Citation Nr: 21012032 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 13-22 481 DATE: March 3, 2021 ORDER 1. Entitlement to service connection for rectal condyloma is denied. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. 3. Entitlement to increases in the (10 percent prior to July 14, 2010 and 50 percent from that date) staged ratings assigned for depression with anxiety, is denied. 4. Entitlement to increases in the (0 percent prior to July 14, 2010 and 30 percent from that date) staged ratings assigned for migraine headaches is denied. 5. Entitlement to a compensable rating for allergic rhinitis is denied. 6. Entitlement to a compensable rating for hemorrhoids is denied. 7. Entitlement to a compensable rating for acne is denied. 8. Entitlement to a compensable rating for bilateral hearing loss is denied. REMANDED 9. Entitlement to service connection for rosacea is remanded. FINDINGS OF FACT 1. The Veteran is not shown to have had a diagnosis of rectal condyloma during the pendency of the instant claim. 2. The Veteran is not shown to have had a diagnosis of PTSD during the pendency of the instant claim. 3. Prior to July 14, 2010, the Veteran’s depression disability picture was best characterized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication; occupational and social impairment with occasional decrease in work efficiency was not shown; from July 14, 2010, the depression disability picture is best characterized as occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas due to depression is not shown. 4. Prior to July 14, 2010, the Veteran’s migraine headaches were not shown to be manifested by characteristic prostrating attacks averaging one in 2 months over the last several months; from that date, the migraine headaches are not shown to have been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 5. At no time is the Veteran’s allergic rhinitis shown to have been manifested by greater than 50 percent obstruction of the nasal passages on both sides or complete obstruction on one side. 6. At no time are the Veteran’s hemorrhoids shown to have been more than mild or moderate; large or thrombotic, or irreducible, hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences, are not shown. 7. Throughout, the Veteran’s acne has been superficial (and not deep); it is not shown to have been manifested by scars of the head, face, and neck. 8. At no time under consideration is the Veteran’s hearing acuity shown to have been worse than Level III in the left ear or Level II in the right ear. CONCLUSIONS OF LAW 1. Service connection for rectal condyloma is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303, 3.304. 2. Service connection for PTSD is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303, 3.304. 3. Entitlement to increases in the (10 percent prior to July 14, 2010 and 50 percent from that date) ratings assigned for depression with anxiety is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code (Code) 9434. 4. Entitlement to increases in the (0 percent prior to July 14, 2010 and 30 percent from that date) ratings assigned for migraine headaches is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.124a, Code 8100. 5. A compensable rating for allergic rhinitis is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.97, Code 6522. 6. A compensable rating for hemorrhoids is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.114, Code 7336. 7. A compensable rating for acne is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Code 7828. 8. A compensable rating for bilateral hearing loss is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, Code 6100, 4.86. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from July 1982 to July 1986, December 1992 to March 2004, and September 2006 to May 2009. These matters are before the Board of Veterans’ Appeals (Board) on appeal from November 2011, February 2012,, and May 2013 rating decisions. In November 2016, a videoconference hearing was held before the undersigned; a transcript is in the record. In October 2017, the case was remanded for further development. The November 2011 rating decision assigned a 0 percent rating for migraine headaches. A May 2013 rating decision increased the rating for migraine headaches to 30 percent, effective July 14, 2010. An April 2016 rating decision implemented a reduction in the rating from 30 to 0 percent effective July 1, 2016; however, a March 2020 rating decision increased the rating for migraine headaches to 30 percent effective July 1, 2016, essentially restoring the pre-reduction rating. The March 2020 rating decision also granted service connection for lumbar strain and gastroesophageal reflux disease (GERD). Therefore, those issues are no longer on appeal. The October 2017 Board remand noted that an August 2016 rating decision denied service connection for left and right wrist carpal tunnel syndrome and continued a 0 percent rating for right epididymal cyst. In November 2016 the Veteran filed a notice of disagreement (NOD) with that decision, initiating an appeal in the matter. The Board indicated that the matters were downstream issues, and were not yet fully before the Board, and would only be so if the Veteran perfected appeals in the matters by timely filing a substantive appeal after (and if) a Statement of the Case (SOC) was issued. It was also noted that a March 2015 rating decision denied a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) and that the matter of entitlement to a TDIU rating was not before the Board at that time, and would only be before the Board if the Veteran timely filed a substantive appeal after a SOC was issued. In October 2017 a SOC for TDIU, a compensable rating for right epididymal cyst, and service connection for left and right carpal tunnel syndrome was issued. In November 2017 the Veteran filed a Form 9 in response to the October 2017 SOC and requested a videoconference hearing. A Board hearing on those issues has not yet been held; therefore, they are not currently before the Board. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a present disability; incurrence or aggravation of a disease or injury in service; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). 1. Service connection for rectal condyloma is denied. The Veteran’s service treatment records (STRs) are silent for complaints of, treatment for, or a diagnosis of, rectal condyloma. In a November 2011 statement, the Veteran reported that during service (approximately 15 years earlier) he sought private treatment for rectal condyloma. He did not identify the private provider. On April 2013 VA rectum and anus examination, a previous diagnosis of hemorrhoids was noted. The Veteran reported hemorrhoids during service but currently was not bothered by hemorrhoids, and did not take medication for them. Rectal condyloma was not diagnosed. On examination, his rectal/anal area was normal, and it was indicated that external hemorrhoids, anal fissures or other rectal abnormalities were not noted. On July 2016 VA rectum and anus examination, rectal condyloma was not diagnosed. The examiner noted a previous diagnosis of hemorrhoids. The Veteran reported that he had not been bothered by hemorrhoids in quite a while and was not currently receiving treatment for them. At the November 2016 videoconference hearing, the Veteran testified that he only sought private treatment (and no military treatment) for rectal condyloma during service. He related that in 1992 he sought treatment from a private provider and indicated that the records of such treatment were no longer available. He reported that he did not have any current residuals of the rectal condyloma but that