Citation Nr: 21071726 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-45 614 DATE: December 1, 2021 ORDER A rating of 70 percent for posttraumatic stress disorder (PTSD) prior to March 1, 2019, is granted. A rating in excess of 40 percent for degenerative arthritis of the lumbar spine as of July 18, 2016, and prior to September 22, 2016, is denied. A rating of 40 percent for degenerative arthritis of the lumbar spine as of September 22, 2016, and prior to March 1, 2019, is granted. A compensable rating for pseudofolliculitis barbae is denied. REMANDED Entitlement to a rating in excess of 50 percent for PTSD as of March 1, 2019, is remanded. Entitlement to a rating in excess of 40 percent for degenerative arthritis of the lumbar spine to include intervertebral disc syndrome (IVDS) and minimal dextroscoliosis thoracic spine from March 1, 2019, is remanded. Entitlement to service connection for a gastrointestinal condition is remanded. FINDINGS OF FACT 1. Prior to March 1, 2019, the Veteran's PTSD manifested through occupational and social impairment, with deficiencies in most areas. 2. As of July 18, 2016, and prior to September 22, 2016, the weight on the competent evidence reflects that the Veteran's degenerative arthritis of the lumbar spine was not manifested by unfavorable ankylosis of the entire thoracolumbar spine nor its functional equivalent. 3. As of September 22, 2016, and prior to March 1, 2019, the weight of the competent and probative evidence is at least in equipoise as to whether the Veteran's degenerative arthritis of the lumbar spine was manifested by forward flexion of the thoracolumbar spine 30 degrees or less. 4. Throughout the period on appeal, the Veteran's pseudofolliculitis barbae affected less than 5 percent of the exposed areas affected on the face and neck and less than 5 percent of total body area. CONCLUSIONS OF LAW 1. Prior to March 1, 2019, criteria for a rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 2. As of July 18, 2016, and prior to September 22, 2016, the criteria for a rating in excess of 40 percent for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C. § 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5242-5237. 3. As of September 22, 2016, and prior to March 1, 2019, the criteria for a rating of 40 percent, but no higher, for degenerative arthritis of the lumbar spine have been met. 38 U.S.C. § 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5242-5237. 4. The criteria for entitlement to an initial compensable rating for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7813. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1988 to October 2011. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Procedurally, the Board notes that the Veteran requested a videoconference hearing before a Veterans Law Judge (VLJ). 08/24/2017, Form 9 (checking box 8B and requesting a hearing). However, the Veteran later withdrew the hearing request. 03/23/2021, VA 21-4138. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of the initial disability rating assigned after a grant of service connection, the evidence since the effective date of the award must be evaluated and staged ratings must be considered. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct periods during the course of the appeal. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 1. Entitlement to a rating in excess of 30 percent for PTSD prior to March 1, 2019. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The United States Court of Appeals for Veterans Claims (Court) has observed that the listed symptoms are examples of the type and degree of the manifestations of a mental disability required for a given disability rating, and that "the presence of all, most, or even some, of the enumerated symptoms" is not required to support a disability rating. Mauerhan, 16 Vet. App. at 442. Accordingly, it is not sufficient for the Board to simply match the symptoms listed in the rating criteria against those exhibited by a veteran. Rather, "VA must engage in a holistic analysis" of the severity, frequency, and duration of the signs and symptoms of the veteran's mental disorder, determine the level of occupational and social impairment caused by those signs and symptoms, and assign an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, in pertinent part, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent is warranted if the Veteran experiences occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent is warranted when the Veteran experiences 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 work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A December 2016 rating decision granted service connection for PTSD and assigned a 30 percent rating, effective July 18, 2016. As noted above, in order to warrant a higher rating, the Veteran's disability would have to be manifested by at least occupational and social impairment with reduced reliability and productivity. The treatment records reveal that the Veteran's employer accommodates his psychiatric symptoms by scheduling the Veteran to work at night when he does not have to be around other people. 