Citation Nr: 21011264 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 17-38 784 DATE: March 1, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for polycystic ovarian syndrome (PCOS), with uterine leiomyoma, (hereafter “gynecological disability”) prior to October 23, 2017, and since January 1, 2018, exclusive of when a temporary total disability evaluation was assigned from October 24, 2017 to December 31, 2017 based on surgery necessitating convalescence, is denied. Entitlement to a rating in excess of 50 percent for migraine headaches is denied. Entitlement to an earlier effective date for the service-connected migraine headaches is denied. A disability rating of 50 percent, but no higher, prior to September 2, 2015 for service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to a disability rating in excess of 50 percent from September 2, 2015 to November 29, 2016 for service-connected PTSD is denied. The reduction of the service-connected right knee instability disability from 20 percent to a noncompensable rating, effective March 13, 2017, was improper, and the 20 percent rating is restored. REMANDED Entitlement to service connection for bursitis of the right foot is remanded. Entitlement to service connection for bursitis of the left toes is remanded. Entitlement to service connection for bursitis of the left foot is remanded. Entitlement to service connection for bursitis of the right toes is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected right wrist peripheral autonomic neuropathy is remanded. FINDINGS OF FACT 1. For the periods prior to October 23, 2017, and since January 1, 2018, the Veteran is in receipt of the maximum allowed evaluations for a gynecological condition. 2. The Veteran’s service-connected migraine headaches are shown to have caused very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; these symptoms are contemplated by the applicable rating criteria. 3. The Veteran did not appeal an August 2015 rating decision, from the RO, which denied entitlement to service connection for migraine headaches; no subsequent claim of service connection was received prior to December 12, 2016. 4. For the period prior to September 2, 2015, the Veteran’s PTSD is manifested by such symptoms as panic attacks more than once a week and disturbances of motivation and mood; more severe impairment has not been shown. 5. For the period from September 2, 2015 to November 29, 2106, the Veteran’s PTSD has not been shown to produce occupational and social impairment with deficiencies in most areas. 6. The reduction in the 20 percent rating assigned to the service-connected right knee instability disability was not supported by evidence demonstrating improvement in the disability at the time of the reduction. CONCLUSIONS OF LAW 1. For the period prior to October 23, 2017, and since January 1, 2018, the criteria for a disability rating in excess of 30 percent for a service-connected gynecological disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.116, Diagnostic Code 7615. 2. The criteria for a rating in excess of 50 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.124a, Diagnostic Code 8100. 3. Entitlement to an earlier effective date for migraine headaches is denied. 38 U.S.C. §§ 1101, 1155, 5110; 38 C.F.R. §§ 3.155, 3.400, 20.201. 4. For the period prior to September 2, 2015, the criteria for a 50 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. For the period from September 2, 2015 to November 29, 2106, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411. 6. The reduction of the rating for the service-connected right knee instability from 20 percent to a noncompensable disability rating, effective March 13, 2017, was improper, and the 20 percent rating is restored. 38 U.S.C. §§ 1155, 5112; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2000 to September 2004. In July 2019, the Board denied, in part, the issues of entitlement to an initial rating in excess of 30 percent prior to September 1, 2015, in excess of 50 percent from September 2, 2015 to November 29, 2016, and in in excess of 70 percent since November 30, 2016 for service-connected PTSD, entitlement to an initial rating in excess of 10 percent for service-connected right wrist peripheral autonomic neuropathy, and found that the reduction of the 20 percent disability rating for a service-connected right knee instability disability, effective March 13, 2017, was proper. The Veteran appealed the July 2019 decision, in part, to the United States Court of Appeals for Veterans Claims (Court). In a Joint Motion for Partial Remand (JMR) dated in July 2020, the Court vacated the Board’s decision of the appealed issues and remanded the claims to the Board for compliance with the terms of the JMR. Further, the remaining issues on appeal are before the Board of Veterans’ Appeals (Board) on appeal of an October 2018 rating decision of the Department of Veterans Affairs (VA). Of note, in this rating decision, the RO granted the Veteran a temporary total disability rating for her service-connected polycystic ovarian syndrome from October 24, 2017 to December 31, 2017, under 38 C.F.R. § 4.30 based on surgery necessitating convalescence. Effective January 1, 2018, the presurgical 30 percent rating was reestablished. The Veteran continues her appeal. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). 