he was concerned about having once had them for fear such might predispose him to rectal cancer. The threshold requirement that must be met with respect to this claim (as with any claim seeking service connection, whether direct or secondary) is that there must be competent evidence that the Veteran currently has (during the pendency of the claim has had) the disability for which service connection is sought, rectal condyloma. See 38 U.S.C. § 1110, 1131. The record does not include any such evidence. Postservice VA and private treatment records associated with the record, including VA examinations, do not show a diagnosis of, or treatment for, rectal condyloma; such disability simply is not shown. The Veteran has not provided any competent evidence he has rectal condyloma and/or current residuals of rectal condyloma during the period on appeal (and he does not allege that he currently has rectal condyloma. In the absence of proof of the disability for which service connection is sought (rectal condyloma), there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against the claim of service connection for rectal condyloma, and the appeal in this matter must be denied. 2. Entitlement to service connection for PTSD is denied. The Veteran’s STRs are silent for complaints of, treatment for, or a diagnosis of, PTSD. A November 2009 PTSD screen was negative. On May 2011 VA mental disorders examination, depressive disorder not otherwise specified (NOS) was diagnosed . The Veteran reported that he had not had any previous mental health treatment and that he was prescribed Bupropion and Zanax through a community physician to improve his mood symptoms. The examiner opined that the Veteran did not meet the diagnostic criteria for PTSD and that he had not had a trauma incident related to hostile military or terroristic activity. The Veteran did, however, meet the criteria for Depression NOS based on his symptom profile. It was further noted that the Veteran had anxiety with the depression, but it was not severe enough to include a separate diagnosis. An October 2010 PTSD screen was positive. On April 2013 VA mental disorders examination, major depressive disorder, recurrent, moderate to severe, was diagnosed. PTSD was not diagnosed. The examiner noted that the Veteran had not sought VA mental health treatment since November 2010. A July 2013 PTSD screen was positive. On February 2015 VA mental disorders examination, alcohol use disorder and major depressive disorder, recurrent, moderate, with anxious distress, were diagnosed. PTSD was not diagnosed. On July 2016 VA mental disorders examination, alcohol use disorder and major depressive disorder, recurrent, moderate, with anxious distress were diagnosed. PTSD was not diagnosed. The Veteran reported that he had not sought VA psychiatric treatment since his February 2015 examination; he indicated that he received psychotropic medication from a private provider. At the November 2016 videoconference hearing, it was noted that the Veteran did not have a DSM-V diagnosis for PTSD, and did not indicate that any medical provider (VA or private) had diagnosed PTSD. He testified that he had not sought VA treatment for his psychiatric disability other than appearing for compensation and pension examinations. He related that he sought private treatment from a general practitioner (not a psychologist or psychiatrist) who prescribed medication for depression. The initial threshold matter that must be addressed here (as in any claim seeking service connection) is whether there is competent evidence that the Veteran currently has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., a clinical diagnosis of PTSD. See 38 U.S.C. § 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007). As noted, the May 2011 VA examiner found that the Veteran did not have a diagnosis of PTSD. No postservice treatment records or examination reports show that he has PTSD; his depression is service-connected. While the Veteran is competent to observe that he has had mental health complaints or symptoms in the past, the diagnosis of a psychiatric disability is a medical question. The evidence does not show that the Veteran has, or at any time during the pendency of the instant claim has had, a diagnosis of PTSD in accordance with DSM provisions by a medical professional competent to diagnose mental disorders. The Board notes the Veteran’s statements contending he has PTSD. While he is competent to describe lay discernible psychiatric symptoms, he is not competent to establish by his own opinion that the symptoms he has observed reflect an underlying diagnosis of PTSD. The diagnosis of a PTSD is a medical question beyond the scope of general knowledge and incapable or resolution by lay observation; it requires medical training/expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is a medical professional (a nurse) he is not a psychiatrist or psychologist and does not cite to an adequate supporting medical opinion or medical treatise evidence. The only competent, and adequate, medical evidence in the record addressing whether the Veteran has/has had, a diagnosis of PTSD, is in the report of a May 2011 VA mental disorders examination, which found that his symptoms do not meet the criteria for a diagnosis of PTSD. The report is by a medical professional who is competent to provide it, and it is probative evidence regarding whether the Veteran has a diagnosis of PTSD. As there is no adequate competent evidence to the contrary, it is persuasive. The Board notes that October 2010 and July 2013 VA PTSD screens were positive; however, the questions only noted that the Veteran reported nightmares and that avoided situations reminding him of an incident, but the incident was not identified and there was no indication that it occurred during his active duty service. In the absence of proof of a current diagnosis of PTSD, there is no valid claim of service connection for such disability. See Brammer v. Derwinski, 3 Vet. App. at 225; see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998), cert. denied, 526 U.S. 1144 (1999). The preponderance of the evidence is against the Veteran’s claim. Accordingly, the benefit of the doubt rule does not apply; the appeal in this matter must be denied. Gilbert v. Derwinski, 1 Vet. App. at 55. (The Veteran is advised that future evidence that he has a diagnosis of PTSD may present a basis for reopening this claim.) Increased rating claims Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular code, the higher rating is to be assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is to be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. When the appeal is from the initial rating assigned with a grant of service connection, (as is the case for the depression, migraine headaches, allergic rhinitis, hemorrhoids, and acne claims) the severity of the disability during the entire period from the grant of service connection to the present is to be considered. “Staged” ratings may be assigned for distinct periods when different levels of impairment are shown. Fenderson v. West, 12 Vet. App. 119 (1999). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. 