Citation Nr: 21011958 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 18-41 110 DATE: March 3, 2021 ORDER Entitlement to service connection for elevated blood pressure, including as secondary to service-connected Parkinson’s Disease, is denied. Entitlement to an initial 50 percent rating, but no higher, for bilateral eye diplopia is granted. Entitlement to an initial rating in excess of 50 percent for obstructive sleep apnea is denied. Entitlement to an initial rating in excess of 30 percent for seborrheic keratosis with actinic keratosis is denied. REMANDED The claim for an effective date prior to March 14, 2017, for the grant of service connection for neurocognitive disorder and depressive disorder (previously characterized as sleep disturbances) is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for erectile dysfunction is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for service connection for tremor, muscle rigidity, and bradykinesia of the right upper extremity is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for service connection for tremor, muscle rigidity, and bradykinesia of the right lower extremity is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for service connection for tremor, muscle rigidity, and bradykinesia of the left upper extremity is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for service connection for tremor, muscle rigidity, and bradykinesia of the left lower extremity is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for balance impairment is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for stooped posture is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for speech changes, right, is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for speech changes, left, is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for partial loss of smell is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for face masking, right, is remanded. The claim for an effective date prior to March 14, 2017, for the grant of service connection for face masking, left, is remanded. The claim for an effective date prior to March 14, 2017, for the grant of special monthly compensation (SMC) based on the loss of use of a creative organ is remanded. The claim for an effective date prior to March 14, 2017, for the grant of Dependents’ Educational Assistance (DEA) benefits is remanded. Entitlement to service connection for skin melanomas, right arm, status post surgery, including as secondary to service-connected Parkinson’s Disease, is remanded. Entitlement to service connection for scraped shins, including as secondary to service-connected Parkinson’s Disease, is remanded. Entitlement to service connection for hearing loss, including as secondary to service-connected Parkinson’s Disease, is remanded. Entitlement to an initial rating in excess of 40 percent for tremor, muscle rigidity, and bradykinesia of the right upper extremity is remanded. Entitlement to an initial rating in excess of 40 percent for tremor, muscle rigidity, and bradykinesia of the right lower extremity is remanded. Entitlement to an initial rating in excess of 20 percent for stooped posture is remanded. Entitlement to an initial rating in excess of 10 percent for right wrist sprain is remanded. Entitlement to an initial rating in excess of 10 percent for left wrist sprain is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The evidence does not show that the Veteran has been diagnosed with hypertension for VA purposes during the period on appeal. 2. The Veteran’s bilateral diplopia has been productive of corrected visual acuity of 20/40 or better, bilateral visual field of 46 to 60 degrees, and constant bilateral diplopia in the central 20 degrees of vision. 3. The Veteran’s obstructive sleep apnea has not manifested with chronic respiratory failure with carbon dioxide retention or cor pulmonale, nor has it required a tracheostomy. 4. The Veteran’s seborrheic keratosis with actinic keratosis is manifested by characteristic lesions involving more than 20 to 40 percent of the entire body and 20 to 40 percent of exposed areas affected. CONCLUSIONS OF LAW 1. The criteria for service connection for elevated blood pressure, to include as secondary to service-connected Parkinson’s Disease, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for an initial 50 percent rating for the bilateral eye disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.79, Diagnostic Codes 6065, 6080, 6090. 3. The criteria for an initial rating in excess of 50 percent for sleep apnea are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.97, Diagnostic Code 6847. 4. The criteria for an initial rating in excess of 30 percent for seborrheic keratosis with actinic keratosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806, 7820. