Citation Nr: 21024414 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 16-24 407 DATE: April 22, 2021 ORDER New and material evidence has not been received to reopen the claim of entitlement to service connection for a right knee disorder. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a bilateral foot disorder, to include pes planovalgus deformity with arthritis capsulitis is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for allergic rhinitis is granted. Entitlement to an initial 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) is granted from September 27, 2013. Entitlement to an initial compensable rating for pseudofolliculitis barbae (PFB) is denied. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is granted from May 26, 2014. REMANDED Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for a left knee disability is remanded. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for left knee scars is remanded. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for PTSD is remanded. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for PFB is remanded. Entitlement to an initial rating in excess of 10 percent for left knee disability is remanded. Entitlement to an initial compensable rating for left knee scars is remanded. Entitlement to service connection for an upper-gastrointestinal disorder, to include gastroesophageal reflux disease (GERD) and gastritis is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for tinea of hands and feet is remanded. Entitlement to service connection for a left ear cyst is remanded. Entitlement to service connection for a left hip disorder is remanded. FINDINGS OF FACT 1. A November 2006 rating decision denied service connection for right knee disorder; the Veteran did not appeal that decision, and new and material evidence was not received within one year of notice of its issuance. 2. Evidence received more than one year since the November 2006 rating decision is cumulative or redundant of evidence at the time of the prior decision, and does not raise a reasonable possibility of substantiating the Veteran’s claim for entitlement to service connection for a right knee disorder. 3. The Veteran’s hypertension did not have its clinical onset in service or within one year of separation from service and is not otherwise related to service. 4. The Veteran’s bilateral foot disorder, to include pes planovalgus deformity with arthritis capsulitis, did not have its clinical onset in service or within one year of separation from service and is not otherwise related to service. 5. The Veteran’s right ankle arthritis did not have its clinical onset in service or within one year of separation from service and is not otherwise related to service. 6. The Veteran’s allergic rhinitis had its onset in service. 7. Since September 27, 2013, the Veteran’s PTSD most nearly approximates occupational and social impairment with deficiencies in most areas but not total occupational and social impairment. 8. The Veteran’s pseudofolliculitis barbae symptoms most nearly approximate papular lesions and inflammation affecting less than 5 percent of the exposed body surface area and less than 5 percent of the total body surface area. 9. From May 26, 2014, the Veteran’s PTSD precludes substantially gainful employment. CONCLUSIONS OF LAW 1. The November 2006 rating decision denying the Veteran’s service connection claim for a right knee disorder is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 2. New and material evidence has not been received to reopen the service connection claim for a right knee disorder. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. § 3.156(a). 3. The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a bilateral foot disorder are not met. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for right ankle arthritis are not met. 38 U.S.C. §§ 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for allergic rhinitis are met. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for a 70 percent rating for PTSD, but no higher, are met from September 27, 2013. 38 U.S.C. §§ 1154(a), 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 8. The criteria for an initial compensable rating for PFB are not met. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.118, DC 7899-7806. 9. The criteria for a TDIU are met from May 26, 2014.  38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1976 to June 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2014 and May 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in November 2018 for additional development. New and Material Evidence 1. New and material evidence has not been received to reopen the claim of entitlement to service connection for a right knee disorder. A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision, or new and material evidence is received during the appeal period after the decision. 38 U.S.C. § 7105 ; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. I f a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108 ; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence is defined as existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The RO denied the Veteran’s claim for service connection for a right knee disorder in a November 2006 rating decision for lack of an in-service incurrence and lack of a nexus. The Veteran did not appeal this decision and new and material evidence was not received within one year of its issuance. Thus, the November 2006 rating decision is final. 38 U.S.C. § 7105 ; 38 C.F.R. §§ 3.156(b), 20.1103; Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). Since the final November 2006 rating decision, new VA and private treatment records have been associated with the claims file. Additionally, the Veteran was afforded a knee and lower leg conditions VA examination in August 2014. However, the August 2014 Knee and Lower Leg Conditions VA Examination Report document his continued complaints and diagnoses pertaining only to his service-connected left knee disability. While the new treatment records show continued complaints regarding the bilateral knees, none contain information related to the previously unestablished in-service incurrence element or nexus to service. Therefore, the new treatment records and August 2014 Knee and Lower Leg Conditions VA Examination Report are not material because they do not raise a reasonable possibility of substantiating the claim. The Board acknowledges that the threshold for reopening a claim is low, but it is a threshold, nonetheless. Shade v. Shinseki, 24 Vet. App. 110 (2010). Here, the threshold has not been met and the previously denied claim of entitlement to service connection a right knee disorder is not reopened because new and material evidence has not been submitted. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 2. Entitlement to service connection for hypertension is denied. 3. Entitlement to service connection for a bilateral foot disorder is denied. 4. Entitlement to service connection for a right ankle disorder is denied. In August 2005, the Veteran reported right ankle pain for several months, without injury. A contemporaneous radiograph was normal. Certain chronic disabilities, including hypertension and arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that the Veteran has not been afforded a VA examination for his claimed hypertension, right ankle, or bilateral foot disorders and an opinion as to the etiology of such conditions has not otherwise been obtained. In this instance, there is no indication that the Veteran’s hypertension, right ankle, or bilateral foot disorders may be associated with his military service or a service-connected disability. Further, the Veteran has not provided credible evidence of any in-service event, injury or disease, or any competent medical evidence that the condition may be related to any incidence of service or a service-connected disability. Thus, a VA examination is not required. See McLendon, 20 Vet. App. at 83. Here, the presence of a current disability is not in dispute, as the Veteran has been diagnosed with hypertension. See April 2009 private treatment record. The Veteran also has a diagnosis of right ankle arthritis. See August 2005 private treatment record. Lastly, the Veteran has diagnoses of right foot capsulitis and tendonitis, pes planovalgus deformity with arthritis, bursitis, metatarsalgia, and hallux abduction valgus deformity, and bilateral plantar fasciitis. See December 2011 and June 2013 private treatment records. Thus, the first element of service connection is established. Turning to the second element, in-service incurrence of a disease or injury, the Veteran’s service treatment records (STRs) do not identify any complaints, treatment for, or diagnosis of, hypertension, high blood pressure, or symptoms indicative of the same. The Veteran’s blood pressure at service entrance in December 1975 was 130/80 and he denied high blood pressure. Moreover, at the May 1980 separation examination, clinical evaluation was normal, his blood pressure was recorded as 106/68, and the Veteran reported having ailments that did not include problems associated with his blood pressure. He specifically denied high blood pressure. Notably, there is only one reading of record demonstrating a diastolic level of higher than 90 (recorded in August 1979), and since this is only 1 measured reading, it does not qualify as diastolic blood pressure “predominantly 90 mm. or greater,” as is necessary for a diagnosis of hypertension during active service. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. There are no other in-service blood pressure readings. As such, element two is not met, and the claim fails on this basis alone. Furthermore, STRs are silent for complaints, diagnosis, or treatment of bilateral foot and right ankle disorders. On his May 1980 separation examination, clinical evaluation was normal. He specifically denied foot trouble. Although he reported “swollen or painful joints,” the Veteran only reported a left knee contusion. Thus, the second element of direct service connection is not met, and the claims fail on this basis alone. The first report of a right ankle disorder came in August 2005. The Veteran reported right ankle pain for several months without injury. The contemporaneous x-ray was normal but marginal osteophytes was noted. In December 2011, the Veteran reported right foot pain of two years duration. At that time, the Veteran reported that his work shoes caused a significant amount of discomfort. In June 2013, the Veteran reported bilateral foot pain of two or three years duration due to his 12 hour work shift on concrete floors and steel-toed shoes. Regarding the final element, a nexus to service is also not established, as there is no competent evidence of record linking the Veteran’s hypertension, right ankle, or bilateral foot disorders to his military service. To the extent that the Veteran relates such disorders to service, the Board finds that he is not competent to do so, as the determination as to the etiology of such condition is a complex medical question that is beyond the ken of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, there is no evidence that the Veteran’s hypertension, right ankle arthritis, or bilateral foot arthritis manifested to a compensable degree within a year of service to allow for presumptive service connection for a chronic disease but instead first manifested many years after service. Indeed, during private treatment in April 2009, the Veteran reported elevated blood pressure of ten years duration, which is still many years after his active service. Additionally, marginal arthritis of the right ankle was first noted in August 2005, many years after his active service. Bilateral foot arthritis was first noted in June 2013. For similar reasons, a nexus through a continuity of symptomatology is not available. See Walker, supra. Accordingly, the preponderance of the evidence is against the claims of entitlement to service connection for hypertension, right ankle, and bilateral foot disorders. As such, the benefit of the doubt doctrine is not for application, and service connection must be denied. See 38 U.S.C. § 5107(b). 