3. Entitlement to increases in the (10 percent prior to July 14, 2010 and 50 percent from that date) staged ratings assigned for depression with anxiety, is denied. Depression is rated under Code 9434 and the criteria in the General Rating Formula for Mental Disorders (General Formula). A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or with symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is 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. A 70 percent rating is warranted when there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9434. Ratings for psychiatric disability are assigned according to the manifestation of particular symptoms, but the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to 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). Accordingly, the evidence considered in determining the level of impairment from a psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms listed in the General Rating Formula for Mental Disorders. Instead, VA must consider all symptoms of a claimant’s condition that affect occupational and social function. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A November 2011 rating decision granted service connection for depression with symptoms of anxiety at 10 percent, effective June 1, 2009. The Veteran filed a timely NOD, and a May 2013 DRO decision increased the rating for depression with symptoms of anxiety to 50 percent, effective July 14, 2010. Therefore, the period from June 1, 2009 is on appeal and the issue has been characterized as entitlement to entitlement to increases in the (10 percent prior to July 14, 2010 and 50 percent from that date) staged ratings assigned for depression with anxiety. A November 2009 depression screen was negative. A February 2010 private psychiatric treatment record notes that the Veteran’s judgment and insight were realistic, and he showed no signs of impulsiveness. There was no evidence of recent or distant memory impairment, his mood was level, and his affect was appropriate. His speech was normal, and no impairment to abstract thinking was shown. A March 2010 private treatment record notes that the Veteran’s judgment and insight were normal, he was alert and oriented, and there was no evidence of recent or distant memory impairment. His mood was level, his affect was appropriate, and the quantity, rate, volume, and clarity of his speech was normal. There was no impairment to abstract thinking shown. A November 2010 VA treatment record notes that the Veteran was not suicidal or homicidal. He reported insomnia but did not have trouble falling asleep. He woke up in the middle of the night for an hour, which occurred 3-4 nights a week. A February 2011 private treatment record notes that the Veteran’s judgment and insight were normal, he was alert and oriented, and there was no evidence of recent or distant memory impairment. His mood was level, his affect was appropriate, and the quantity, rate, volume, and clarity of his speech was normal. There was no impairment to abstract thinking shown. On May 2011 VA mental disorders examination, the Veteran reported that he was first seen by VA in 2010 because irritability and anger began to interfere in his life and relationship. He related that he became jumpy and irritable while still in service about two years earlier because of having to work overnight hours as nurse in urgent care without another person to assist him in a crisis. He reported that Zanax helped him sleep and calmed him down to a small degree; that he had not previously sought mental health treatment; and that he took Bupropion and Zanax prescribed by a private provider. The examiner noted that the Veteran’s symptoms included depressed mood, anxiety, disturbances of motivation and mood, exaggerated startle effect, diminished interest in pleasurable activities, irritability (anger/road rage), insomnia, loss of energy and motivation, withdrawal, reduced socialization, and recurring mildly distressing dreams. Depressive disorder not otherwise specified (NOS) was diagnosed. The examiner opined that the Veteran’s occupational and social impairment with regard to all mental diagnoses was best described as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner opined that the Veteran appears to have a depressive disorder, but his symptoms are mostly physical/vegetative except for anger/impulse control problems. His depressed mood appears mild and may resolve with counseling and through environmental changes. A May 2011 VA treatment record notes that the Veteran denied feelings of anxiety, depression, or mood swings. A June 2011 private treatment record notes that the Veteran’s judgment and insight were normal, he was alert and oriented, and there was no evidence of recent or distant memory impairment. His mood was level, his affect was appropriate, and the quantity, rate, volume, and clarity of his speech was normal. There was no impairment to abstract thinking shown. An October 2011 private treatment record notes that the Veteran’s judgment and insight were normal, he was alert and oriented, and there was no evidence of recent or distant memory impairment. His mood was level and his affect was appropriate. The quantity, rate, volume, and clarity of his speech was normal, and no impairment to abstract thinking was shown. A December 2011 private psychiatric treatment record notes that the Veteran’s judgment and insight were realistic, and he showed no signs of impulsiveness. He was alert and oriented, and there was no evidence of recent or distant memory impairment. His mood was level and his affect was appropriate. On April 2013 VA mental disorders examination, the Veteran reported that he worked away from home but returned home e weekends to spend time with his partner of 16 years. He reported that he and his partner have “gone through a pretty rough time in the last few years,” mainly related to the geographical distance between them. The Veteran related that he is introverted, but his partner is outgoing, and that caused tension. He reported that he remained close to his sisters who live across the country and that he has some friends but feels uncomfortable meeting new people, particularly in large groups. He related that he can be temperamental. The Veteran reported that he has worked as a VA nurse for the past two years and enjoys his job, but had a conflict with a doctor about six months earlier when he was approached in an aggressive manner. He related that his depression and anxiety have increased due to that situation. The Veteran reported that he had not sought VA mental health treatment, but his private provider prescribed him Bupropion for depression, Provigil for daytime fatigue, and Xanax as needed for anxiety and sleep. The examiner noted that the Veteran’s symptoms included almost daily depression, anxiety, lack of motivation to exercise, anhedonia, increase in appetite (has gained 30 pounds), a lack of self-confidence, hopelessness, middle-night waking (averages 5 hours of sleep per night), decline in energy, restlessness, ruminative thoughts regarding work stress, decline in sex drive, poor concentration, a decline in short-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, include work or a worklike setting, and social withdrawal. On mental status examination, the Veteran was oriented to all spheres, his appearance was disheveled, his speech, thought content, and psychomotor activity were within normal limits. His judgment and insight were adequate, and he denied hallucinations. His recent mood was mainly depressed/hopeless. The Veteran admitted to having thoughts such as, “If I didn’t wake up tomorrow, I would have no regrets.” However, he denied overt suicidal thoughts and had never attempted suicide. He denied homicidal ideation. Major depressive disorder, recurrent, moderate to severe, was diagnosed. The examiner opined that the Veteran’s occupational and social impairment with regard to all mental diagnoses was best described as occupational and social impairment with reduced reliability and productivity. A July 2013 VA treatment record notes a diagnosis of depression with no anxiety or nightmares. August 2013 to February 2014 private