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 required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Entitlement to a disability rating in excess of 30 percent for a gynecological disability prior to October 23, 2017, and since January 1, 2018, is denied. The Veteran’s gynecological disability is currently rated pursuant according to the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs and 38 C.F.R. § 4.116, Diagnostic Code 7615, which provides that a 10 percent disability rating where symptoms require continuous treatment and a maximum 30 percent rating when symptoms are not controlled by continuous treatment. As noted above, the Veteran has been granted a period of temporary total disability; as such, that period is not at issue. There is no evidence of record, including that described below, indicating further convalescence beyond the period noted above. 38 C.F.R. § 4.30. The Board has reviewed all relevant evidence, to include lay statements and private and VA medical records, and the VA January 2017, February 2018 and August 2018 VA examination reports. VA treatment records reflect that the Veteran experiences heavy and irregular bleeding. A private examiner medical record, dated in October 2017, shows that assessments of polycystic ovaries and excessive or frequent menstruation were provided. The January 2017 VA gynecological conditions examination report shows that diagnoses of dysfunctional uterine bleeding, uterine leiomyoma, and right ovarian cyst were provided. The Veteran experienced symptoms of intermittent severe pain, pelvic pressure, irregular menstruation, and frequent or continuous menstrual disturbances, and noted difficulty having sex due to pain and spontaneous bleeding. The Veteran’s condition required treatment or medication. The Veteran noted that she was unable to conceive due to her condition. The VA examiner indicated that the symptoms were not controlled by continuous treatment for the conditions of the vagina, cervix, uterus, fallopian tubes and ovaries. The Veteran experienced uterine fibroids and irregular and frequent menstrual disturbances. It was noted that the Veteran had a complex left adnexal mass, a markedly enlarged left and mildly enlarged right ovary, and multiple intramural and subserosal uterine leiomyomata. PCOS was noted regarding the Veteran’s fallopian tubes. It was reported that the Veteran had not undergone a hysterectomy, an oophorectomy or had complete atrophy of one or both ovaries. The Veteran’s condition did not impact her ability to work. The February 2018 VA gynecological conditions examination report shows that moderate, intermittent pain due to her condition. It was noted that the Veteran had undergone laparoscopic surgery to remove fibroids and unblock her fallopian tubes in 2017. Frequent menstrual disturbances and uterine fibroids were noted. It was reported that the Veteran had not undergone a hysterectomy or an oophorectomy. The Veteran’s condition did not impact her ability to work. The August 2018 VA gynecological conditions examination report shows symptoms of moderate intermittent pain, irregular menstruation, and dysmenorrhea associated with ovarian dysfunction. It was noted that the Veteran took medication for her symptoms and that her conditions of the uterus and ovaries were not controlled by continuous treatment. It was reported that the Veteran had not undergone a hysterectomy, an oophorectomy, or had complete atrophy of one or both ovaries. The Veteran’s condition did not impact her ability to work. The Board finds that a rating in excess of 30 percent for the Veteran’s gynecological disability is not warranted. Notably, the Veteran’s disability is rated 30 percent disabling. As noted above, a 30 percent rating is the maximum rating assignable under Diagnostic Code 7615. As such, a rating in excess of 30 percent is not permitted under the General Rating Formula. The Board notes that disability ratings for gynecological conditions may be assigned pursuant to Diagnostic Codes 7610-7625 & 7627-7629. Diagnostic Codes 7610-7614, 7620, 7622 are not raised by the record, because the maximum disability rating available under these Diagnostic Codes is 30 percent; and the Veteran has already been assigned a disability rating of at least 30 percent throughout the period on appeal under Diagnostic Code 7615. Next, Diagnostic Codes 7621 (prolapse of uterus), 7623 (surgical complications of pregnancy), 7624 (recto-vaginal fistula), 7625 (urethrovaginal fistula), 7627 (malignant neoplasms), 7628 (benign neoplasms), and 7629 (endometriosis) are not raised by the record, as the Veteran has not been diagnosed with any of the above noted disabilities. 38 C.F.R. § 4.118, Diagnostic Codes 7610-7625 & 7627-7629; See VA examination reports. The Board notes that under Diagnostic Code 7617, a total disability rating is assigned for three months after the complete removal of both ovaries and the uterus, and a disability rating of 50 percent is assigned thereafter. Under Diagnostic Code 7618, a total disability rating is assigned for three months after the removal of the uterus, and a disability rating of 30 percent is assigned thereafter. Under Diagnostic Code 7619, a total disability rating is assigned for three months after the removal of the ovaries, and a disability rating of 30 percent is assigned thereafter if both ovaries were removed. However, the Veteran’s surgical record, dated on October 24, 2017, does not indicate that the Veteran did underwent surgery to remove either her uterus and/or her ovaries. A higher rating would only be available on an extraschedular basis. In order to warrant entitlement to an extraschedular rating, the diagnostic criteria must not reasonably describe the severity and symptomatology of the Veteran’s gynecological disability. A review of the evidence reveals no