Citation Nr: 21008145 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 16-00 208A DATE: February 11, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and unspecified trauma and stressor related disorder, is granted. Service connection for anemia is granted. An initial compensable rating for acne prior to February 21, 2020, is denied. A rating in excess of 10 percent for facial eczema with acne from February 21, 2020, is denied. REMANDED Entitlement to service connection for a sleep disorder, to include sleep apnea, is remanded. Entitlement to an initial rating in excess of 10 percent for right hip strain is remanded. Entitlement to an initial rating in excess of 10 percent for left knee strain is remanded. Entitlement to an initial rating in excess of 10 percent for left ankle strain is remanded. Entitlement to an initial compensable rating for left tibia stress fracture is remanded. FINDINGS OF FACT 1. The evidence is in equipoise on whether the Veteran has a diagnosis of PTSD, major depressive disorder, anxiety disorder, and unspecified trauma and stressor related disorder, which are related to in-service stressors. 2. The Veteran has a diagnosis of anemia, which is related to her service. 3. For the period of appeal prior to February 21, 2020, the acne involved less than five percent of the entire body or exposed areas, and systemic therapy was not required. 4. For the period of appeal from February 21, 2020, the facial eczema with acne involves at least 5 percent but less than 20 percent of exposed affected areas and systemic therapy is not required. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder to include PTSD, major depressive disorder, anxiety disorder, and unspecified trauma and stressor related disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for anemia have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial compensable rating for acne for the period prior to February 21, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806, 7828. 4. The criteria for a rating in excess of 10 percent for facial eczema with acne for the period from February 21, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806, 7828. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 2009 to March 2010. The Board remanded the case in April 2019 for further development, including obtaining outstanding treatment records and scheduling the Veteran for VA examinations. VA treatment records, private treatment records, and Social Security Administration (SSA) records were subsequently associated with the record and the Veteran had a VA skin disorders examination in February 2020. The Board therefore finds there has been substantial compliance with the remand directives with regard to the claims for service connection for an acquired psychiatric disorder and anemia and the increased rating for the skin disability. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or an injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability also may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disability or if it is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439 (1995). 1. Service connection for an acquired psychiatric disorder. The Veteran asserts that she fell and injured herself in training. Afterward, she was unable to participate in certain types of physical training, and she was constantly harassed, threatened, and physically assaulted in the form of pushing. She has flashbacks, depression, sleep impairment, and uses alcohol to get through the day. See the November 2010 and November 2020 statements. Service connection for PTSD generally requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The PTSD diagnosis must be made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Id.; 38 C.F.R. § 4.125(a). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Additionally, lay evidence alone may establish an alleged stressor where: 1) the stressor is related to the Veteran’s fear of hostile military or terrorist activity; 2) a VA psychiatrist, VA psychologist, or VA-contracted psychiatrist or psychologist, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor; 3) the stressor is consistent with the places, types, and circumstances of the Veteran’s service; and 4) there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304 (f)(3). Fear of hostile military or terrorist activity is defined as occurring when a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. After a review of all the evidence, the Board finds that the Veteran’s account her in-service experience be credible and consistent with the circumstances of her service. Service treatment records (STRs) contain record of an October 2011 Physical Evaluation Board (PEB) Proceedings in which the Veteran was noted ot have fallen during a physical training exercise in September 2009. She sustained two stress fractures of the left tibia, which caused chronic left knee and left ankle pain. She also had chronic right hip pain due to overuse syndrome. In an October 2009 Soldier’s Statement, the Veteran asserted that after she fell, she could not get up and a drill sergeant took her dog tags and threatened an Article 15. After the injury, her legs continued to hurt; but when she told her drill sergeants, they told her she was unmotivated and not used to training, and if she went to sick hall too many times, she would be a restart. She was also required to attend road marches despite being on profile, and that she had to keep up with the rest of the formation. Furthermore, following separation from service, the Veteran has consistently reported the in-service trauma to VA clinicians. See Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011) (holding that post service medical records can be used to establish the occurrence of a stressor). VA treatment records indicate that in a May 2010 initial assessment, the Veteran denied having depression, anxiety, or insomnia; however, she stated that she had difficulty sleeping since release form the military, using alcohol to put herself ot sleep, and depression with