treatment records note that on examination, the Veteran was alert, and he had normal speech, judgment, and insight. He was oriented to time, place, and person and had normal recent and remote memory. No anxiety, agitation, and depressed affect were shown. Major depressive affective disorder, recurrent, mild was consistently diagnosed. A March 2014 private treatment record notes that the Veteran had normal judgment and insight, and he was oriented to time, place, and person. He had normal remote memory. An October 2014 private mental capacity assessment notes the Veteran’s degree of limitation in certain activities. The provider indicated that he had no limitations in ability to interact appropriately with the general public and his ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. he had slight limitations in ability to sustain an ordinary routine without special supervision, his ability to work in coordination with or in proximity to others without being distracted by them, his ability to make simple work-related decisions, his ability to ask simple questions or request assistance, his ability to accept instructions and respond appropriately to criticism from supervisors, his ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, his ability to be aware of normal hazards and take appropriate precautions, and his ability to set realistic goals or make plans. He had moderate limitations in ability to carry out very short and simple instructions, ability to carry out detailed instructions, ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary limits, ability to complete a normal workday without interruptions from psychologically based symptoms, ability to respond appropriately to changes in the work setting, and ability to travel in unfamiliar places or use public transportation. The provider indicated that the Veteran had extreme limitations in ability to maintain attention and concentration for extended periods and to perform at a consistent pace with a one hour lunch break and two fifteen minute rest periods, and would likely have more than ab average amount of absences in a normal month. On February 2015 VA mental disorders examination, the Veteran reported that he lived with his partner of the past 17 years and that their relationship has improved because he used to commute to work and only be at home on weekends, but quit working 1.5 years ago and was now home full time. He related that they enjoy cooking, watching movies, and caring for their pets and that he enjoys boating. He reported that he had a close relationship with his sisters, had infrequent contact with his father, and had not had contact with his mother for 20 years. He reported that he had a few personal friendships and went to the gym once a week. He related that he had no difficulties during his employment except for one incident when a physician approached him aggressively with fists clenched. He filed an incident report and after that was treated less favorably by the administration; he never received negative performance evaluations. He reported that he last received mental health treatment approximately 1.5 years earlier. Bupropion was prescribed, but had not renewed it for the past 8 months. The examiner noted that the Veteran’s symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, the Veteran was oriented to all spheres, his affect was congruent with his stated mood and symptoms, and he was relatively calm and responsive. His speech had normal rhythm and content, and he maintained focus on topics and responded appropriately to questions. There was no evidence of a formal thought disorder. The Veteran’s insight and judgment were grossly intact, and he denied active suicidal ideation, planning, and intent. He reported a lack of pleasure in activities, occasional hopelessness, feelings of worthlessness, and nightmares, and denied significant energy impairments. Alcohol use disorder and major depressive disorder were diagnosed. The examiner opined that the Veteran’s occupational and social impairment with regard to all mental diagnoses was best described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner opined that regarding physical and sedentary employability, the Veteran’s current symptoms contribute to mild to moderate impairments. He had performed well in recent employment settings and may experience anxiety that might necessitate brief breaks at work. He may also experience mild decreases in efficiency at work related to poor sleep/energy and occasional concentration impairments. On July 2016 VA mental disorders examination, the Veteran reported that he is married and lives with his partner of 20 years. He related that their relationship was good, he was estranged from his mother, had a decent relationship with his father, and had a very close relationship with his 3 sisters. He reported that he enjoyed staying home and watching movies with his two dogs and that he and his partner recently bought an RV and they had been traveling frequently. He related that they socialize but expressed frustration at maintaining relationships because some friends do not maintain contact. He reported that he has been unemployed since 2013 and had unsuccessfully attempted to find a nursing job since then. He had prescriptions for Wellbutrin and Modafinil. The examiner noted that the Veteran’s symptoms included depression, anxiety, low self-esteem, anhedonia, sleep issues (attributes it to working so many different shifts), middle insomnia (difficulty staying asleep), impaired concentration, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, the Veteran’s mood was sad because he was frustrated over inability to lose weight. His remote and recent memory was good, his concentration was impaired, his orientation was within normal limits, and his appearance was neat. His speech and thought process were normal, and he denied hallucinations. His judgment was adequate, his insight was fair, and he denied suicidal and homicidal ideation. The examiner observed that the Veteran reported experiencing some depression and anxiety related to being unemployed, and that he last worked as a VA nurse but resigned due to stressors from his supervisor. He reported trying to find another job, without success, and this, in turn, increased his feelings of depression, anxiety, and low self-esteem. Additionally, he continued to drink daily which only exacerbated his depressive symptoms. The examiner opined that the Veteran’s depressive symptoms may be inhibiting him from finding employment, but such symptoms do NOT preclude him from being gainfully employed. Alcohol use disorder and major depressive disorder were diagnosed. The examiner opined that the Veteran’s occupational and social impairment with regard to all mental diagnoses was best described as occupational and social impairment with reduced reliability and productivity. At the November 2016 videoconference, the Veteran testified that he had a severe lack of energy, was socially withdrawn, and preferred to stay home most of the time. He related that he did not take sick leave when he was working due to his mental disorder, and that the disorder did not affect his ability to go to work. He reported that his mental disorder affected his ability to relate to other people, and the impact of his mental disorder on such situations had not improved but also not worsened. He prepares meals, buys groceries, and does light house chores. He reported he does not like large crowds, but does not mind shopping; that he is easily startled; and that he is comfortable with small groups in closed spaces. He reported that he was close with his sisters and that they are about the only people