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Marine Corps from March 1971 to June 1975. This case was most recently before the Board in August 2019, at which time the Board, in part, denied the earlier effective date claims on appeal. The Veteran appealed the decision to the Court of Appeals for Veterans’ Claims (Court). Pursuant to the terms of a July 2020 Joint Motion for Partial Remand (JMPR), the Court vacated that portion of the Board’s August 2019 decision that denied the Veteran’s earlier effective date claims and returned the claims to the Board. Those issues, as well as additional issues the Board remanded for development in August 2019, are again before the Board for consideration. The Board notes that the JMPR states that the Veteran abandoned his appeal to those portions of the Board’s August 2019 decision that denied his claims for entitlement to a higher initial rating for neurocognitive and depressive disorder, rated 30 percent disabling from March 14, 2017 to June 19, 2018, and 50 percent disabling from June 20, 2018, an initial rating in excess of 30 percent for balance impairment, an initial rating in excess of 20 percent for tremor, muscle rigidity, and bradykinesia in left upper and lower extremities, an initial rating in excess of 10 percent for speech changes right and left, an initial compensable rating for ED, and an initial compensable rating for face masking right and left. Therefore, those issues are no longer on appeal and will not be addressed herein. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Additionally, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either: (a) caused or (b) aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Finally, the Board notes that certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation; without a current disability, service connection is not warranted. 38 U.S.C. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 1. Entitlement to service connection for elevated blood pressure The Veteran seeks service connection for elevated blood pressure, to include as secondary to his service-connected Parkinson’s Disease. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For VA purposes, hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Board concludes that the Veteran does not have a current diagnosis of hypertension and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Review of the Veteran’s VA and private medical treatment records show the Veteran has been found to have elevated blood pressure readings throughout the period on appeal, but he has not been diagnosed with hypertension under the criteria set forth in 38 C.F.R. § 4.104, Diagnostic Code 7101. VA treatment records include an August 2017 note documenting “[h]ypertension today only” with a reading of 171/81. However, the rest of the Veteran’s treatment records, including VA treatment records after that date, are silent for diagnosis of hypertension or blood pressure readings showing diastolic predominantly 90 mm or greater and systolic blood pressure predominantly 160mm or greater. As previously discussed, the existence of a current disability is the cornerstone of a claim for VA disability compensation. Because the evidence does not show that the Veteran has met the criteria for hypertension for VA purposes during the period on appeal, the Veteran’s claim of entitlement to service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). A Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 2. Entitlement to an initial rating in excess of 30 percent for bilateral eye diplopia The Veteran seeks a higher rating for diplopia, for which he has been assigned a 30 percent rating under 38 C.F.R. § 4.79, Diagnostic Code 6090. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75 (a). Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76 (b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76 (b)(4). Evaluations of visual impairment of muscle function is based on the degree of diplopia. The examiner must record test results for the four major quadrants (upward, downward, and right and left lateral) and the central field (20 degrees or less). 38 C.F.R. § 4.78 (a). Diplopia in the central field (20 degrees or less) of any of the four major quadrants equates to 5/200 visual acuity. From 21 to 30 degrees, diplopia in the down quadrant equates to 15/200 visual acuity, diplopia in either lateral quadrant equates to 20/100 visual acuity, and diplopia in the up quadrant equates to 20/70 visual acuity. From 31 to 40 degrees, diplopia in the down quadrant equates to 20/200 visual acuity, diplopia in either lateral quadrant equates to 20/70 visual acuity, and diplopia in the up quadrant equates to 20/40 visual acuity. An evaluation for diplopia will be assigned to only one eye. When a claimant has both diplopia and decreased visual acuity or visual field defect, the rater will assign a level of corrected visual acuity for the poorer eye (or the affected eye, if disability of only one eye is service-connected) that is: one step poorer than it would otherwise warrant if the evaluation for diplopia under Diagnostic Code 6090 is 20/70 or 20/100; two steps poorer if the evaluation under Diagnostic Code 6090 is 20/200 or 15/200; or three steps poorer if the evaluation under Diagnostic Code 6090 is 5/200. This adjusted level of corrected visual acuity cannot exceed a level of 5/200. The rater will apply the adjusted visual acuity for the poorer eye and the corrected visual acuity for the better eye to Diagnostic Codes 6065-66 in the table of Impairment of Central Visual Acuity to determine the rating. 