4.125-4.130. The Board notes that the Veteran's diagnosis of PTSD is evaluated under Diagnostic Code 9411 and is rated according to the General Rating Formula for Mental Disorders. Pursuant to the rating formula, a 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Turning to the evidence of record, in an April 2016 Disability Benefits Questionnaire (DBQ) completed by Dr. W. A., a private psychologist, the Veteran reported he was never married but most recently romantically involved prior to September 2011. He worked for the Federal Emergency Management Agency (FEMA) and had earned a doctorate in education in 2015. Dr. W. A. noted that symptoms associated with the Veteran's PTSD included anxiety, suspiciousness, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory, or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. Dr. W. A. determined that the Veteran's psychiatric disorder caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. The Veteran was afforded a VA examination in August 2016. He reported he had never been married, nor did he have children. The Veteran denied long term relationships, noting that he had difficulty keeping romantic relationships as he would lose interest quickly. He stated he had contact with his siblings but indicated they would reach out to him. The Veteran reported having a few acquaintances from service that he kept in touch with on social media. He enjoyed photography and spent time with other photographers. The Veteran reported spending his leisure time on photography, work, or going home and doing nothing. For work, the Veteran was employed by FEMA since 2010 as a watch analyst. He noted that many of his duties were similar to his duties in service, which would sometimes act as a trigger. The Veteran reported irritability and verbal conflicts with coworkers whom he felt were not doing their jobs adequately. The Veteran also taught emergency management part time at a local college. The VA examiner confirmed a diagnosis of PTSD and noted associated symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, and impaired impulse control. The examiner determined that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran was afforded a VA examination in October 2020. He reported he lived alone and had never been married or had children. The Veteran stated he was close with his two siblings and spoke to them weekly. He also noted he had some friends who he did not see often; they usually communicated by email or phone. The Veteran reported he did not date or have romantic relationships and was last involved with someone last year. The relationship lasted two years and ended when she moved abroad. The Veteran stated he was an analyst for FEMA and had worked there since 2010. He had completed his doctorate in education in 2016. The Veteran noted he did photography on the side for money and as a therapeutic hobby. The Veteran reported he did not have issues that interfered with his ability to go to work, and that most of his issues revolved around being social, specifically romantic. The VA examiner confirmed a diagnosis of PTSD and noted associated symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. The examiner determined that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. Following a review of the evidence of record, the Board finds that the preponderance of the evidence is against finding that symptoms of the Veteran's PTSD cause both total occupational and social impairment. Based on the Veteran's level of occupational and social impairment, he would be ineligible for a 100 percent disability rating for his PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The April 2016 DBQ, August 2016 VA examination, and October 2020 VA examination fail to show that the Veteran suffers from total occupational and social impairment. In fact, Dr. A. W. and both VA examiners indicated that the Veteran's PTSD fell short of causing total occupational and social impairment. Further, treatment records reflect similar symptoms as the VA examinations of record, with no indication that the Veteran suffers from both occupational and social impairment. As noted above, a 100 percent disability rating requires both total occupational impairment and total social impairment and this has not been demonstrated by the record. The Veteran maintains relationships and employment, and although both these may be difficult at times, he has demonstrated he is capable of maintaining interpersonal relationships and employment. The severity of his difficulties with social and occupational functioning have been contemplated in the assignment of a 70 percent disability rating. Accordingly, as the preponderance of the evidence is against a finding that the Veteran's PTSD causes both total occupational and total social impairment, the benefit-of-the-doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to a 10 percent disability rating for an epidermal cyst prior to April 23, 2019 is granted. 3. Entitlement to a disability rating in excess of 10 percent for residual status post epidermal cyst excision scar is denied. The Veteran is seeking increased disability ratings for his service-connected epidermal cyst condition. Specifically, the Veteran contends that his epidermal cyst and subsequent scar are more severe than reflected by his assigned disability ratings. The Veteran's epidermal cyst was evaluated under Diagnostic Code 7819 prior to April 23, 2019 and following removal, is evaluated under Diagnostic Code 7819-7804 from April 23, 2019. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, Diagnostic Code 7819 pertains to benign skin neoplasms. This code directs VA to rate the disability as a skin disorder under Diagnostic Codes 7800 through 7805 or based on impairment of function. The RO has rated the Veteran's disorder under Diagnostic Code 7804. See 38 C.F.R. § 4.118. Scars that, as here, do not impact the head, face, or neck are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805. During the pendency of this appeal, VA recently published a final rule amending its regulations on skin disabilities effective August 13, 2018. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted VA to do otherwise and VA did so. See VAOGCPREC 7-2003. However, "the case law is clear that a regulation is not to be applied retroactively unless the regulation is intended to be retroactive." Ervin v. Shinseki, 24 Vet. App. 318, 322 (2011) (citing Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003)). Here, the recently revised skin regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, August 13, 2018. Hence, for the period beginning August 13, 2018, the version more favorable to the Veteran will apply. Under the former criteria of Diagnostic Code 7801, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is deep and nonlinear, and covers an area of at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § § 4.118, Diagnostic Code 7801. Under the former criteria of Diagnostic Code 7802, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is superficial and nonlinear, and covers an area of at least 144 square inches (929 sq. cm.) 38 C.F.R. § § 4.118, Diagnostic Code 7802. Under the former criteria of Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable of painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § § 4.118, Diagnostic Code 7804. Under the former criteria of Diagnostic Code 7805, any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § § 4.118, Diagnostic Code 7805. Under the revised criteria since August 13, 2018, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are associated with underlying soft tissue damage. Scars that are associated with underlying soft tissue damage in an area or areas exceeding 6 square inches (39 sq.cm.) are rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq. cm.) are rated as 40 percent disabling. 38 C.F.R. § § 4.118, Diagnostic Code 7801. Under the revised criteria since August 13, 2018, Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are not associated with underlying soft tissue damage. A scar that is not associated with underlying soft tissue damage in an area or areas of 144 square inches (929 sq. cm.) or greater is rated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7802. Under the revised criteria since August 13, 2018, Diagnostic Code 7804 provides ratings for scars that are unstable or painful. One or two scars that are unstable or painful are rated as 10 percent disabling. Three or more scars that are unstable or painful are rated as 20 percent disabling. Five or more scars that are unstable or painful are rated as 30 percent disabling. Note (1) to Diagnostic Code 7804 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 may be added to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804 Under the revised criteria since August 13, 2018, Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. Turning to the evidence of record, in an April 2016 consultation performed by Dr. P. Y., a private physician, the Veteran's epidermal cyst was noted to be enlarged substantially and weep liquid through his clothing. The pressure of shirts and jackets caused the cyst to be painful. The Veteran was afforded a VA examination for his epidermal cyst in July 2016. The VA examiner confirmed a diagnosis of epidermal cyst: hypopigmented subcutaneous nodule about 1 cm in size over the mid-upper back that was non-tender with no drainage. The examiner noted a history of epidermal cyst over the Veteran's back. There was no pain or discharge. No scarring or disfigurement of the head, face, or neck was noted. The Veteran had not been treated with oral or topical medications in the past 12 months of any skin condition. He had not had any debilitating episodes in the past 12 months. The examiner indicated that the Veteran's epidermal cyst covered less than 5 percent of his total body and no portion of exposed area. The Veteran was afforded VA examinations for skin conditions and scars in October 2020. The VA examiner noted that the Veteran had an epidermal cyst for years that was painful and continually draining. He had it removed in 2019 and now had a scar that was tender when pressed. The VA examiner changed the Veteran's diagnosis of epidermal cyst to status post tender scar from epidermal cyst removal, noting this was a continuation of the previous diagnosis. The examiner noted that the Veteran had one painful scar that was mildly tender with direct palpation. He did not have unstable scars, scars with underlying soft tissue damage or scars due to burns. The Veteran's upper posterior trunk had a linear scar that measured 7 cm by 1 cm. The examiner indicated that there were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with his scar. Following a review of the evidence of record, the Board finds that the criteria for a 10 percent disability rating, but no higher, prior to April 23, 2019 has been met. During this period, the Veteran's epidermal cyst was tender and painful with draining, and is most appropriately evaluated under Diagnostic Code 7804, as directed by Diagnostic Code 7819. The Board has considered only the former criteria of the regulations pertaining to skin disorders for the appeal period prior to August 13, 2018 and both the former and revised criteria of the regulations pertaining to skin disorders from August 13, 2018 to April 22, 2019. The Veteran's epidermal cyst was located on his back, covering only a small surface area, and did not cause impairment of function; therefore, the Board finds that Diagnostic Codes 7800, 7801, 7802, and 7805 are not applicable. For the period from April 23, 2019, the Board finds that the preponderance