that he speaks to on a regular basis other than his spouse. He related that his sisters live in California, so he communicates with them by phone about every three days. The Veteran related that his spouse tries to get him to go out, and that when they went out, they would have dinner with small groups of friends. The Board finds that prior to July 14, 2010, the Veteran’s depression most closely approximated a disability picture characterized as occupational and social occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or with symptoms controlled by continuous medication, as contemplated by the criteria for the 10 percent rating assigned. The disability picture presented does not reflect or suggest occupational and social impairment with occasional decrease in work efficiency, which would warrant a 30 percent rating. VA and private mental health treatment records from June 2009 to July 2010 are sparse. A November 2009 VA depression screen was negative. February and March 2010 private psychiatric treatment records note that the Veteran’s judgment and insight were realistic, he had no signs of impulsiveness, and there was no evidence of recent or distant memory impairment. His mood was level, his affect was appropriate, his speech was normal, and no impairment to abstract thinking was shown. Such symptoms are not consistent in nature and severity with the types of symptoms in the criteria for a 30 percent rating. More significantly, he is not shown to have had occupational and social impairment with occasional decrease in work efficiency. Therefore, a rating in excess of 10 percent for depressive disorder was not warranted prior to July 14, 2010. The Board finds that from July 14, 2010, the Veteran’s depression has most closely approximated a disability picture characterized as occupational and social impairment with reduced reliability and productivity, as contemplated by the criteria for the 50 percent rating assigned. The disability picture presented does not reflect or suggest occupational and social impairment with deficiencies in most areas, which would warrant a 70 percent rating. His symptoms of depression, anxiety, low self-esteem, occasional hopelessness/worthlessness, chronic sleep impairment, impaired concentration, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, include work or a worklike setting, and social withdrawal, while certainly disabling are not consistent in nature and severity with the types of symptoms in the criteria for a 70 percent rating (except for the one instance of difficulty in adapting to stressful circumstances, include work or a worklike setting noted on April 2013 VA examination). He is not shown to have ever had occupational and social impairment with deficiencies in most areas. From July 14, 2010 the Veteran was able to maintain employment (full-time until he resigned from VA in 2013) and to maintain relations with family. Throughout, he has reported various issues in his marital relationships such as wanting to isolate but being prodded by his spouse to go out more and dine with friends, but has also expressed how much he enjoyed certain activities with his spouse such as watching movies, cooking, and traveling in their RV. He reported estrangement from his mother, but he reported good relationships with his father and sisters. He related that although he would rather be by himself most of the time, he has no difficulty shopping and going to the grocery store on a regular basis. The Board finds that rather than reflecting deficiencies in familial relationships, his accommodations for family and choices in prioritizing conflicting demands from his spouse and friends, reflect admirable familial responsibility and functioning. He has tended to activities of daily living on his own. On April 2013 VA examination, a symptom of difficulty in adapting to stressful circumstances, include work or a worklike setting, was noted and the Veteran related that “If I didn’t wake up tomorrow, I would have no regrets.” However, he denied overt suicidal thoughts, had never attempted suicide, and denied homicidal ideation. During the period for consideration, the Veteran has not reported having suicidal ideation prior, or subsequent to, the April 2013 statement. The Veteran also related that although he had recently had some conflict at work, he enjoyed his job, and he indicated that he got along well with his sisters and did have some friends. An October 2014 private mental capacity assessment notes the Veteran’s degree of limitation in certain work-related activities, and the Board notes that the assessment does not specifically indicate the impact that his service-connected depression (solely) has on his mental capacity; rather it seems to take into account all of the Veteran’s (not specifically identified) cognitive difficulties. Although the provider noted that the Veteran would have extreme limitations in his ability to maintain attention and concentration for extended periods and his ability to perform at a consistent pace with a one hour lunch break and two fifteen minute rest periods, and he would likely have more than the average amount of absences in a normal month, it was also noted that he only had slight limitations in ability to sustain an ordinary routine without special supervision, work in coordination with or in proximity to others without being distracted by them, make simple work-related decisions, accept instructions and respond appropriately to criticism from supervisors, and set realistic goals or make plans. And at the November 2016 videoconference hearing, he testified that his mental disorder did not affect his ability to go to work. The Board observes that from July 14, 2010, the Veteran worked full-time, until May 2013, and denied ever being reprimanded for work performance. The records do not show or suggest an inability to tend to activities of daily or to financial matters, and while he described some difficulty at work (such as the incident with his supervisor ) and difficulty with family members, nonetheless, he has been successfully committed to his partner for over 20 years, has maintained good relationships with his sisters and father, is able to dine out with small groups of friends, and enjoys traveling with his spouse. Therefore, a rating in excess of 50 percent from July 14, 2010 is not warranted. 4. Entitlement to increases in the (0 percent prior to July 14, 2010 and 30 percent from that date) staged ratings assigned for migraine headaches is denied. Migraine headaches are rated under Code 8100, which provides for a 0 percent rating with less frequent attacks; a 10 percent rating when there are characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating when there are characteristic prostrating attacks occurring on an average once a month over the last several months; and a higher (50 percent, maximum schedular) rating is warranted for migraines with very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The rating criteria do not define “prostrating” and the courts have not undertaken to define “prostrating” for purposes of Diagnostic Code 8100. See Fenderson, 12 Vet. App. at 119. According to Webster’s New World Dictionary of American English, Third College Edition (1986), p. 1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A November 2011 rating decision granted service connection for migraine headaches, rated 0 percent, effective June 1, 2009. A February 2010 private treatment record notes that the Veteran denied headaches. An October 2010 VA treatment record notes that the Veteran reported migraine headaches but no dizziness or weakness. A December 2011 private treatment record notes that the