indication that the Veteran’s service-connected disability has resulted in any additional symptomatology not contemplated by the 30 percent rating criteria. In short, there is nothing exceptional or unusual about the Veteran’s gynecological condition, in relation to the applicable diagnostic criteria, and referral for an extraschedular rating is not warranted. See Morgan v. Wilkie, 31 Vet. App. 162 (2019). Lastly, the Board notes that in her Notice of Disagreement (NOD), the Veteran asserted that she was entitled to special monthly compensation (SMC) for the loss of use of a creative organ. Subsequently, in an April 2020 rating decision, the RO granted SMC based on the loss of use or creative organ, effective December 12, 2016. As such, this matter is not before the Board. As the preponderance of the evidence is against the claim for a rating in excess of 30 percent for a gynecological condition for the periods prior to October 23, 2017, and since January 1, 2018, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a disability rating in excess of 50 percent for migraine headaches is denied. The Veteran contends that a higher evaluation is warranted for her migraine headaches. Her service-connected disability is rated as 50 percent under 38 C.F.R. § 4.71a, Diagnostic Code 8100. Under Diagnostic Code 8100, headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated as 10 percent disabling. A 30 percent disability rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. Headaches manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent disability rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Neither the disability rating criteria nor the United States Court of Appeals of Veterans Claims (Court) has defined the term “prostrating.” See Fenderson v. West, 12 Vet. App. 119 (1999). According to Merriam Webster’s Collegiate Dictionary, 11th Edition (2007), p. 999, “prostration” is defined as “complete physical or mental exhaustion.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary, 31st Edition, p. 1554, in which “prostration” is defined as “extreme exhaustion or powerlessness.” The words “severe,” as used in the various Diagnostic Codes, are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Veteran was afforded a VA headaches examination in July 2018. The Veteran reported experiencing headaches in the front of her head, spreading to her right temple. She noted dull to throbbing pain, rated as 9 out of 10, with associated aura, nausea, and photophobia. Daily medication use was noted. Symptoms of pulsating or throbbing head pain, with nausea, sensitivity to light and sound and changes in vision were found. The migraines lasted 1-2 days and occurred more than once per month. The headache pain was characterized as prostrating and productive of severe economic inadaptability. No other findings, complications or symptoms were noted. The Veteran noted that she sometimes missed work due to her condition. The Board notes that the maximum schedular rating under Diagnostic Code 8100 for migraine headaches is 50 percent. A higher rating would only be available on an extraschedular basis. In order to warrant entitlement to an extraschedular rating, the diagnostic criteria must not reasonably describe the severity and symptomatology of the Veteran’s migraine headache disability. A review of the evidence reveals no indication that the Veteran’s service-connected migraines have resulted in any additional symptomatology not contemplated by the 50 percent rating criteria and no argument as to specifically what symptoms the Veteran has that are not contemplated by Diagnostic Code 8100 has been provided. Accordingly, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture and notes there is nothing exceptional or unusual about the Veteran’s migraine headaches because the rating criteria reasonably describes her disability level and symptomatology. Referral for an extraschedular rating is thus not warranted. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). As the preponderance of the evidence is against the claim for a rating in excess of 50 percent for migraine headaches, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, supra. Entitlement to an earlier effective date for the service-connected migraine headaches is denied. The Veteran contends that she is entitled to an earlier effective date than December 12, 2016, for the grant of service connection for migraine headaches. The Veteran’s current effective date has been granted from the date of her claim to reopen the claim for migraines. This appeal arose from the Veteran’s January 2019 NOD, where she disagreed with the rating assigned and the effective date of the grant of service connection. Except as otherwise provided, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). This statutory provision is implemented by a VA regulation, which provides that the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. Further, there exists no provision in the law for awarding an earlier effective date based simply on the presence of the disability in treatment records. See Brannon v. West, 12 Vet. App. 32, 35 (1998). After a thorough review of the evidence, the Board finds that an earlier effective date for service connection is not warranted. Here, a rating decision was issued in August 2015 denying entitlement to migraine headaches. The August 2015 rating decision was not appealed, and new and material evidence was not submitted within a year. Because of this, it became final. 