38 C.F.R. § 4.78 (b)(1). When diplopia extends beyond more than one quadrant or range of degrees, diplopia is evaluated based on the quadrant and degree range that provides the highest evaluation. 38 C.F.R. § 4.78 (b)(2). When diplopia exists in two separate areas of the same eye, the equivalent visual acuity is increased under Diagnostic Code 6090 to the next poorer level of visual acuity, not to exceed 5/200. 38 C.F.R. § 4.78 (b)(3). In essence, the rating criteria for diplopia establish an equivalent visual acuity to the degree of diplopia present, with that acuity then used in applying the table for rating central visual acuity impairment. With respect to field of vision impairment, 38 C.F.R. § 4.76a, Table III, reflects that the normal visual field extent at the 8 principal meridians totals 500 degrees. The normal for the 8 principal meridians are as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. The degrees lost are then added together to determine the total number of degrees lost, which are subtracted from 500. The total remaining degrees of the visual field are then divided by eight to represent the average contraction for rating purposes. 38 C.F.R. § 4.76a. Under Diagnostic Code 6080, visual field defects are evaluated as follows: A 10 percent evaluation for concentric contraction of visual field with remaining field of 46 to 60 degrees bilaterally or unilaterally; with remaining field of 31 to 45 degrees unilaterally; with remaining field of 16 to 30 degrees unilaterally; loss of superior half of visual field bilaterally or unilaterally; loss of interior half of visual field unilaterally; loss of nasal half of visual field bilaterally or unilaterally; and loss of temporal half of visual field unilaterally. A 20 percent evaluation if assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees unilaterally. A 30 percent evaluation is assigned for concentric contraction of visual field with remaining field of 31 to 45 degrees bilaterally; remaining field of 5 degrees unilaterally; loss of inferior half of visual field bilaterally; loss of temporal half of visual field bilaterally; and homonymous hemianopsia visual field defects. A 50 percent rating is assigned for concentric contraction of visual field with remaining field of 16 to 30 degrees bilaterally. A 70 percent rating is assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees bilaterally. A 100 percent rating is assigned for concentric contraction of visual field with remaining field of 5 degrees bilaterally. When both decreased visual acuity and visual field defect are present, they are separately rated and expressed as a level of visual acuity, and then combined under the provisions of § 4.25. Turning to the evidence, the Veteran was afforded a VA examination in October 2018. The Veteran reported being frustrated with his vision and that he had stopped the majority of his driving during the past year. He reported trying different glasses and prisms, to no avail. Uncorrected distance visual acuity was 20/40 in the right eye and 20/50 in the left eye; corrected distance visual acuity was 20/40 in both eyes; uncorrected near visual acuity was 20/200 in both eyes; and corrected near visual acuity was 20/40 in both eyes. His pupils were equal in diameter, round, and reactive to light, and there was no afferent pupillary defect present. There was also no anatomical loss, light perception only, extremely poor vision, blindness, or corneal irregularity that resulted in severe irregular astigmatism. The Veteran had diplopia in the central 20 degrees, lateral 21 to 30 degrees, and lateral 31 to 40 degrees. The examiner indicated that the diplopia was constant, and it was not correctable with standard spectacle correction, including a special prismatic correction. Visual field testing yielded the following results: Meridian Normal degrees Right Eye Left Eye Temporally 85 63 64 Down temporally 85 70 67 Down 65 55 50 Down nasally 50 44 43 Nasally 60 49 41 Up nasally 55 48 39 Up 45 33 37 Up temporally 55 47 51 Total 500 409 392 To obtain remaining visual field (average concentric contraction) for an eye, add up the remaining visual field at each of the eight principal meridians for that eye and divide the sum by eight. 