Veteran denied headaches. An August 2012 private medical statement notes that the Veteran reported that his migraines had been associated with nausea and vomiting as well as a preceding aura with decreased peripheral vision that last 15 to 20 minutes. He related that he took Sumatriptan which was very effective, and experienced an average of one migraine a month. The provider noted that the Veteran had two episodes of left monocular amaurosis fugax (temporary vison loss) consistent with probable transient ischemic attacks in the setting of hypertension and hypercholesterolemia. An August 2012 brain MRI showed mild cerebellar atrophy, mild supratentorial atrophy, and no acute or subacute ischemic process. A September 2012 headache disability benefits questionnaire (DBQ) notes a diagnosis of migraines, and the Veteran reported right hemicranial headaches with sharp quality worse in the right periorbital region associated with restriction of visual fields as an aura as well as nausea and vomiting. The Veteran related that he took medication for his migraines, that he had characteristic prostrating attacks of migraine headache pain once a month, and that he experienced no very frequent prostrating and prolonged attacks of migraine (or non-migraine) headache pain. It was noted that the Veteran experienced two episodes in the last two years of left eye amaurosis fugax (temporary vision loss). September 2012 brain MRI, carotid duplex, and echocardiogram were within normal limits. The provider indicated that the Veteran’s migraine headaches would impact his ability to work but provided no further explanation. On April 2013 VA headaches examination, the examiner noted a diagnosis of migraine headaches. The Veteran reported that he took Sumatriptan as needed, experienced constant head pain on both sides of his head that lasted less than one day per episode and worsened with activity, and had non-headaches symptoms such as nausea, sensitivity to light, and changes in vision. He reported characteristic prostrating attacks of migraine headache pain once every two months and no very frequent prostrating and prolonged attacks of migraine headache pain. He reported no prostrating attacks of non-migraine headache pain. The examiner opined that the Veteran’s migraine headaches did not impact his ability to work. A May 2013 Decision Review Officer (DRO) decision increased the rating for migraine headaches from 0 percent to 30 percent, effective July 14, 2010. A July 2013 VA treatment record notes that the Veteran reported headaches/migraines with no dizziness or weakness. In a May 2014 private vocational assessment, the provider notes that the Veteran’s migraine headaches impacted his ability to work; however, no rationale was provided that indicated what migraine headache symptoms impacted his ability to work. A May 2014 VA treatment record notes that the Veteran reported that his migraine medication was working well. On March 2015 VA headaches examination, the examiner noted a diagnosis of migraine headaches. The Veteran reported that he took Zomig for headache pain and experienced a migraine once every 2 weeks that lasted for approximately 1 hour if he had medication on hand. He reported headache pain localized to one side of his head that worsened with physical activity and that felt like he had been struck with an icepick between the eyes. It was noted that the Veteran had two episodes in the last few years in which he temporarily lost sight in one eye. He reported non-headache symptoms of nausea, vomiting, sensitivity to light and sound, changes in vision, and sensory changes. The duration of the pain was typically less than a day; the pain was on the right side of his head. The Veteran reported non characteristic prostrating attacks of migraine/non-migraine pain. The examiner opined that migraine headaches do not impact the Veteran’s ability to work. A March 2015 rating decision proposed to reduce the rating for the migraine headaches from 30 percent to 0 percent based on the results of the March 2015 VA headaches examination. A May 2015 VA treatment record notes that the Veteran reported no headaches, dizziness, or weakness. An April 2016 rating decision reduced the rating for migraine headaches from 30 percent to 0 percent, effective July 1, 2016. On July 2016 VA headaches examination, the examiner noted a diagnosis of migraine headaches. The Veteran reported that he took Zomig for headache pain and experienced a migraine episode once a week that lasted up to 8 hours per episode. He related that he had not experienced further episodes of the amaurosis fugax. The Veteran reported pulsating or throbbing head pain that was localized to one side of his head, and he reported non-headache symptoms of nausea, sensitivity to light and sound, and changes in vision. He reported characteristic prostrating attacks of migraine/non-migraine headache pain that occurred once a month. He did not report any very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The examiner opined that there was no objective evidence to support that the Veteran’s migraine headaches would present functional impairments that would impact physical or sedentary employment. At the November 2016 videoconference hearing, the Veteran testified that he experienced migraine headaches once a week in varying severity and took medication for the migraines, as needed. He related that during a migraine episode he experienced blurry vision and a painful point on his head where the migraines started, and that a typical migraine lasted from two to five hours. He related that the severity of his migraine headaches had remained about the same for the last several years and had not decreased in severity. A March 2020 rating decision increased the rating for the Veteran’s migraine headaches to 30 percent, effective July 1, 2016. Prior to July 14, 2010, the Veteran’s migraines are rated 0 percent disabling. The evidence does not show the migraines were manifested by characteristic prostrating attacks averaging one in 2 months over the last several months (for a 10 percent rating under Code 8100). Private and VA treatment records provide evidence against the Veteran’s claim. Specifically, a February 2010 private treatment record notes that the Veteran reported no current headaches. There is no evidence that he has had characteristic prostrating attacks averaging one in 2 months, or more frequently (or equivalent disability). The level of related impairment (no characteristic prostrating attacks) falls squarely within the criteria for a 0 percent rating under Code 8100. Therefore, a compensable rating for migraine headaches prior to July 14, 2010, is not warranted. From July 14, 2010, the Veteran’s migraines are rated 30 percent disabling. The evidence does not show that at any time since the migraines were manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability (so as to warrant a 50 percent rating under Code 8100). On April 2013 VA examination, the Veteran reported characteristic prostrating attacks of migraine headache pain once every two months, and on July 2016 VA examination, he reported characteristic prostrating attacks of migraine/non-migraine headache pain once a month. He denied very frequent prostrating and prolonged attacks of migraine headache pain on each examination. At the November 2016 videoconference hearing, he testified that the frequency of his migraine headaches seemed to have increased (up to once a week) but the severity of the migraine headaches did not appear to have reached the level of completely prostrating and prolonged attacks productive of severe economic inadaptability. The level of related impairment (characteristic prostrating attacks occurring on an average once a month over the last several months) falls squarely within the criteria for a 30 percent rating under Code 8100. Therefore, a rating in excess of 30 percent for migraine headaches from July 14, 2010, is not warranted. 