adjusting to civilian life after being separated due to medical issues. She was referred for evaluation of depressive symptoms. In the mental health evaluation, the Veteran reported being harassed by a drill sergeant, including being pushed and verbally harassed, and not being supported by supervisors when she reported the behavior. The Veteran was assessed by a VA psychologist as having adjustment disorder with depression and anxiety. In June 2010, the Veteran was noted by the same psychologist to have diagnoses of anxiety disorder, depressive disorder, rule out PTSD, and alcohol dependence versus abuse. The Veteran’s lay statements are found to be credible because she has consistently reported the in-service injury and subsequent harassment and threats for the last 11 years, since separating from service. The Veteran is competent to describe observable events, including a personal injury and harassment and threats by superiors. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In light of the Veteran’s consistent statements and the VA treatment records, the Board finds that there is sufficient credible supporting evidence that the in-service events described by the Veteran occurred. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board also finds that there is at probative medical evidence diagnosing the Veteran with acquired psychiatric disorder based on the in-service events. In a February 2011 VA examination, the Veteran reported being physically harassed by a drill sergeant during basic training, followed by months of verbal threats from various other commanding officers. Her symptoms included irritability, avoidance of people involved with the military, nervousness, frequent thoughts of the incident, edginess regarding physical contact, social isolation, physiological reactions to people that remind her of the drill sergeant, and trouble sleeping. She also reported depression, with symptoms of hopelessness, sadness, anger, irritability, trouble sleeping, weight fluctuations, and low self-esteem. The examining psychologist indicated that the Veteran was a reliable historian. The examiner diagnosed PTSD under the criteria in the DSM-IV, major depressive disorder, and alcohol abuse, which she opined was at least as likely as not due to the military trauma she experienced while enlisted. In February 2020, a VA clinical neuropsychologist reviewed the Veteran’s claims file and determined that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria, but that she had another mental disorder diagnosis of other trauma and stressor based disorder. The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and impaired impulse control. The examiner explained that the reported personal assault by superiors in training did not meet criterion A (exposure to actual or threatened death, serious injury, or sexual violence) of the PTSD diagnostic criteria. The examiner opined that the Veteran’s diagnosis was at least as likely as not due to the in-service personal assault, as no other etiology for the distress was reported and another trauma reported by the Veteran was not within her service period. The Board finds the VA examiners’ opinions to be probative, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The 2011 opinion was rendered after reviewing the Veteran’s claims file, soliciting a medical history from the Veteran, and conducting an interview and administering clinical tests to Veteran. The 2020 opinion was rendered after reviewing the Veteran’s claims file, including 10 years of medical evidence. Both examiners provided detailed facts and rationale on which their opinions were based See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner’s access to the claims folder and the Veteran’s history, and the thoroughness and detail of the opinion). There can be no doubt that further medical inquiry could be undertaken with a view toward development of the claim. Specifically, a VA medical opinion could be obtained to clarify the conflicting findings of whether the Veteran had a diagnosis of PTSD. However, under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that the evidence of record is at least in equipoise on whether the Veteran has a diagnosis of an acquired psychiatric disorder, which is due to an in-service injury and subsequent harassment and threats. Thus, in resolving all reasonable doubt in the Veteran’s favor, service connection for an acquired psychiatric disorder is warranted. 2. Service connection for anemia. The Veteran contends that she passed out a few times in service after completing a road march due in part to being forced to march on her injured leg and in part due to anemia. See the November 2020 statement. STRs indicate that a May 2009 entrance examination report is silent for mention of a history or diagnosis of anemia. In September 2009, she was prescribed ferrous sulfate. A February 2010 medical board examination report is silent for mention of a history or diagnosis of anemia. Post-service VA treatment records indicate that in a May 2010 initial visit, the Veteran reported having a history of heavy menses and anemia. In June 2010, she was referred to the gynecology clinic due to iron deficiency anemia and heavy menses. She was started on iron pills three times per day. In August 2010, the Veteran’s iron level was noted to still be low. In a December 2010 VA examination, the Veteran reported that she had been diagnosed with anemia in September 2009, with symptoms of lightheadedness, headaches, easy fatigability, easy bleeding, syncope, and shortness of breath after walking one city block. Results of a CBC (complete blood count) were within normal limits, including normal hemoglobin and hematocrit levels. The examiner concluded that there was no pathology to render a diagnosis of anemia. In August 2011, October 2012, March 2013, and July 2014 VA treatment records, the Veteran was again noted to have iron deficiency anemia. She was advised to continue with the iron supplement. Private treatment records dated in 2014 and 2015 indicate that the Veteran was taking ferrous fumarate (iron oral). In September 2018 and October 2019, the Veteran was noted to have iron deficiency anemia due to chronic blood loss (fibroid uterus) and was prescribed ferrous sulfate with vitamin C. In February 2020, a VA physiatrist reviewed the Veteran’s claims file and determined that the Veteran’s anemia was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that the Veteran was shown to have iron deficiency anemia in service as far back as September 2009 when she was prescribed ferrous sulfate. Post-service records showed ongoing issues with anemia associated with uterine fibroids causing dysfunctional uterine bleeding. The Board finds the February 2020 VA examiner’s opinion to be probative. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinion was rendered after a review of all available records and a rationale was provided. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner’s access to the claims folder and the Veteran’s history, and the thoroughness and detail of the opinion); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board). Thus, as there is at least “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Board finds that this is a situation where the benefit of the doubt rule applies. Ashley, 6 Vet. App. at 59; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. In resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for anemia is warranted. Increased Rating 3. – 4. Increased ratings for facial eczema with acne. The Veteran contends generally that her facial eczema and acne disability is worse than it has been rated. See the June 2012 notice of disagreement, May 2016 VA Form 9. Disability evaluations are 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 the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Here, the Veteran was assigned an initial noncompensable (zero percent) rating for acne effective March 24, 2010, under Diagnostic Code 7828, the rating code for acne. In a July 2020 rating decision, the disability was recharacterized to facial eczema with acne and the rating was increased to 10 percent effective February 21, 2020, under Diagnostic Code 7828-7806. The hyphenated diagnostic code indicates that the acne (Diagnostic Code 7828) is rated by analogy under the criteria for dermatitis or eczema (Diagnostic Code 7806). Diagnostic Code 7828 Under this diagnostic code, superficial acne (comedones, papules, pustules, superficial cysts) of any extent warrants a noncompensable rating. Deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck warrants a 10 percent rating. Deep acne affecting 40 percent or more of the face and neck warrants a 30 percent rating, the maximum rating under Diagnostic Code 7828. Acne may be rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801-7805), depending upon the predominant disability. Diagnostic Code 7806 Diagnostic Code 7806 addresses dermatitis or eczema. Prior to August 13, 2018, a noncompensable rating was assigned when the disorder covered less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating was assigned when the disorder covered 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 was assigned when the disorder covered 20 to 40 percent of the entire body or of exposed areas, or by systemic therapy being required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating was assigned when the disorder covered more than 40 percent of the entire body or exposed areas, or by constant or near-constant systemic therapy during the past 12-month period. The disorder could be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800, or as scars under Diagnostic Codes 7801 through 7805, depending upon the predominant disability. The Federal Circuit addressed the meaning of “systemic” and “topical” for rating skin disabilities under the regulatory criteria in force prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (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 on the facts of each case. Id. at 1356. The new rating criteria in effect from August 13, 2018, include the addition of 38 C.F.R. § 4.118(a), which states that systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. Under the new criteria, disabilities rated under Diagnostic Codes 7806 are to be evaluated under a General Rating Formula for the Skin. A noncompensable rating is warranted where 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. A 10 percent rating is warranted where 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, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, PUVA or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted if at least one of the following applies: characteristic lesions affect more than 40 percent of the entire body or more than 40 percent of exposed areas; 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, was required over the past 12-month period. The disorder can be alternatively be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800, or as scars under Diagnostic Codes 7801 through 7805, depending upon the predominant disability. Amended rating criteria, if favorable to the claim, can be applied only for periods from and after the effective date of the regulatory change. However, a claimant does get the benefit of having both the old regulation and the new regulation considered for the period after the change was made. VAOPGCPREC 3 00 (2000), 65 Fed. Reg. 33422 (2000). An increase in benefits cannot be awarded earlier than the effective date of the change in law pursuant to which the award is made. 38 U.S.C. § 5110(g); 65 Fed. Reg. 33422 (2000). The Board will consider both the former and current rating criteria and apply whichever is more favorable to the Veteran. Analysis The Board finds that an initial compensable rating is not warranted for the period of appeal prior to February 21, 2020 under Diagnostic Code 7828 or Diagnostic Code 7806 (in force prior to August 13, 2018). The Board also finds that a rating in excess of 10 percent for the period of appeal from February 21, 2020, is not warranted under the former or