38 C.F.R. § 4.77(b). In this case, adding the remaining visual field at each of the eight principal meridians for the right eye (409) and dividing the sum by eight yields an average concentric contraction of 51.125 degrees. Adding the remaining visual field at each of the eight principal meridians for the left eye (392) and dividing the sum by eight yields an average concentric contraction of 49 degrees. The Veteran did not have any incapacitating episodes, and there was no scarring or disfigurement attributable to an eye condition. The examiner found that the Veteran’s diplopia and visual field defects were attributable to his service-connected Parkinson’s Disease. Review of VA and private medical treatment records from the period on appeal show that the Veteran’s best corrected visual acuity was no worse than 20/40 in both eyes. Overall, after careful review of the evidence of record, and resolving doubt in favor of the Veteran, the Board finds that a 50 percent disability rating under Diagnostic Code 6090, but no higher, is warranted for the Veteran’s visual impairment for the entire period on appeal. Visual field test results from the period show the Veteran’s average concentric contraction was, at worst, 51.125 degrees in the right eye and 49 degrees in the left eye. According to Diagnostic Code 6080, these average concentric contractions are each evaluated as 20/50. Evaluating both eyes as 20/50 under Diagnostic Code 6066 is commensurate with a 10 percent disability rating. The equivalent visual acuity for the Veteran’s diplopia in the central 20 degrees of vision is 5/200. Under Diagnostic Code 6090, diplopia ratings must be applied to the poorer eye while the better eye is rated according to the best corrected visual acuity or visual field. In this case, a 40 percent rating is warranted when vision in one eye is 5/200 and vision in the other eye is 20/50. As discussed above, when both decreased visual acuity and visual field defect are present, they are separately rated and expressed as a level of visual acuity, and then combined under the provisions of § 4.25. Here, the diplopia rating is based on visual acuity. Thus, the 40 percent rating for diplopia and 10 percent rating for visual field loss are combined to warrant a 50 percent rating for the bilateral eye disability. A higher rating would require more severe levels of visual impairment. Therefore, a rating in excess of 50 percent for visual impairment is not warranted. 3. Entitlement to an initial rating in excess of 50 percent for obstructive sleep apnea The Veteran asserts that he is entitled to a higher initial rating for his service-connected obstructive sleep apnea, currently evaluated as 50 percent disabling under 38 C.F.R. § 4.97, Diagnostic Code 6847. Under these criteria, a 50 percent evaluation is assigned for sleep apnea requiring the use of a breathing assistance device such as a continuous airway pressure (CPAP) machine. A 100 percent evaluation is assigned for sleep apnea with chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requiring a tracheostomy. In a November 2017 letter, private physician D.P. wrote that the Veteran underwent a sleep study that showed mild to moderate obstructive sleep apnea. The sleep study recording technologist noted that the Veteran was seen having a multitude of respiratory disturbances in both NREM and REM sleep, with some periods of hypoxemia noted in absence of respiratory disturbances. Dr. D.P. recommended that the Veteran use a CPAP. The Veteran was afforded a VA examination in April 2018. The examiner noted that the Veteran had been diagnosed with mild obstructive sleep apnea. The Veteran reported being unable to tolerate his CPAP machine, although it had been recommended. He indicated he was working on finding a mask he could tolerate through the night. He reported that his wife hears him hold his breath and stop breathing during the night. He reported feeling exhausted every day, and that he was unable to stay awake during the day. He was prescribed Trazodone to sleep. He endorsed experiencing persistent daytime hypersomnolence. The examiner noted that the Veteran had been prescribed a CPAP machine and was awaiting issue of the machine at the time of the examination. VA and private medical treatment records show the Veteran was diagnosed with obstructive sleep apnea and instructed to use a CPAP, but the records are silent for reports of or treatment for chronic respiratory failure with carbon dioxide retention or cor pulmonale related to sleep apnea, or that that his sleep apnea required a tracheostomy. Overall, the Board finds that the weight of the evidence is against assigning an initial rating in excess of 50 percent for obstructive sleep apnea. In this regard, as detailed herein, the Veteran’s sleep apnea has required the use of a CPAP machine, which is contemplated by the currently assigned 50 percent rating. However, the Veteran does not contend, and the evidence does not show, that his sleep apnea has caused chronic respiratory failure with carbon dioxide retention or cor pulmonale, or that it has required a tracheostomy, as required for the assignment of a 100 percent rating. Therefore, an initial rating in excess of 50 percent for service-connected obstructive sleep apnea is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. 4. Entitlement to an initial rating in excess of 40 percent for skin seborrheic keratosis with actinic keratosis The Veteran seeks a higher rating for his service-connected seborrheic keratosis with actinic keratosis, currently assigned a 30 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7820, which pertains to infections of the skin not listed elsewhere in the regulations. The Diagnostic Code instructs the rater to rate the disability as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending on the predominant disability. In this case, the Veteran’s disability is rated as dermatitis pursuant to Diagnostic Code 7806. 