of the evidence is against finding that a disability rating in excess of 10 percent is warranted. The Veteran's scar from epidermal cyst removal is a single painful linear scar that is not unstable and measures 7 inches by 1 inch. The Board has considered only the current rating criteria of the regulations pertaining to skin disorders and finds that a 10 percent disability rating for one painful scar under Diagnostic Code 7819-7804 best contemplates the severity of the Veteran's skin disability. Accordingly, a 10 percent disability rating for the Veteran's epidermal cyst under Diagnostic Code 7819-7804 for the period prior to April 23, 2019 is granted. However, the preponderance of the evidence is against finding that the Veteran has met the criteria for a disability rating in excess of 10 percent for any period during the appeal. As such, the benefit-of-the-doubt rule is not for application, and the claim for a disability rating in excess of 10 percent must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Entitlement to a compensable disability rating for lichen simplex chronicus prior to October 15, 2020 and in excess of 10 percent thereafter is denied. The Veteran is seeking increased disability ratings for his service-connected lichen simplex chronicus. Specifically, the Veteran contends that his lichen simplex chronicus is more severe than reflected by his assigned disability ratings. The Veteran's lichen simplex chronicus is evaluated under Diagnostic Code 7806. The criteria under this code changed during the pendency of the appeal, effective August 13, 2018. VA's intent is that 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 Under the former criteria of Diagnostic Code 7806, a noncompensable rating is assigned for dermatitis or eczema affecting less than 5 percent of the entire body or less than 5 percent of exposed areas, and no more than topical therapy is required during the past 12-month period. A 10 percent rating is assigned for dermatitis or eczema affecting 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; or, when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema affecting at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or when systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent rating is assigned for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. The Federal Circuit addressed the meanings of "systemic" and "topical" for rating skin disabilities under the regulatory criteria prior to August 13, 2018. See Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). For these purposes, 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. at 1355. The Federal Circuit acknowledged that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based upon the facts of each case. Id. at 1356. Under the revised schedule of skin ratings, effective August 13, 2018, Diagnostic Code 7806 for dermatitis or eczema is rated under the General Rating Formula for the Skin (General Rating Formula), Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. 38 C.F.R. § 4.118. Under the General Rating Formula, a noncompensable rating is assigned when there is 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 or rate as disfigurement of the head, face, or neck (Code 7800) or scars (Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. A 10 percent disability is assigned if there is 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. Higher ratings of 30 or 60 percent are warranted based on a higher degree of affected areas or higher frequency of systemic therapy. The 10, 30, and 60 percent criteria list examples of types of systemic therapy as including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. 38 C.F.R. § 4.118. VA's revised regulations explicitly state that for purposes of the skin disability ratings, "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). Turning to the evidence of record, the Veteran was afforded a VA examination for skin diseases in July 2017. The Veteran's service-connected lichen simplex chronicus had been treated with topical corticosteroids, specifically triamcinolone for six weeks or more, but not constant. His lichen simplex chronicus affected less than 5 percent of his total body area and none of his exposed area of the body. It was located over the antecubital fossa, popliteal fossa, and mid-back. The VA examiner indicated that the Veteran's skin condition did not cause scarring or disfigurement of the head, face, or neck. He did not have any systemic manifestations due to skin diseases. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's skin condition. The Veteran was afforded another VA examination for skin disease in October 2020. His lichen simplex chronicus was noted to be located on his arms, chest, shoulders, back, and abdomen. It was treated with topical corticosteroids or other immunosuppressive medications, specifically triamcinolone, on a constant or near constant basis. The Veteran's lichen simplex chronicus affected 5 to less than 20 percent of his total body area and none of his exposed area of the body. It presented as dry, scaly, hyperpigmented patches. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's skin condition. Prior to October 15, 2020, the Veteran's lichen simplex chronicus was noted to affect less than 5 percent of his total body and was treated for six weeks or more, but not constant, with topical corticosteroids. As noted above, under the former criteria of Diagnostic Code 7806, a compensable rating is not warranted unless a skin disease affects at least 5 percent of total body area. Under the revised criteria of Diagnostic Code 7806, a compensable rating is not warranted unless there are characteristic lesions involving at least 5 percent of the entire body affected, skin disease affecting at least 5 percent of exposed areas, or intermittent systemic therapy or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. As such, prior to October 15, 2020, the Veteran's lichen simplex chronicus is not entitled to a compensable rating under either the former or revised criteria of Diagnostic Code 7806. From October 15, 2020, the Veteran's lichen simplex chronicus affected 5 to less than 20 percent of total body area and was treated with topical corticosteroids or other immunosuppressive medications on a constant or near constant basis. As noted above, under the revised criteria of Diagnostic Code 7806, the only criteria applicable for this period, a higher rating of 30 percent is warranted with 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 six weeks or more but not constantly over the past 12-month period. Here, the record does not indicate that the Veteran's topical medication used to treat his lichen simplex chronicus amounted to systemic therapy. The topical corticosteroid treatment does not appear to be administered on a large enough scale to affect the body as a whole. Likewise, there is no probative medical evidence suggesting that the Veteran's topical corticosteroids had a broad, systemic effect. Therefore, he does not meet the criteria for disability rating in excess of 10 percent under Diagnostic Code 7806. In sum, the preponderance of the evidence of record does not support a finding that the Veteran's service-connected lichen simplex chronicus warrants a compensable disability rating prior to October 15, 2020 or a disability rating in excess of 10 percent from October 15, 2020. As such, the benefit-of-the-doubt rule is not for application and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 5. Entitlement to TDIU is denied. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extra-schedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The term substantially gainful employment refers to, at the minimum, the ability to earn a living wage, and is not engaged in substantially gainful employment if annual income below the poverty threshold for one person. See Bowling v. Principi, 15 Vet. App. 1, 7 (2001). In Faust v. West, 13 Vet. App. 342, 356 (2000), the United States Court of Appeals for Veterans Claims (Court) held actual employability is shown as a matter of law by substantially gainful employment. This means employment that provides annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the veteran actually works. Id. There is an exception to this rule for sheltered employment. Cantrell v. Shulkin, 28 Vet. App. 382 (2017). The claimant bears the burden of presenting and supporting his or her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). However, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. After a review of the record, the Board finds that the Veteran has not met the burden of establishing that he is unable to gain or maintain substantially gainful employment as a result of his service-connected disabilities. In October 2019, the Board determined that the issue of TDIU had been raised by the record. See Rice v. Shinseki, 22Vet. App.447, 454 (2009). Specifically, the Board noted treatment records that reflected severe occupational impairments due to service-connected disabilities and the Veteran's statement that his supervisor was constantly addressing his "sliding performance" due to his PTSD symptomatology. Pursuant to the Board's remand directives, the Veteran was sent notice regarding the requirements to substantiate entitlement to TDIU in December 2019 along with VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability. The Veteran failed to complete the form or provide VA with comparable information. Evidence in the Veteran's claims file reflects he has worked full time for FEMA as an analyst since 2010 and works part time as a photographer and as a professor at a local college. He competed his doctorate in education in 2015 or 2016; the record contains conflicting dates. In February 2020, the Veteran reported aspects of his job with FEMA reminded him of service and agitated his PTSD. He noted that he wanted to focus on developing his photography business. In the October 2020 VA examination for PTSD, the Veteran reported his PTSD did not interfere with his ability to go to work. He reported that most of his issues from PTSD involved being social, specifically, romantic. The Board notes that in addition to PTSD, the Veteran is also service connected for bilateral knee disabilities, a left shoulder disability, obstructive sleep apnea, lichen simplex chronicus, status post epidermal cyst removal, and a binge eating disorder. The functional impact of the Veteran's knee and shoulder disabilities include painful ambulation, no kneeling, running or stairs, the need for the ability to alternate sitting and standing, and avoidance of overhead activities that aggravate pain. His obstructive sleep apnea causes daytime hypersomnolence and he cannot submerge his skin in fluids or work in direct sunlight due to his lichen simplex chronicus. There is no functional impact found to be associated with the Veteran's status post epidermal cyst removal and binge eating disorder. The Board notes that the evidence of record does not support a finding that these service-connected disabilities impact the Veteran's ability to obtain and sustain substantially gainful employment. The Board acknowledges that the Veteran's symptomatology associated with his service-connected disabilities, especially his PTSD, may impact his ability to work. However, this impact is taken into consideration in the evaluation of the disabilities and the ratings assigned. The evidence establishes that despite any impact from service-connected disabilities, the Veteran is not unable to maintain employment and, in fact, has been gainfully employed working a full-time job and two part-time jobs. Accordingly, as the most probative evidence of record fails to sufficiently support entitlement to TDIU, the Board finds that the preponderance of the evidence is against the Veteran's claim. Accordingly, there is no reasonable doubt to be resolved, and TDIU is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 20 percent for left shoulder degenerative arthritis with impingement syndrome and partial rotator cuff tear is remanded. 