38 U.S.C. § 7105. Subsequently, in an October 2018 rating decision, the RO granted service-connection for migraine headaches and awarded an effective date of December 12, 2016, corresponding to the date of receipt of the Veteran’s request to reopen. In the NOD, the Veteran and her attorney pointed to a May 2014 VA PTSD examination report which included an opinion by the VA examiner regarding a relationship between the Veteran’s migraine headaches and her service-connected PTSD. However, the record does show that the claim was denied by the RO in a July 2014 rating decision because after weighing the evidence of record, it did not support an award of service connection. Because the Veteran did not perfect an appeal regarding this determination, and/or the subsequent rating decisions, the August 2015 denial is final. The Veteran’s application to reopen, received on December 12, 2016, was granted based on the evidence received after the date of the application to reopen. As noted above, the applicable law provides that the effective date of an award of compensation based on a claim reopened after final disallowance will be the date of receipt of the claim or date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. There is no legal basis upon which to assign an earlier effective date for the grant of service connection under the facts of this case. See Flash v. Brown, 8 Vet. App. 332, 340 (1995) (“When a claim to reopen is successful and the benefit sought is awarded upon re-adjudication, the effective date is the date of the claim to reopen”). Thus, for the reasons above, the date of the December 12, 2016 application to reopen is the appropriate effective date of the award of service connection for the migraine headaches disability. In sum, the benefit of the doubt has been considered, but it is inapplicable where the Board finds that the preponderance of the evidence is against the claim of entitlement to an earlier effective date for migraine headaches. A disability rating of 50 percent, but no higher, prior to September 2, 2015 for service-connected PTSD is granted, and entitlement to a disability rating in excess of 50 percent from September 2, 2015 to November 29, 2016, is denied. The Board notes that in its JMR, the Court stated that the Board was to determine whether increased ratings were warranted for the periods on appeal as it addressed the relevant evidence of record. The Veteran’s service-connected PTSD is currently evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this Diagnostic Code, a 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with an 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), and chronic sleep impairment, mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted if it is productive of 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating contemplates 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); inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted for a total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communications; 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; memory loss for names or close relatives, own occupation, or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). The Veteran was afforded a VA examination in May 2014. The VA examiner noted that the Veteran’s level of occupational and social impairment was due to mild or transient symptoms which decreases work efficiency and her ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran’s symptoms were noted as anxiety, panic attacks that occur weekly or less often, chronic sleep impairment and mild memory loss. The Veteran was neatly and professionally dressed, she was fully alert and oriented, pleasant and cooperative throughout interview, and her speech was a normal rate and tone, logical and goal directed. Her affect was noted as broad and appropriate to topic. Her mood was noted as irritable and anxious at times, but with no agitation, and no evidence of thought disorder was found. No suicidal ideations were indicated. An August 2014 VA mental health note shows that the Veteran noted experiencing panic attacks beginning in April of that year. She noted that they were constant and daily. It was noted that it was precipitated by her grandfather’s passing. The Veteran was afforded a VA examination in June 2015. The VA examiner noted that the Veteran’s level of occupational and social impairment was due to mild or transient symptoms which decreased work efficiency and her ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran’s symptoms were noted as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and flattened affect. The VA examiner noted that the Veteran experienced moderate sadness and repetitive negative cognitions, along with moderate nervousness, anger, guilt, shame, and shortness of breath. It was noted that, at times, she felt like she was reliving the past, re-experiencing the trauma and lamenting on the losses she had endured. From time to time, she felt like someone was watching her. She also noted experiencing reoccurring dreams, up to four times per week, of falling off a cliff and waking up before impact. The Veteran presented as alert, attentive, and pleasant, with a forthcoming personality. She was well groomed and attired. There were no discernible problems with psychomotor movements and her eye contact was direct and appropriate, except when she was overcome by emotion and crying at various times during the examination. Relating sensitive content intensified her reactions anguished depressed state. Her thoughts were linear, coherent and goal-directed. There were no indications of thought disorder or ideations of self-harm or of harm to others. A March 2015 VA mental health