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 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, under Diagnostic Code 7806, 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 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. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, 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 30 percent rating is assigned for 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. Turning to the evidence, the Veteran was afforded a VA examination in connection with his claim in October 2018. The examiner noted diagnoses of seborrheic keratosis with actinic keratosis. Regarding the actinic keratosis, the examiner noted that it was located on the Veteran’s right forearm and bilateral hands, and that the Veteran underwent cryotherapy every six months for treatment of lesions. Regarding the seborrheic keratosis, the examiner noted that it was located on the Veteran’s scalp, face, trunk, neck, and extremities, and that the Veteran underwent cryotherapy every six months for treatment of lesions. The examiner noted that the Veteran had not been treated with medication in the past 12 months for any skin condition, but that he had been treated with cryotherapy for actinic keratosis and seborrheic keratosis in April 2018. The examiner indicated that the total duration of medication use in the past 12 months was less than six weeks. The examiner found that the Veteran’s visible characteristic lesions due to his skin conditions covered approximately 20 percent to 40 percent of the Veteran’s total body area and approximately 20 percent to 40 percent of his exposed area (face, neck, and hands). The examiner described the appearance of the conditions as brown macules to face and forearms and raised, red lesions to the face. The examiner indicated that the Veteran’s conditions did not cause scarring or disfigurement of the head, face, or neck. Review of the Veteran’s VA and private medical treatment records confirm the Veteran underwent cryotherapy to treat his actinic keratosis. Private records show the Veteran was treated for a rash on his back, abdomen, arms, legs, and feet that was associated with a burning itch in February 2016. At the time, the Veteran was most concerned about his back because he reportedly woke up with blood on his sheets daily. He was prescribed triamcinolone ointment, a corticosteroid, to use twice daily “as needed” for dry, red, or pruritic areas. Overall, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under the pre-August 13, 2018, regulations because the Veteran’s seborrheic keratosis with actinic keratosis does not more nearly approximate 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. The Board further finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under the August 13, 2018, regulations because the Veteran’s seborrheic keratosis with actinic keratosis does not more nearly approximate 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 required over the past 12-month period. As previously discussed, the October 2018 VA examination report documented visible characteristic lesions covering approximately 20 percent to 40 percent of the Veteran’s total body area and exposed area. The VA examination report and private medical treatment records show the Veteran was prescribed a corticosteroid ointment to use “as needed” and that he received cryotherapy every six months. The evidence does not show constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs, or constant or near-constant systemic therapy required during the past 12-month period. The Veteran has not asserted, and medical treatment records and the October 2018 VA examination report do not show, that the Veteran’s disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim of a rating in excess of 30 percent for seborrheic keratosis with actinic keratosis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND For reasons discussed below, the remaining issues on appeal must be remanded for additional development. 1. Effective dates prior to March 14, 2017 for the award of service connection for neurocognitive disorder and depressive disorder; tremor, muscle rigidity, and bradykinesia of the right and left upper extremities and right and left lower extremities; balance impairment; stooped posture; erectile dysfunction; face masking right and left; partial loss of smell; speech changes right and left; award of special monthly compensation (SMC) based on loss of use of a creative organ; and award of Dependents’ Educational Assistance (DEA) benefits The claims of entitlement to earlier effective dates must be remanded for an addendum opinion. While his claim for service connection for Parkinson’s Disease was pending, VA amended 38 C.F.R. §§ 3.307 and 3.309 to allow service connection on a presumptive basis for certain enumerated diseases, including Parkinson’s Disease, related to exposure to contaminated drinking water at Camp Lejeune. Accordingly, the Veteran was awarded service connection for Parkinson’s Disease and the residual disabilities