03/24/2015, Medical Treatment Record Non-Government Facility. A September 2016 PTSD disabilities benefits questionnaire (DBQ) was completed by a private clinician. The Veteran's noted symptoms included: depressed mood; anxiety; panic attacks that occurred weekly or less often; panic attacks that occur more than once a week; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material while forgetting to complete tasks; memory loss for names of close relatives, own occupation, or own name; flattened affect; gross impairment in thought process or communication; disturbances of motivation and mood; difficulty in establishing and maintain effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; obsessional rituals which interfere with routine activities; persistent delusions or hallucinations; persistent danger or hurting self or others; neglect of personal appearance and hygiene; and, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The clinician noted that the Veteran resides with his spouse and child. The clinician did not initially provide a clear assessment regarding the Veteran's occupational and social impairment, rather suggesting a range of impairment between occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (which warrants a 30 percent rating), occupational and social impairment with reduced reliability and productivity (which warrants a 50 percent rating), and occupational and social impairment, with deficiencies in most areas (which warrants a 70 percent rating). 09/23/2016, C&P Exam. Subsequently, the same clinician that completed the September 2016 PTSD DBQ further clarified that the Veteran has severe impairment in functioning with significant thinking and concentration problems accompanied by prominent distress and dysphoria. Further, the Veteran demonstrates unusual complaints of somatic impairment, as well as dysfunctional thinking pattern that includes magical and possible delusional beliefs. 10/06/2017, Medical Treatment Record Non-Government Facility. After review of the competent and probative evidence, the Board finds the Veteran's PTSD most nearly approximated the criteria for a 70 percent initial rating, prior to March 1, 2019. Throughout this period, the Veteran has had a history of obsessional rituals which interfere with routine activities, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and neglect of personal appearance and hygiene. The Board does not find that a higher rating of 100 percent is more nearly approximated prior to March 1, 2019. In that regard, Board acknowledges that the Veteran's private clinician noted evidence of delusional beliefs and thought processes, persistent danger of hurting self or others, as well as memory loss for names of closest relatives, own occupation, or own name. However, upon considering the aforementioned evidence, the private clinician also opined that the Veteran did not exhibit total occupational and social impairment. Moreover, the relevant competent evidence does not tend to show incidents of the Veteran posing a threat to himself or others, and that the record consistently demonstrates that the Veteran does not have suicidal or homicidal ideation. Furthermore, despite having difficulties, the Veteran did not demonstrate a total inability to maintain relationships, as the Veteran maintains a relationship with his spouse and child. See Total, Merriam-Webster, https://www.merriam-webster.com/dictionary/total (defining the adjective "total" as, among other entries, absolute). As such, the Board finds that when viewed against other evidence of record, to include the treatment records, that the Veteran's overall disability picture is most nearly approximated by the 70 percent evaluation, and not the 100 percent. Therefore, looking at the totality of the Veteran's PTSD disability picture, the Board finds that the preponderance of the evidence warrants a rating of 70 percent prior to March 1, 2019. The period from March 1, 2019 will be addressed in the Remand section below. 2. Entitlement to a rating in excess of 40 percent for degenerative arthritis of the lumbar spine as of July 18, 2016, and prior to September 22, 2016. The Veteran contends that he is entitled to a rating in excess of 40 percent for degenerative arthritis of the lumbar spine as of July 18, 2016, and prior to September 22, 2016, evaluated under Diagnostic Codes 5242-5237. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. This is because "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss." Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See Plate V, 38 C.F.R. § 4.71a, Note (2). 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." Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In this instance, the evidence does not support a change to the assigned rating. As of July 18, 2016, and prior to September 22, 2016, the Veteran's lumbar spine disability is rated as 40 percent disabling. As noted above, in order to warrant a higher rating, the Veteran's disability would have to be manifested by unfavorable ankylosis of the entire thoracolumbar spine. A September 2015 VA examination conducted ROM testing and noted forward flexion of 65 degrees. Pain was noted on forward flexion, causing functional loss. The examiner found that the Veteran did not have ankylosis or muscle atrophy. Although the Veteran was noted to have intervertebral disc syndrome (IVDS), the report reflects that the Veteran did not have any incapacitating episodes in the past twelve months. The examiner noted radiculopathy symptoms involving the sciatic nerve bilaterally. 