5. Entitlement to a compensable rating for allergic rhinitis is denied. The Veteran’s allergic rhinitis is rated 0 percent. A 30 percent rating is warranted for allergic or vasomotor rhinitis with polyps. Without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, a 10 percent evaluation is warranted. 38 C.F.R. § 4.97, Code 6522. A December 2011 private treatment record notes that the Veteran denied nasal stuffiness, drainage, and sinus trouble. On April 2013 VA sinusitis and rhinitis examination, allergic rhinitis was diagnosed. The Veteran reported that he took Fexofenadine daily which helped control his symptoms. On examination, it was noted that there was not greater than 50 percent obstruction of both nasal passages, not complete obstruction of one nasal passage due to rhinitis, no permanent hypertrophy of the nasal turbinates, and no nasal polyps. A March 2014 private treatment record notes that the Veteran reported no nasal discharge. A May 2015 VA treatment record notes that a prescription for Loratadine was ordered for the Veteran’s rhinitis. On July 2016 VA sinusitis and rhinitis examination, allergic rhinitis was diagnosed. The Veteran reported that he had required ongoing care and daily treatment for his allergic rhinitis. He reported symptoms of itchy, watery eyes, rhinitis, and frequent sneezing and that he took Claritin daily. On examination, it was noted that there was not greater than 50 percent obstruction of both nasal passages, not complete obstruction of one nasal passage due to rhinitis, and no nasal polyps. There was permanent hypertrophy of the nasal turbinates. At the November 2016 videoconference hearing, the Veteran testified that he took daily medication (a prescribed nasal spray and oral medication) for itchy, watery, burning eyes, and a runny nose. Neither the April 2013 nor the July 2016 VA examination found complete obstruction of a nasal passages on one side or a greater than 50 percent obstruction on both sides. Accordingly, the criteria for a compensable rating for allergic rhinitis are not met. The symptoms and related functional impairment the Veteran describes in his own reports do not satisfy the schedular criteria for a rating for a compensable rating for allergic rhinitis. Accordingly, the Board finds that the preponderance of the evidence is against this claim. 6. Entitlement to a compensable rating for hemorrhoids is denied. The Veteran’s hemorrhoids are rated under Code 7336, which provides for a 0 percent rating for mild or moderate external or internal hemorrhoids. A 10 percent rating is warranted for large or thrombotic external or internal hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A (maximum) 20 percent rating is warranted for external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114. A December 2011 private treatment record notes that the Veteran reported that he currently did not have hemorrhoids. On April 2013 VA rectum and anus examination, a previous diagnosis of hemorrhoids was noted. The Veteran reported that he had intermittent episodes of hemorrhoids and did not take medication for them. On examination, his rectal/anal area was normal, and it was indicated that no external hemorrhoids, anal fissures or other rectal abnormalities were noted. On July 2016 VA rectum and anus examination, a previous diagnosis of hemorrhoids was noted. The Veteran reported that his hemorrhoids had not bothered him in a while and that he was not currently taking any medication for them. No anal/rectal examination was conducted because the Veteran reported that he was totally asymptomatic. At the November 2016 videoconference hearing, the Veteran reported occasional rectal bleeding if he drove for an extended period of time, that he did not currently have hemorrhoids, and that if he had a hemorrhoid, he used Preparation H. The evidence outlined above shows that the symptoms of the Veteran’s hemorrhoids do not exceed the criteria for a 0 percent rating under Code 7336. Although VA treatment records and the Veteran’s testimony note occasional occurrences of hemorrhoids, at no time during the period on appeal have his hemorrhoids been described (even by the Veteran) as large or thrombotic external or internal hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences, which would warrant a 10 percent rating, and VA examinations do not note that presence of hemorrhoids. The preponderance of the evidence (including the Veteran’s self-reports of symptoms) is against a finding of more than mild or moderate hemorrhoids; a compensable rating is not warranted. 7. A compensable rating for acne is denied. Code 7828 provides for a 0 percent rating when there is superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent rating is warranted when there is deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. A 30 percent rating is warranted when there is deep acne (deep inflamed nodules and pus- filled cysts) affecting 40 percent or more of the face and neck. It may also be rated as disfigurement of the head, face, or neck (Code 7800) or scars (Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Id. 38 C.F.R. § 4.118. An October 2010 VA treatment record notes that the Veteran sought treatment for acne, but the severity of the acne was not described. He reported that he took Clindamycin, which was very helpful. A February 2011 VA treatment record notes that the Veteran took topical Clindamycin for a skin infection. An August 2012 private treatment record notes that the Veteran took PanOxyl for acne. On April 2013 VA skin diseases examination, acne was diagnosed. The Veteran reported that he has had acne on his face and back since service and that the acne is presently under good control. He related that he took ORACEA and Clindamycin on a constant or near constant basis. On examination, it was noted that the acne did not cause scarring or disfigurement of the head, face, or neck, and that the acne was superficial and affected less than 40 percent of his face and neck. He did not have a benign or malignant neoplasm related to his acne. A March 2014 treatment record notes that the Veteran treated his acne with ORACEA. On July 2016 VA skin diseases examination, acne was diagnosed. The Veteran reported that he has continued to require ongoing care and daily treatment for face and back acne and that he takes oral Doxycycline on a constant or near constant basis. On examination, it was noted that the acne did not cause scarring or disfigurement of the head, face, or neck, and was superficial and affected less than 40 percent of his face and neck. He did not have a benign or malignant neoplasm related to his acne. At the November 2016 videoconference hearing, the Veteran testified that he had chronic acne, usually on his back that seemed a little worse with sweat and heat, and that he took an oral antibiotic daily. He did not recall that any private or VA physician had informed him that his acne was “deep.” The Veteran currently has active acne for which he takes daily medication. However, on April 2013 and July 2016 VA examinations, the examiners commented that his acne was superficial, and no other VA or private treatment records during the period on appeal note any more than superficial acne. At no time under consideration are the Veteran’s acne manifestations objectively shown to have consistent with other than superficial (i.e., deep) acne. Accordingly, under the criteria outlined above, it does not warrant a compensable rating. The Veteran’s acne also does not warrant a compensable rating under any possible alternative diagnostic codes. On April 2013 and July 2016 VA examinations, the examiner specifically noted that the acne does not cause scarring or disfigurement of the head, face, or neck, and there are no benign or malignant skin neoplasms. Accordingly, Codes 7800, 7801, 7802, 7803, 7804, and 7805 are not for application. 