listed above on a presumptive basis effective March 14, 2017, the date the amendment went into effect. Nevertheless, the Veteran contends that service connection is warranted on a direct basis prior to March 14, 2017. He was afforded a VA examination in June 2017 in which the examiner opined that the Veteran’s Parkinson’s Disease was less likely than not caused by or a result of the Veteran’s exposure to contaminated water while stationed Camp Lejeune during active service. However, as noted by the parties to the July 2020 Joint Motion for Partial Remand, the June 2017 VA examiner’s negative opinion appeared to be based in part on an inaccurate factual premise—namely, that the Veteran was exposed to Camp Lejeune contaminated water for a period of only 68 days. Review of the Veteran’s service personnel records, including his chronological record of service, shows the Veteran served at Camp Lejeune from March 1974 through May 1975, a period much longer than 68 days. Because the VA examiner’s opinion was based in large part on an inaccurate factual premise, the Board finds that remand for an addendum opinion is warranted. The Board notes that the Veteran’s claim for an earlier effective date for the award of Dependents’ Educational Assistance (DEA) benefits is inextricably intertwined with the effective date claims enumerated above, as adjudication of those issues may impact the Veteran’s eligibility date for DEA benefits. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). 2. Service connection for skin melanomas The Veteran seeks service connection for skin melanomas. VA treatment records show the Veteran has a history of melanomas and indicate he has had melanomas removed during the period on appeal. Though a March 2018 VA treatment note indicates a history of melanoma “without recurrence,” and the October 2018 VA skin examination report did not note the presence of tumors and neoplasms of the skin, including malignant melanomas, at the time of examination, service connection may be granted upon competent evidence that a claimed disability existed at any time during the appeal period, even if the disability resolves prior to VA’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board notes that the Veteran’s private medical records indicate the Veteran is at increased risk of melanoma due to his Parkinson’s Disease. Given the evidence indicating the Veteran has been treated for melanomas during the period on appeal, as well as indications the Veteran is at increased risk for melanoma due to his Parkinson’s Disease, the Board finds that remand is warranted to address the relationship between the Veteran’s history of melanomas and his service-connected Parkinson’s Disease. 3. Service connection for bilateral hearing loss The Veteran was afforded a VA audiological examination in March 2018. The examiner diagnosed bilateral sensorineural hearing loss but opined that the Veteran’s current hearing loss was not at least as likely as not caused by or a result of an event in military service. In an accompanying opinion, the examiner further opined that the Veteran’s current hearing loss disability was less likely than not proximately due to or the result of his service-connected Parkinson’s Disease. However, the examiner did not address the question of whether the Veteran’s hearing loss has been aggravated by his service-connected Parkinson’s Disease. Therefore, remand is warranted to obtain an addendum opinion addressing the question of whether the Veteran’s current hearing loss disability has been aggravated by his service-connected Parkinson’s Disease. 4. Service connection for a shin disability The Veteran seeks service connection for scraped shins, suggesting he has a current disability related to a history of breaking his shin due to a fall. The Board notes that the Veteran is service connected for balance issues related to Parkinson’s Disease. A February 2018 VA treatment note indicates the Veteran had a history of breaking his shin because of a fall. In October 2018, the Veteran was afforded a VA muscle injuries examination, a VA fractures and bone diseases examination, and a VA foot conditions examination. During the muscle injuries examination, the Veteran reported trauma to the bilateral shins after falling the year prior due to unsteady gait from Parkinson’s disease. None of the examiners diagnosed a shin disability or residual disability associated with prior trauma to the bilateral shins. However, it does not appear that the VA bone conditions examiner was specifically asked to assess the Veteran for a possible shin disability, and there is no indication she conducted x-rays or other diagnostic testing of the shins, as was completed for the Veteran’s chest, another disability for which the Veteran sought service connection. There is also no indication the Veteran’s shins were examined for other possible residuals of a shin disability, to include scars from scrapes. The Board finds that remand is warranted to afford the Veteran a VA examination to specifically assess the Veteran’s shins. 