09/11/2015, C&P Exam. The private treatment records reveal that, on August 15, 2016, the Veteran was noted to have forward flexion of 20 degrees. 10/07/2016, Medical Treatment Record Non-Government Facility. After reviewing the pertinent evidence, the Board finds that it does not reflect a disability picture with functional limitation significant enough to more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine. Therefore, the criteria for a disability rating higher than 40 percent as of July 18, 2016, and prior to September 22, 2016, are not met. 3. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the lumbar spine as of September 22, 2016, and prior to March 1, 2019. The Veteran contends that he is entitled to a rating in excess of 20 percent as of September 22, 2016, and prior to March 1, 2019, evaluated under Diagnostic Codes 5242-5237. And, as of September 22, 2016, and prior to March 1, 2019, the Veteran's lumbar spine disability is rated as 20 percent disabling. As noted above, in order to warrant a higher rating, the Veteran's disability would have to be manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The Board notes that the basis of the effective date of September 22, 2016, for the 20 percent disability rating is the examination conducted on August 22, 2016. See 12/07/2016, Rating Decision. An August 2016 VA examination conducted ROM testing and noted forward flexion of 65 degrees. Pain was not noted in ROM testing. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. The examiner found that the Veteran did not have ankylosis or muscle atrophy. Although the Veteran was noted to have intervertebral disc syndrome (IVDS), the report reflects that the Veteran did not have any incapacitating episodes in the past twelve months. The examiner noted radiculopathy symptoms involving the sciatic nerve bilaterally. The Veteran did report daily flareups lasting one hour. However, the examination was not conducted during a flareup and the examiner indicated it was not feasibly to describe additional limitations during flareups in terms of range of motion. 08/22/2016, C&P Exam. Nonetheless, the Board notes that ROM testing was conducted on August 15, 2016, just days prior to the VA examination on August 22, 2016. At that time, the Veteran was described to be experiencing sharp pain that worsened with activity, which aligns with the Veteran's description of his flareups during the August 2016 VA examination. The Veteran was noted to have forward flexion of 20 degrees. 10/07/2016, Medical Treatment Record Non-Government Facility. The Board finds that a rating of 40 percent, but no higher, is warranted for degenerative arthritis of the lumbar spine as of September 22, 2016, and prior to March 1, 2019. Specifically, the August 2016 VA examination, which is the basis of the effective date of September 22, 2016 for the current 20 percent rating, noted that the Veteran experiences daily flareups lasting one hour. And, the Veteran's forward flexion during was measured during flareup just days prior to the August 2016 VA examination, which noted forward flexion of 20 degrees. Based on these pieces of evidence, the Board finds that a 40 percent disability rating is warranted due to forward flexion of the thoracolumbar spine 30 degrees or less during flareups. For example, the Veteran had 5/5 strength on the left and right sides. The Board does not find that a higher rating of 50 percent is more nearly approximated as of September 22, 2016, and prior to March 1, 2019, as the record does not tend to show unfavorable ankylosis of the entire thoracolumbar spine or the functional equivalent thereof. See Chavis v. McDonough, 34 Vet. App. 1, 20-23 (2021) (holding that holding that ankylosis of a joint can be demonstrated by its functional equivalent). Entitlement to a rating in excess of 40 percent from March 1, 2019 is addressed in the Remand section below. 4. Entitlement to a compensable rating for pseudofolliculitis barbae. The Veteran seeks an initial compensable rating for pseudofolliculitis barbae. In this instance, the Veteran's pseudofolliculitis barbae is rated by analogy to the rating code that includes disabilities such as dermatophytosis tinea barbae (Diagnostic Code 7813). This code states the disability is to be rated under the General Rating Formula for the Skin. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction (AOJ) on or after August 13, 2018. 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. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, 38 C.F.R. § 4.118, Diagnostic Code 7813 rated dermatophytosis tinea barbae as disfigurement of the head, neck, or fact (DC 7800), scars (DCs 7801-7805), or dermatitis (DC 7806), depending on the predominant disability. Initially, while acknowledging the criteria pertaining to Diagnostic Codes 7800-7805 ("former" and amended criteria under 73 Fed. Reg. 54, 708 (Sept. 23, 2008)), the Board notes that there is no evidence the Veteran's service-connected pseudofolliculitis barbae manifested by scarring or disfigurement. Thus, Diagnostic Codes 7800, 7801, 7802, 7803, 7804, and 7805 are not for application. Under Diagnostic Code 7806 (applicable to dermatitis or eczema), a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 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. Additionally, effective August 13, 2018, 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. Additionally, 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 (Code 7800) or scars (Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. The Court has found that the Board must make an explicit finding whether treatment used was "constant or near-constant systemic therapy," or discuss whether treatments other than corticosteroids or immunosuppressive therapies can constitute such therapies under DC 7806. See Warren v. McDonald, 28 Vet. App. 194, 198 (2016); see Burton v. Wilkie, 30 Vet. App. 286, 290 (2018) (defining "systemic" as "pertaining to or affecting the body as a whole" and "therapy" is defined as "treatment of diseases"). In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit held 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, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Warren v. McDonald, 28 Vet. App. 194, 197 (2016), the Court held that the types of systemic treatment that are compensable under Diagnostic Code 7806 are not limited to "corticosteroids or other immunosuppressive drugs;" rather, compensation is available for "all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs." Finally, in Burton v. Wilkie, 30 Vet. App. 286, 291 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. Turning to the evidence, a July 2015 VA examination noted a diagnosis of pseudofolliculitis barbae, with the onset occurring during the Veteran's period of active service. Regarding treatment, the examiner reported that the Veteran had not been treated during the last 12 months with oral or topical medications. The examiner further indicated that the Veteran had not had any treatments or procedures other than systemic or topical medications in the past 12 months. 07/16/2015, C&P Exam. An August 2016 VA examination noted a diagnosis of pseudofolliculitis barbae. The Veteran reported that he had been dealing with bumps to the bearded area of his face since active duty. The Veteran indicated that he had not sought medical treatment for this condition since separation from active service. Regarding treatment, the examiner reported that the Veteran had not been treated during the last 12 months with oral or topical medications. The examiner further indicated that the Veteran had not had any treatments or procedures other than systemic or topical medications in the past 12 months. Finally, the examiner reported that there was evidence of pseudofolliculitis barbae on the Veteran's beard area, and that it covered 5 percent of the exposed areas affected and less than 5 percent of the total body area. 08/22/2016, C&P Exam. A March 2019 VA examination noted a diagnosis of pseudofolliculitis barbae. Regarding treatment, the examiner reported that the Veteran had not been treated during the last 12 months with oral or topical medications. The examiner further indicated that the Veteran had not had any treatments or procedures other than systemic or topical medications in the past 12 months. Finally, the examiner reported that there was evidence of pseudofolliculitis barbae and that it covered 5 percent of the exposed areas affected and less than 5 percent of the total body area. 03/19/2019, C&P Exam. The Veteran waived the right to AOJ review of this additional evidence. 08/29/2019, Correspondence. Here, the Board finds that the preponderance of the evidence weighs against the assignment of an initial compensable rating for pseudofolliculitis barbae. The criteria for a compensable rating have not been more nearly approximated under any of the potentially applicable rating codes. In this regard, all of the VA examinations found that the Veteran's pseudofolliculitis barbae affected less than 5 percent of the exposed area affected, and less than 5 percent of the entire body. All of the VA examiners further indicated that the Veteran's pseudofolliculitis barbae did not result in scarring or disfigurement. Finally, all of the VA examinations made note of the Veteran's report that he had not sought any medical treatment for this condition. The Board acknowledges the Veteran's belief that he is entitled to a higher initial rating for his pseudofolliculitis barbae, but finds that his contentions are outweighed by the competent medical findings of record. That is, the Board assigns greater probative value and weight to the pertinent medical findings on the VA examination reports and treatment records, than to the Veteran's general assertion that he is entitled to an initial