2. Entitlement to a disability rating in excess of 10 percent for left knee degenerative arthritis is remanded. The Veteran is seeking increased disability ratings for his left shoulder degenerative arthritis with impingement syndrome and partial rotator cuff tear and left knee degenerative arthritis. Specifically, the Veteran contends that his left shoulder and left knee disabilities are more severe than reflected by his currently assigned disability ratings. Based on a review of the claims file, the Board finds that additional development is needed prior to adjudication of the claims. In Correia v. McDonald, 28 Vet. App. 158, 169- 170 (2016), the United States Court of Appeals for Veterans Claims (Court) held that an adequate VA examination of the joints must, wherever possible, include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing, and with range-of-motion measurements of the opposite undamaged joint. In this case, the Veteran was afforded VA examinations for his left shoulder and left knee disabilities in October 2020. The Veteran reported functional impairment of the left shoulder, with difficulty raising his arms, lifting weight, and pushing or pulling objects. He reported functional impairment of the left knee, with difficulty standing, walking, running, kneeling, and stairs. While objective evidence of pain was noted on passive range of motion testing and non-weightbearing testing of the left shoulder and left knee, range of motion measurements were not provided. The Board is unable to make an informed determination regarding the severity of the functional loss associated with the Veteran's disabilities without information regarding the extent range of motion is affected by pain on passive range of motion testing and on non-weightbearing testing. As such, the Board finds that remand for new VA examinations is required to cure these deficiencies. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA medical examination to assess the orthopedic manifestations of his left shoulder degenerative arthritis with impingement syndrome and partial rotator cuff tear. The Veteran's electronic claims file must be made available for review prior to the examination and the examination report should reflect that such review was accomplished. All testing deemed necessary to rate the Veteran's disability under the criteria of the VA rating schedule must be conducted and the results reported in detail. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and non-weightbearing. The examiner is asked to indicate the point during range-of-motion testing that motion is limited by pain; it is not sufficient merely to indicate whether or not pain was present during one of the required range of motion tests. Testing should be conducted, and results provided, for the opposite joint, unless the opposite joint is damaged. If the opposite joint is determined to be damaged, and no range of motion testing is conducted, this must be explained in the report. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should explain why. The examiner should describe the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology and/or is evidenced by visible behavior such as facial expression or wincing. The examiner should express an opinion as to whether pain or other manifestations during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range-of-motion loss due to pain on repeated use or during flare-ups. If no estimate can be provided, the examiner should provide a sufficiently detailed explanation as to why. A rationale for the opinions in the examination report must be provided. 2. Schedule the Veteran for an appropriate VA medical examination to assess the orthopedic manifestations of his left knee degenerative arthritis. The Veteran's electronic claims file must be made available for review prior to the examination and the examination report should reflect that such review was accomplished. All testing deemed necessary to rate the Veteran's disability under the criteria of the VA rating schedule must be conducted and the results reported in detail. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and non-weightbearing. The examiner is asked to indicate the point during range-of-motion testing that motion is limited by pain; it is not sufficient merely to indicate whether or not pain was present during one of the required range of motion tests. Testing should be conducted, and results provided, for the opposite joint, unless the opposite joint is damaged. If the opposite joint is determined to be damaged, and no range of motion testing is conducted, this must be explained in the report. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should explain why. The examiner should describe the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology and/or is evidenced by visible behavior such as facial expression or wincing. The examiner should express an opinion as to whether pain or other manifestations during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range-of-motion loss due to pain on repeated use or during flare-ups. If no estimate can be provided, the examiner should provide a sufficiently detailed explanation as to why. A rationale for the opinions in the examination report must be provided. (Continued on the next page) 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Silverblatt, 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.