5. Increased ratings for tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities In its August 2019 remand directives, the Board instructed the RO to schedule the Veteran for a VA peripheral nerves examination to clarify which nerves are affected by the Veteran’s service-connected tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities, as the available evidence was unclear in this regard. The Board explained that this information is critical in determining the appropriate disability ratings, to include whether additional ratings are warranted. In accordance with the Board’s remand instructions, the Veteran was afforded a VA peripheral nerves examination in January 2020. Unfortunately, the examiner left the examination report mostly blank, with no indication as to which nerves are affected by the Veteran’s service-connected tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities. The examiner wrote, “[t]he pathophysiology of Parkinson’s Disease arises from the brain and manifests itself in the body with resultant tremors, bradykinesia, muscle rigidity, and stooped posture. It does not affect [range of motion] or specific nerves as it only affects the brain.” The Board finds the January 2020 examination report to be inadequate for rating purposes. The Board notes that ratings for Parkinson’s disease, classified in VA regulations as “paralysis agitans,” are assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8004. Under this Diagnostic Code, a minimum 30 percent rating is assigned when there are “ascertainable residuals” of the disability. However, VA is required to consider whether any of these residuals may otherwise be rated under separate Diagnostic Codes. As is the case here, if there are ascertainable residuals that can be rated under a separate Diagnostic Code, and the combined disability rating resulting from these residuals exceeds 30 percent, then these separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. Neurological conditions such as Parkinson’s disease are evaluated under the section of the Rating Schedule beginning at 38 C.F.R. § 4.120. Evaluations are made by comparison. Disabilities in this section are generally rated in proportion to the impairment of motor, sensory or mental function. The rater is to consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating such disability, the rater is to refer to the appropriate schedule. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The provisions of 38 C.F.R. § 4.124a provide that evaluations of neurological conditions such as Parkinson’s disease and its residuals may also be rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. Psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc. are to be considered. With partial loss of use of one or more extremities from neurological lesions, the rating is by comparison with mild, moderate, severe, or complete paralysis of peripheral nerves. As it pertains to peripheral nerve disabilities, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. In this case, the Veteran’s service-connected tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities are rated by comparison to the Diagnostic Codes presently assigned, even though Parkinson’s, according to the VA examiner, is a condition “of the brain etiology.” Therefore, remand is warranted for another VA examination to clarify which nerves are affected by the Veteran’s service-connected tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities. 6. Increased ratings for stooped posture, right wrist sprain, and left wrist sprain The Board finds that remand is warranted to afford the Veteran VA examinations to determine the severity of his service-connected stooped posture and right and left wrist sprains. While the record contains contemporaneous VA examinations regarding these disabilities, the examination reports not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups. The examinations also do not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016), as they do not contain passive range of motion measurements. The Board notes that the Veteran, through his attorney, as specifically contended that higher ratings are warranted based on painful motion. 7. TDIU The Board notes that the Veteran has been in receipt of a combined schedular 100 percent disability rating for his service-connected disabilities for the duration of the period on appeal. However, a 100 percent disability rating does not necessarily render the issue of TDIU moot. VA’s duty to maximize a claimant’s benefits includes consideration of whether his disabilities establish entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). SMC under 38 U.S.C. § 1114 (s) is available when a Veteran has a single service-connected disability rated as total and has additional service-connected disability or disabilities ratable at 60 percent or more. Notably, the Court has interpreted 38 U.S.C. § 1114 (s) to mean that the “total” disability rating does not have to be a 100 percent schedular rating. The total rating requirement may be satisfied where a Veteran has been awarded a TDIU rating for a single disability. See Bradley, 22 Vet. App. at 293. The Bradley decision also held that the direction to treat multiple disabilities as one under 38 C.F.R. § 4.16 (a) was specifically limited to TDIU ratings. A TDIU rating based on multiple service-connected disabilities does not satisfy the criteria of one total disability in considering entitlement to SMC under 38 U.S.C. § 1114 (s). In this case, the Board finds that the Veteran’s TDIU claim has not yet been rendered moot, as the Board is remanding some of the increased rating claims on appeal. Adjudication of these claims may impact the disability ratings assigned. As previously discussed, the appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris, 1 Vet. App. at 180. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician concerning the relationship between the Veteran’s Parkinson’s Disease and associated residual disabilities and his in-service exposure to contaminated water at Camp Lejeune from March 1974 through May 1975. The examiner is requested to render an opinion addressing whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s Parkinson’s Disease and associated residual disabilities are related on a direct basis to exposure to contaminated water at Camp Lejeune, North Carolina, regardless of whether the disorders are included under the regulation providing presumptive service connection for such exposure. The opinion must be accompanied by an adequate rationale, with conclusions supported with references to and discussion of findings on examination (prior examination or any new examination), to clinical findings in the medical evidence of record and/or to accepted medical literature. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has had skin melanomas at any point during the period on appeal that are at least as likely as not proximately due to or aggravated beyond its natural progression by his service-connected Parkinson’s Disease. 3. Obtain an addendum opinion from an appropriate clinician regarding whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current bilateral hearing loss disability has been aggravated (increased beyond the natural progression of the disability) by his service-connected Parkinson’s Disease. The examiner is advised that the term “aggravation” in this context does not require that there be “permanent” worsening of the nonservice connected disability. Ward v. Wilkie, 31 Vet. App. 233 (2019). 4. Schedule the Veteran for an examination with the appropriate medical professional to determine the origin and nature of his bilateral shin disability. The examiner is asked to provide an opinion as to the following: (a.) After appropriate diagnostic testing, including x-ray or other imaging studies, diagnose any current left and/or right shin disability. (b.) Determine whether any shin disability is at least as likely as not (50 percent probability or greater) began in service or is otherwise related to service. (c.) If the answer to (b) above is “no,” determine if the current shin disability is at least as likely as not (50 percent probability or greater) caused or aggravated by the Veteran’s service-connected Parkinson’s Disease, including balance issues related to Parkinson’s Disease. Any increase in disability should be described in terms of diagnosis, severity, and duration. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation the shin(s), by the service-connected disability. The examiner is advised that the term “aggravation” in this context does not require that there be “permanent” worsening of the nonservice connected disability. Ward v. Wilkie, 31 Vet. App. 233 (2019). 5. Schedule the Veteran for a VA peripheral nerves examination concerning the Veteran’s service-connected tremor, muscle rigidity, and bradykinesia of the right upper and lower extremities. The examiner should review all pertinent evidence of record in connection with the examination. The examiner should list and describe the severity of each affected nerve in the right upper and lower extremities. In doing so, the examiner should specifically indicate whether the Veteran’s tremors, muscle rigidity, and bradykinesia affect all right radicular groups and his right sciatic nerve. The examiner should then address all functions affected by each damaged nerve. The examiner should specifically indicate whether any function affected by the damage in one nerve overlaps with a function affected by the damage in another nerve and, if so, identify those cases. 6. Schedule the Veteran for VA examinations to determine the current severity of his service-connected stooped posture and right and left wrist sprains. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, for each disability, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Additionally, for each disability, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 7. Then, readjudicate the Veteran’s claims. If the claims remain denied, issue the Veteran and his attorney a supplemental statement of the case and allow the appropriate time for response. Then, return the claims to the Board for adjudication. TIFFANY DAWSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. T. Raftery, 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.