treatment note shows that the Veteran was nicely and professionally groomed. She noted difficulty falling asleep at night. She noted familial strains, but no suicidal intention or safety issues were noted. An April 2015 VA mental health note shows that the Veteran noted increased panic attacks due to her grandfather’s passing and her risks surrounding pregnancy. The Veteran was afforded a VA examination in January 2016. The VA examiner noted that the Veteran’s level of occupational and social impairment was due to mild or transient symptoms which decreased work efficiency and her ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran’s symptoms were noted as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood and difficulty in adapting to stressful circumstances, including work or a worklike setting. The VA examiner noted that the Veteran’s expression was sad, and her mood was anxious and dysthymic, with tearful and labile affect. Her attitude was cooperative, there were no unusual psychomotor movements or behaviors and she was oriented to person, place, and time. She was casually dressed, alert, and focused. Her speech was normal in volume, tone and rate and her thinking was logical and goal directed. Observable cognitive function suggested average capacity in domains of memory and executive function. There were no psychotic thoughts and no suicidal or homicidal ideations. No hallucinations or delusions were reported. PTSD prior to September 2, 2015 Although some of the language in the examination reports mirrors the impairment level for a 30 percent rating, when reasonable doubt is resolved in the Veteran’s favor, the Board finds that the impairment level more closely approximates a 50 percent rating. The Board acknowledges the VA examiners reported occupational and social impairment due to mild or transient symptoms; however, when viewing her symptoms as a whole, the Board concludes that her symptoms more nearly approximate a higher rating. Specifically, the Veteran’s VA examinations and treatment records reflect that her PTSD was manifested by panic attacks noted to be constant and daily, flattened affect, moderate sadness and nervousness, and depression. It is important to consider the severity, duration, and frequency of the Veteran’s symptoms and when these factors are taken into consideration, and giving the Veteran the benefit of the doubt, occupational and social impairment is more nearly approximated to warrant a 50 percent rating. Conversely, the record does not reflect that the Veteran’s PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood, nor does it produce total social and occupational impairment. As such, a higher rating of 70 percent or 100 percent is not warranted. Thus, a disability rating of 50 percent, but no higher, prior to September 2, 2015, is warranted for the Veteran’s PTSD. See 38 U.S.C. § 5107(b). PTSD from September 2, 2015 to November 29, 2016 Following a review of the evidence of record, with particular attention to the VA examination and VA treatment records, the Board concludes that the Veteran’s PTSD more nearly approximates the impairment required for a 50 percent rating than that required for a 70 percent rating. The Board acknowledges symptoms reported during the mental health examination, to include difficulty in adapting to stressful circumstances. However, when looking at the totality of the evidence, the Board does not find that the Veteran’s psychiatric disorder results in occupational and social impairment or symptoms that warrant a higher disability evaluation. The Veteran has not endorsed withdrawal symptoms or social isolation; the Veteran did not report experiencing panic and anxiety attacks, nor describe attacks of such severity to be near continuous panic. She did not display or report speech intermittently illogical, obscure, or irrelevant, or spatial disorientation. The Veteran was presentable at her VA examination and was able to appropriately engage with the examiner. While she had some depression, there is no indication this this affected her ability to function independently, appropriately, and effectively, further evidenced by her ability to maintain some relationships, to include with her family. The evidence of record has not shown that the Veteran struggles with impaired impulse control resulting in periods of violence. The evidence does not show obsessional rituals that interfere with routine activities. Further, there were no reported or observed manifestations, not included in the rating schedule, which would indicate that a higher rating is warranted. When considering the totality of all the evidence, as instructed by Mauerhan and Vazquez-Claudio, the Veteran’s overall symptoms do not support the assignment of a disability rating in excess of 50 percent. While the Board is sympathetic to the difficulties presented by the Veteran’s PTSD for this period on appeal, the evidence of record does not support a rating in excess of 50 percent. Neither the objective findings shown on examination nor the subjective reports from the Veteran are more consistent with a 70 percent or 100 percent evaluation than with a 50 percent evaluation. The claim thus must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The reduction of the service-connected right knee instability disability from 20 percent to a noncompensable rating, effective March 13, 2017, was improper. The procedural facts in this case are not in dispute. Service connection for a right knee instability disability has been in effect since September 16, 2004, at which time a 20 percent disabling rating was