compensable rating. Ultimately, upon physical examination, the Veteran' pseudofolliculitis barbae was shown to affect less than 5 percent of his total body, less than 5 percent of the total exposed area, and did not require the use of systemic therapy. Moreover, to the extent that the Veteran alleges that he is entitled to a higher initial rating due to symptoms such as break outs, irritation, itching, redness and swelling, it is noted that such symptoms are contemplated under the current rating. Accordingly, the Board finds that a preponderance of the evidence is against an initial compensable rating for pseudofolliculitis barbae, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 5. Entitlement to a rating in excess of 50 percent for PTSD as of March 1, 2019, is remanded. After the issuance of the August 2017 Statement of the Case (SOC) denying a rating in excess of 30 percent for PTSD, the RO issued a May 2019 rating decision granted a 50 percent disability rating for PTSD, effective March 1, 2019. However, the RO did not issue a Supplementary Statement of Case (SSOC) with regards to the Veteran's claim for an increased rating for PTSD. The grant of a 50 percent rating effective March 1, 2019, in the May 2019 rating decision did not resolve the Veteran's claim for an increased rating. As such, the 50 percent rating is not a grant in full of the benefits sought by the Veteran because he did not specifically state that he would be satisfied with 50 percent. Therefore, a remand is necessary for the issuance of an SSOC. 38 C.F.R. § 19.31 (2020) 6. Entitlement to a rating in excess of 40 percent for degenerative arthritis of the lumbar spine to include IVDS and minimal dextroscoliosis thoracic spine as of March 1, 2019, is remanded. After the issuance of the August 2017 Statement of the Case (SOC) denying a rating in excess of 40 percent for a lumbar spine disability as of July 18, 2016, and prior to September 22, 2016, and denying a rating in excess of 20 percent thereafter, the RO issued a May 2019 rating decision granted a 40 percent disability rating for a lumbar spine disability, effective March 1, 2019. However, like with the PTSD issue, the RO did not issue a Supplementary Statement of Case (SSOC) with regards to the Veteran's claim for an increased rating for a lumbar spine disability. The grant of a 40 percent rating effective March 1, 2019, in the May 2019 rating decision did not resolve the Veteran's claim for an increased rating. As such, the 40 percent rating is not a grant in full of the benefits sought by the Veteran because he did not specifically state that he would be satisfied with 50 percent. Therefore, a remand is necessary for the issuance of an SSOC. 38 C.F.R. § 19.31 (2020) 7. Entitlement to service connection for a gastrointestinal condition is remanded. The Veteran contends that his stomach condition is related to his period of active service. An August 2016 VA examination noted a diagnosis of gastroesophageal reflux disease (GERD). The Veteran reported that he developed a stomach condition in 2011 and the medical records show a diagnosis of GERD in 2013. The Veteran further contended his gastroenteritis is related to his GERD condition. The examiner opined that the Veteran's gastroenteritis is less likely than not related to his period of active service in Southwest Asia. The rationale was based on the Veteran having been diagnosed with GERD, which purportedly has a clear and specific etiology and diagnosis. However, the examiner did not clarify or opine as to the etiology of the Veteran's GERD condition. 08/22/2016, C&P Exam; 08/22/2016, C&P Exam (medical opinion). As such, the Board finds the August 2016 VA examination to be incomplete and that an addendum opinion is necessary to determine the nature and etiology of the Veteran's gastrointestinal condition. Also, based on the relevant evidence of record, to include the 2016 VA examination report, the Board has recharacterized and broadened the claim of service connection for gastroenteritis as entitlement to service connection for a gastrointestinal disability. These matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. After completing directive #1, schedule the Veteran for an examination and opinion from an appropriate clinician to determine the nature and etiology of each of the Veteran's gastrointestinal disorders. The clinician is to review the virtual file, including a copy of this Remand. The clinician is to provide an opinion whether any current gastrointestinal disorder, such as GERD and gastroenteritis is at least as likely as not related to an in-service injury, event, or disease. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). If any medical literature is cited, then provide a copy of it or a link to it. (Continued on the next page) 2. Thereafter, readjudicate the issues on appeal, to include the higher ratings for PTSD and degenerative arthritis of the lumbar spine. If the determinations remain unfavorable to the Veteran, he and his representative are to be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David Han 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.