8. Entitlement to a compensable rating for bilateral hearing loss is denied. In a claim for increase, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, “staged” ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim begins one year before the claim for increase was filed. As the instant claim for increase was received on May 19, 2011, the period for consideration is from May 19, 2010, until the present. Ratings for hearing loss disability are derived from Table VII of 38 C.F.R. § 4.85 by a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The numeric designations correspond to eleven auditory acuity levels, indicated by Roman numerals, where Level I denotes essentially normal acuity and Level XI denotes profound deafness. The assignment of the appropriate numeric level is based on the results of controlled speech discrimination tests in combination with average puretone threshold. The average threshold is obtained from puretone audiometry in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85. Rating specialists use either Table VI or VIa of 38 C.F.R. § 4.85 to determine the correct Roman numeral designation. Table VIa is used when speech discrimination tests are inappropriate due to language difficulties, inconsistent speech discrimination scores, etc., or where there is an exceptional pattern of hearing loss (as defined in 38 C.F.R. § 4.86). One such pattern occurs when puretone thresholds at each of the four specified frequencies are 55 decibels or more. Another occurs when the puretone threshold at 1000 Hertz is 30 decibels or less and the puretone threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86. On January 2011 VA audiology assessment audiometry, puretone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 15 40 80 39 LEFT 10 10 35 75 33 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. Under Table VI, the Veteran had level I hearing acuity in each ear, warranting a 0 percent rating under Table VII. He reported difficulty hearing conversational speech in the presence of background noise, difficulty understanding conversational speech without the presence of visual cues, and difficulty hearing conversational speech in group situations. On April 2013 VA audiology assessment audiometry, puretone thresholds were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 10 65 85 45 LEFT 15 15 40 75 36 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 86 percent in the left ear. Under Table VI, the Veteran had level I hearing acuity in the right ear and level II hearing in the left ear each ear, warranting a 0 percent rating under Table VII. He reported that “depending on the person’s tone of voice, sometimes I have a hard time hearing some people.” On July 2016 VA audiology assessment audiometry, puretone thresholds were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 60 65 85 58 LEFT 25 60 65 80 58 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and 84 percent in the left ear. Under Table VI, the Veteran had level II hearing acuity in the right ear and level III hearing in the left ear, warranting a 0 percent rating under Table VII. He reported having a great deal of difficulty understanding speech in groups, background noise and on TV. The record does not include any further pertinent audiometry during the period for consideration on appeal. As the assignment of a disability rating for hearing impairment is derived by mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered, there is no doubt as to the proper evaluation to be assigned. Lendenmann, 3 Vet. App. 345; 38 C.F.R. § 4.85, Code 6100. The findings on official audiometry fall squarely within the parameters of the criteria for a 0 percent rating. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). The Board has no reason to question the Veteran's reports of impairment due to his hearing loss; however, the problem understanding conversations and the TV he describes is encompassed by the criteria for the 0 percent schedular rating assigned. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). REASONS FOR REMAND 9. Entitlement to service connection for rosacea. A February 2012 rating decision denied service connection for rosacea because the Veteran did not have a current diagnosis of rosacea. February 2011, March 2011, and December 2011 private treatment records note a diagnosis of, and treatment for, rosacea. At the November 2016 videoconference hearing, the Veteran testified that although rosacea was not diagnosed during his military service (he related that he had episodes of facial redness during service), he sought treatment from his dermatologist shortly after he retired, later in 2009, and the dermatologist diagnosed the excessive redness and blotching of the skin on his face and chest (supposedly as rosacea). He related that he has been on topical medication for the rosacea since then. The Board notes that the earliest notation of skin treatment for purported rosacea appears to be in November 2009. The Veteran reported redness on his nose and cheeks that had been present for years. He related that he had not been taking any skin medication, that heat and alcohol made flare-ups worse, that he had one lesion on his cheek for one year and another lesion on his left cheek for two years. On examination, seborrheic hyperplasia of the right and left cheek, dysplastic macule of the left upper abdomen, seborrheic keratosis on right upper leg, and dysplastic macule of the left middle back were diagnosed. The Veteran has not been afforded a medical examination for rosacea. Considering his contentions, a current diagnosis of rosacea, and the possibility that rosacea may have been diagnosed as early as November 2009 (shortly after the Veteran’s service retirement), remand to secure an adequate medical advisory opinion regarding the etiology of his rosacea is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following: Arrange for the Veteran’s record to be forwarded to an appropriate clinician (in dermatology) for review and a medical advisory opinion regarding the likely etiology of his rosacea. Based on a review of the record, the consulting provider should provide an opinion that responds to the following: (a) Identify the likely etiology for the Veteran’s rosacea. Specifically, is it at least as likely as not (a 50% or greater probability) that it is etiologically related to the Veteran’s service/was incurred therein (is related to his treatment for acne in service)? (i) The provider should note the November 2009 treatment record and opine whether any skin disorders noted could be considered rosacea. (ii) If a skin disorder found in November 2009 is considered to be rosacea, acknowledge the Veteran’s testimony that he sought private treatment for facial redness (rosacea) in service and opine whether it is at least likely as not (a 50% or greater probability) that the rosacea is etiologically related to his service. (b) If the Veteran’s rosacea is found to not be etiologically related to his service, identify the etiology considered to be more likely (and explain why that is so). All opinions must include rationale. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bayles, 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.