assigned. In a March 2017 rating decision, the RO decreased the rating for the instability of the right knee from 20 to noncompensable, effective March 13, 2017, based on the findings of a March 2017 VA examination. Subsequently, in a July 2019 Board decision, it was determined that the reduction was proper. In a July 2020 JMR, the Court remanded the issue, noting that the Board had not adequately addressed the Veteran’s complaints of right knee locking and popping and that she was unable to perform the joint stability test due to pain during a January 2016 examination. In general, where a reduction in an evaluation of a service-connected disability occurs, VA must notify the Veteran of this proposed reduction, and provide him or her with at least 60 days’ time to present additional evidence showing that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). However, these predetermination procedures do not apply in cases where the reduction in the disability rating does not result in a reduction or discontinuance of total payments being made to the Veteran. See Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007); O’Connell v. Nicholson, 21 Vet. App. 89 (2007). In this case, the record shows that the Veteran was in receipt of compensation benefits for additional disabilities in March 2017. The Veteran had ongoing compensation payments at a combined 100 percent level. Although the March 2017 rating decision reduced the rating for the right knee instability disability, there was no reduction in the overall combined evaluation for compensation. Therefore, there was no prejudice to the Veteran, and the procedures of 38 C.F.R. § 3.105(e) are not for application. The issue remaining is whether the reduction was proper based upon the evidence of record. In cases such as this, where a rating has been in effect for five years or more, the rating agency must make reasonably certain that the improvement will be maintained under the conditions of ordinary life even if material improvement in the physical or mental condition is clearly reflected. Kitchens v. Brown, 7 Vet. App. 320 (1995). The five-year period is calculated from the effective date of the rating to the effective date of the reduction. Brown v. Brown, 5 Vet. App. 413 (1993). If doubt remains, after according due consideration to all the evidence, the rating agency will continue the rating in effect. 38 C.F.R. § 3.344(b). When an RO reduces a rating without following the applicable regulations, the reduction is void ab initio. Greyzck v. West, 12 Vet. App. 288 (1999). The Veteran was granted service connection for right knee instability in a September 2005 rating decision. The RO noted that a June 2005 VA examination report showed that the Veteran had a moderate amount of anterior/posterior instability of the right knee. The Veteran submitted a claim for a higher rating in March 2013. The Veteran’s instability of the right knee is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5257, slight impairment warrants a 10 percent disability rating, moderate impairment warrants a 20 percent disability rating, and severe impairment warrants a 30 percent disability rating. A June 2013 VA knee and lower leg conditions examination report shows that the Veteran reported that her knees locked up, she experienced swelling, and she took Motrin for pain. Flare-ups occurred with prolonged standing and walking. Upon examination, joint stability testing, to include anterior instability, posterior instability, and medial-lateral instability, were found to be normal. No patellar subluxation or dislocation was found. No additional conditions were found upon examination. The use of assistive devices was not noted. An April 2015 VA medical note shows that the Veteran report occasional popping locking and no instability, falls, or swelling. A January 2016 VA knee and lower leg conditions examination report shows that the Veteran reported experiencing problems with her knee locking and popping. The Veteran believed that her condition had worsened. The Veteran noted numbness after being sedentary for 15 minutes. It was noted that the joint stability test could not be performed due to the Veteran experiencing pain. The use of assistive devices was not noted. A March 2017 VA knee and lower leg conditions examination report shows that the Veteran noted that her knee was unstable; she had difficulty getting up, and her knee would pop and get swollen. She noted that she wore a brace approximately 3 times a week. Joint stability testing, to include anterior instability, posterior instability, medial instability, and lateral instability, were all normal. No history of recurrent subluxation was found. As noted above, in a rating reduction case, it is not sufficient to show that an improvement in a disability has actually occurred. That is, it is not sufficient to show that the Veteran’s knee symptoms had decreased in severity. Instead, the evidence must also demonstrate that any such improvement actually reflected an improvement in her ability to function under the ordinary conditions of life and work. See Brown, supra. In this case, although there is medical evidence suggesting that her condition had improved during the reduction period, the Veteran has provided competent lay evidence that her disability level continued during this period. The Veteran has maintained that she experienced knee pain and knee instability throughout the entire appeals period, to include not being able to perform the joint instability test during her January 2016 examination, and experienced her knee locking and popping. Therefore, despite