the current version of Diagnostic Code 7806. VA treatment records indicate that in a May 2010 initial evaluation, the Veteran was noted to have a diagnosis of eczema. She had dry skin areas, and denied having any rashes or other complaints. She was prescribed clobetasol propionate gel. In June 2010, the Veteran complained of a rash on the forehead, chin, and sides of the face. She was prescribed metronidazole gel to apply twice a day to affected areas on face. In August 2010, the Veteran was noted to have contact dermatitis and other eczema, for which she was prescribed benzoyl peroxide gel to apply every day. In November 2010, the Veteran had a dermatology consultation. She described alternating acne breakouts that resolved and dry skin. She was noted to have a mild slightly hyperpigmented patch on the right cheek. Her face was otherwise clear without pustules, comedones, papules, or scale. She was prescribed Sulfacet wash and a trial of hydrocortisone ointment to use on her face. In a December 2010 VA examination, the Veteran reported that her eczema involved areas that were exposed to the sun, including the face, hands, and neck. She had itching and shedding on the face, hands, neck, and arms, and crusting on the face and hands. The symptoms occurred intermittently, as often as monthly, with each occurrence lasting approximately two weeks. She had 24 occurrences in the past year, which she treated with topical corticosteroids. The Veteran denied having exudation or ulcer formation, and she had not used UVB, intensive light therapy, PUVA, or electron beam therapy. On examination, the Veteran had superficial acne on the face with comedones and papules. It covered one percent of the face and neck, with hyperpigmentation of less than six square inches and abnormal texture of less than six square inches. There was no ulceration, exfoliation, crusting, tissue loss, induration, inflexibility, hypopigmentation, limitation of motion, or systemic disease. In a May 2011 VA dermatology appointment, the Veteran indicated that the Sulfacet lotion had worked and she was currently using Neutrogena wash and tretinoin with frequent intermittent breakouts. She was noted to have open and close comedones on her face with hyperpigmented papules. Her chest and back were clear. The Veteran was prescribed sulfacetamide sodium cleanser. In December 2011, the Veteran reported that her skin was improving, and she had rare breakouts. In March and April 2012, the Veteran continued to be prescribed hydrocortisone cream, sulfacetamide sulfur wash, and tretinoin. In July and October 2012, she was prescribed hydrocortisone cream and tretinoin. In January 2013, the Veteran was seen for ringworm on her forehead. She was prescribed terbinafine to take for 30 days and clotrimazole cream. VA treatment records indicate that the Veteran was prescribed hydrocortisone cream consistently in 2013. In October 2013, she was prescribed DermaCerin cream for dry skin. The Veteran continued to be prescribed hydrocortisone cream and DermaCerin cream in 2014. Private treatment records dated in 2015 indicate that the Veteran was prescribed triamcinolone cream and ointment. The Veteran had a VA skin diseases examination on February 21, 2020. She reported that she had persistent dark spots on her cheeks and intermittent dark spots on her forehead. The spots were pruritic and she tried to avoid scratching them. She also had acne and outbreaks of eczema on her hands. The Veteran had not been treated with any medication in the past 12 months for any skin condition. On examination, the Veteran was found to have eczema that covered less than five percent of the total body area and 5-20 percent of the exposed body area, and superficial acne that covered less than five percent of the total body area and exposed body area. There was no scaring or disfigurement. There were also no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The Board first finds that a compensable evaluation is not warranted for the Veteran’s acne prior to February 21, 2020. For a 10 percent rating under Diagnostic Code 7828, the acne must be deep. For a 10 percent rating under Diagnostic Code 7806 in force prior to August 13, 2018, the disorder must cover 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. For a 10 percent rating under Diagnostic Code 7806 in force from August 13, 2018, a 10 percent rating is warranted for 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 for a total duration of less than 6 weeks over the past 12-month period. Here, the evidence for this time period indicates that the Veteran’s acne was superficial and covered only one percent of the total body and/or exposed body area. The Board acknowledges that the Veteran was consistently prescribed various topical creams between 2010 and 2015; however, these creams were for application to the face and forehead and the Board does not find that the face and forehead to be a large enough scale “such that it affected the body as a whole” to constitute systemic therapy. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). There is also no evidence of any systemic manifestations of the acne. As such, a compensable rating prior to February 21, 2020, is not warranted. The Board next finds that a rating in excess of 10 percent is not warranted for the eczema with acne from February 21, 2020. For a higher 30 percent rating under Diagnostic Code 7828, the evidence must show that there is deep acne affecting 40 percent or more of the face or neck. For a higher 30 percent rating under the prior version of Diagnostic Code 7806, the disorder must cover 20 to 40 percent of the entire body or of exposed areas, or systemic therapy being required for a total duration of six weeks or more, but not constantly, during the past 12-month period. For a higher 30 percent rating under the current version of Diagnostic Code 7806, the disorder must involve 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. Here, the evidence for this time period indicates that the Veteran’s acne is superficial and