objective evidence showing improvement, her knee disability had not improved sufficient to reflect an actually improved ability to function under the ordinary conditions of life and work. For these reasons, and resolving all doubt in the Veteran’s favor, the right knee instability disability has remained relatively consistent throughout the relevant appeal period. As such, the weight of the evidence does not show an improvement of her knee disability that is reasonably certain to be maintained under the ordinary conditions of life. Accordingly, restoration of a 20 percent rating is warranted for the right knee instability disability, and the appeal is granted. Other Considerations Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). As a final matter, the Board acknowledges that in Rice v. Shinseki, 22 Vet. App. 447 (2009), it was held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such is raised by the record. Of note, the Veteran is already receiving a combined 100 rating based upon multiple service-connected disabilities since December 12, 2016. Prior to that date, the January 2016 and October 2016 VA foot examinations show that the Veteran’s hallux rigidus conditions limited her standing and walking. The January 2016 VA knee examination report shows that the Veteran’s condition limited her kneeling, crouching, lifting and carrying. As noted above, her gynecological condition did not impact her ability to work, a review of the record does not show that the Veteran’s service-connected wrist condition impacted her ability to work, and there is no evidence suggesting unemployability was due to her service-connected PTSD. While the Veteran experienced some limitation in motion, there is no evidence to suggest that her disabilities rendered her unemployable prior to December 12, 2016. Accordingly, a TDIU claim has not been raised, and no action pursuant to Rice is necessary. REASONS FOR REMAND Entitlement to service connection for bursitis of both feet and both sets of toes Service treatment records show that the Veteran reported foot pain. See March 2003 Medical Record and August 2004 Report of Medical Record. A private medical treatment record, dated in October 2016, shows an assessment of bursitis of the right foot. A review of the record shows that the Veteran has not been afforded a VA examination in connection with her claim of service connection for foot and toe disabilities. Generally, VA is required to provide an examination when the evidence of record indicates that a current disorder “may be associated” with a Veteran’s military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4)(i). This evidentiary requirement is a low threshold. Such evidence exists, and the Board finds that a VA examination and medical opinion are warranted to determine if any current bursitis of the bilateral feet and toes is related to the Veteran’s service. Entitlement to an initial rating in excess of 10 percent for service-connected right wrist peripheral autonomic neuropathy In light of points raised in the July 2020 JMR, further action in connection with this claim on appeal is warranted. The JMR indicated that the Board did not address the evidence that the Veteran experienced decreased strength in her right wrist. See February 2017 VA wrist examination report. The Court noted that the Board must assess the complete severity of the Veteran’s symptomatology. As such, the Board finds that a new VA examination is necessary to assess the severity of the Veteran’s condition. Of note, the Court has held that 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 this regulation 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, combined with the range of motion of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Thus, the new VA examination must conform to Correia. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA foot examination to address her claim for service connection for bursitis of the right and left feet and toes. The claims file must be reviewed in conjunction with the examination. Any tests deemed necessary should be conducted, and all clinical findings should be reported in detail. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether any current disability (right and left foot bursitis, bursitis of the right and left toes) is at least as likely as not (50 percent probability or greater) related to service. In rendering the above requested opinion, the examiner should address the private medical treatment record, dated in October 2016. The examiner should also note that the Veteran is already service connected for hallus valgus of the both feet, with arthritis of the left great toe. The examination report must include a complete rationale for all opinions expressed. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. 2. Schedule the Veteran for a VA wrist examination to evaluate to determine the severity of her right wrist peripheral autonomic neuropathy, to include the required testing pursuant to the holding in Correia. The entire claims file must be reviewed by the examiner. The examiner is to conduct all necessary tests and studies. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability. The joint involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing, he or she should clearly explain why. The VA examiner is asked to note any symptomatology found upon examination which suggest a different or increased disability picture other than that shown and indicated during testing. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A-L Evans, 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.