the eczema with acne covers at least 5 percent but less than 20 percent. There is no evidence of any treatment for the condition. As such, a rating in excess of 10 percent is not for application based upon Diagnostic Codes 7828 or 7806. The Board has considered other potentially applicable Diagnostic Codes, including those for disfigurement of the head, face, or neck (Diagnostic Code 7800). However, there is no indication that the eczema or acne cause scars or disfigurement. Rather, the February 2020 VA examiner specifically reported that there was no disfigurement or scarring. As such, an increased rating is not for application based upon Diagnostic Codes 7800 to 7805. REASONS FOR REMAND 1. Entitlement to service connection for a sleep disorder is remanded. In her August 2010 application for disability compensation, the Veteran indicated that service connection was warranted for sleep apnea. She has also indicated, however, that she has trouble sleeping due to her acquired psychiatric disorder, for which service connection was granted herein. See the November 2010 statement, February 2011 VA psychiatric disorder examination report, February 2020 VA PTSD examination report. VA treatment records indicate that the Veteran has a diagnosis of insomnia and that she consistently reported having at least intermittent difficulty falling asleep and staying asleep. It is unclear whether the Veteran has been diagnosed with sleep apnea. It is also unclear whether any sleep disorder, to include sleep apnea and/or insomnia, is attributable to the service-connected acquired psychiatric disorder, or whether it is a manifestation of a separate disability. As such, the Board finds that a medical opinion should be obtained to determine the nature and etiology of any diagnosed sleep disorder(s), to include scheduling the Veteran for a VA examination if necessary. 2. Entitlement to an increased rating for right hip strain is remanded. 3. Entitlement to an increased rating for left knee strain is remanded. 4. Entitlement to an increased rating for left ankle strain is remanded. 5. Entitlement to an increased rating for left tibia stress fracture is remanded. The Veteran was most recently afforded VA examinations of the right hip, left knee, left ankle, and left tibia in December 2015. The Board finds that these examinations are not sufficient bases on which to adjudicate the increased rating claims. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of 38 C.F.R. § 4.59. That final sentence of 38 C.F.R. § 4.59 directs that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. The 2015 VA examinations were conducted prior to Correia, and thus did not include necessary findings. As such, remand is necessary to ensure that the VA examinations comply with the requirements of the recent holding in Correia. The examiner(s) should also determine whether it is possible to provide retrospective medical opinions for the 2015 examinations. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). Therefore, on remand, the Veteran should be afforded VA examinations to ascertain the severity and manifestations of her right hip, left knee, left ankle, and left tibia disabilities. The matters are REMANDED for the following action: 1. Send the claims file to an appropriate VA examiner and ask the examiner to review the record and prepare a medical opinion on the etiology of the claimed sleep disorder. After reviewing the entire record, the examiner should note any current sleep diagnosis, to include sleep apnea and/or insomnia. The examiner should specify what sleep symptoms are attributable to the service-connected acquired psychiatric disorder as distinguished from other diagnosed sleep conditions. If the various manifestations and degree of disability attributable to the sleep disorder cannot be distinguished from the other disabilities, the examiner should so indicate and explain the reasons for that conclusion. For each sleep disorder that the examiner finds is a separate disability from the service-connected acquired psychiatric disorder, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that the sleep disorder had its origin during, or is in some way the result of, the Veteran’s periods of active military service. The examiner should also opine on whether it is at least as likely as not that any sleep disorder is proximately due to the service-connected acquired psychiatric disorder. If not, did any sleep disorder increase in severity beyond its natural progression by the service-connected psychiatric disorder? All opinions and conclusions expressed must be supported by a complete rationale in a report. The examiner should reconcile any opinion with the service treatment records, post-service treatment records, and lay statements. If the VA examiner determines that an examination is necessary in order to render the requested medical opinions, the AOJ should schedule the Veteran for such an examination. 2. Schedule the Veteran for a VA examination(s) to determine the severity and manifestations of the service-connected right hip, left knee, left ankle, and left tibia disabilities. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is asked to review all relevant records and conduct a clinical evaluation. Based on this review, the examiner is asked to provide an assessment of the current nature of the Veteran’s right hip, left knee, left ankle, and left tibia. Ranges of motion (ROM) should be tested actively and passively, in weight-bearing and nonweight-bearing, and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In addition, the VA examiner should comment on whether ROM measurements for active motion, passive motion, weight-bearing, and nonweight-bearing can be estimated for the period prior to the examination. If the examiner is unable to provide a retrospective opinion as to these specific ROM findings, he or she should clearly explain so in the report. (Continued on the next page)   A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Nelson 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.