5. Entitlement to service connection for allergic rhinitis is granted. The Veteran asserts that he is entitled to service connection for allergic rhinitis because the disorder originated during his active duty service. There is no dispute that the Veteran has a diagnosis of allergic rhinitis. See August 2014 VA examination report. Accordingly, the first element necessary to establish service connection has been demonstrated. Concerning the second element to establish service connection, the Veteran’s in-service medical examination in September 1977 noted a history of sinus problems. Moreover, the Veteran complained of rhinitis in February 1978 and sinusitis in April 1979 and March 1980. Notably, the Veteran’s May 1980 separation examination reflected a history of seasonal allergic rhinitis and hay fever. Based on this evidence, the Board concludes that the second element has been demonstrated. During private treatment in May 2005, the Veteran reported experiencing allergic rhinitis every May and June. See also April 2006 private treatment record. Regarding the final element, a nexus to service, the August 2014 VA examiner opined that it is at least as likely as not that the Veteran’s allergic rhinitis was incurred in service. The examiner explained that the Veteran’s STRs document allergic rhinitis during active service in 2005 and 2006. The Board acknowledges that the August 2014 VA examiner relied on incorrect service dates. However, this error is not fatal to the Veteran’s claim, as the rationale remains the same. The Veteran has a current diagnosis of allergic rhinitis, for which he was treated for multiples times during active service from 1976 to 1980. The Board also acknowledges the October 2014 VA addendum opinion. In providing a negative opinion, the October 2014 examiner indicating that there was nothing to suggest that the Veteran’s allergic rhinitis was caused by service. Notably, the October 2014 VA examiner failed to consider the Veteran’s multiple reports of allergic rhinitis and sinus problems in service. Thus, the Board finds that the October 2014 VA medical opinion has no probative value. Reonal v. Brown, 5 Vet. App. 458, 460 (1993). Giving the Veteran the benefit of the doubt, the Board finds that a nexus to service is established and service connection for allergic rhinitis is warranted. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the evidence demonstrates distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. By way of background, the current appeal period begins on September 27, 2013, the date service connection was established. 6. Entitlement to an initial 70 percent rating, but no higher, for PTSD is granted from September 27, 2013. The Veteran’s PTSD is currently rated as 30 percent disabling. He contends that throughout the entire appeal his PTSD has been more severe than the currently assigned rating and that he is entitled to an increased rating. The Veteran’s PTSD is currently rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for 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 for 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 assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational or 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. Initially, to the extent the record reflects diagnoses of unspecified anxiety disorder and unspecified depressive disorder, the Board notes that the record does not adequately distinguish the symptomatology of these disorders from his service-connected disability, and therefore they will be considered as part of his PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998); see also April 2015 and October 2020 VA psychiatric note. After a review of the medical and lay evidence, the Board finds that the criteria for a higher rating of 70 percent are met throughout the appeal, effective September 27, 2013. The evidence shows that the Veteran’s PTSD produces deficiencies in most areas due to such symptoms as: depressed mood, anxiety, anger, chronic sleep impairment, intrusive memories, nightmares, avoidance, memory loss, crying spells, suspiciousness, panic attacks, disturbances of motivation and mood, hypervigilance, isolation, impaired impulse control (such as unprovoked irritability), suicidal ideation, difficulty establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Conversely, the Board finds that the Veteran’s symptoms do not more nearly approximate a rating of 100 percent, as they are not of such a severity or frequency to result in total occupational and social impairment. In this regard, there is no medical or lay evidence in the record of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for own occupation, or own name. Notably, the August 2014 VA examiner did not find the Veteran to be totally occupationally and socially impaired. See also June 2017 private disability benefits questionnaire (DBQ). As to social impairment, the Veteran endorsed markedly diminished interest and participation in activities, social withdrawal, feelings of detachment or estrangement from others, and depressed affect during his August 2014 VA examination. See also June 2017 DBQ. The Veteran reported that he had “lots of girlfriends” but that he never married. He reported a positive relationship with his adult daughter, family, and one friend. See March 2015 VA treatment record. The June 2017 private DBQ notes the Veteran had a girlfriend of two years duration. Throughout the appeal, the Veteran has endorsed trust issues, social isolation, and mood swings. See February 2021 Correspondence. Thus, the Board notes that the Veteran maintained a relationship with his family and daughter and otherwise demonstrated an ability to maintain some social relationships, despite significant, social impairments due to symptoms described above. As to occupational impairment, the Veteran retired as a mechanic in May 2014. The Veteran described his relationship with his co-workers and supervisors through the years as positive and productive. The August 2014 VA examiner determined that the Veteran’s PTSD resulted in 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 medication. The Veteran’s assertions of unemployability are further addressed below. In a January 2015 Social Security Administration (SSA) evaluation, the Veteran endorsed symptoms of homicidal ideation in the past. The January 2015 SSA examiner determined that the Veteran was not a danger to himself or others. A review of VA treatment records shows a consistent denial of suicidal or homicidal ideation, plan, or intent. See August 2014 VA examination report; see also August 2015, March 2016, January 2017, and November 2018, October 2020 VA treatment record. VA treatment records note the Veteran’s concern with his irritability and angry outburst. Id; see also April 2015 and November 2018 VA mental health treatment record. For example, the Veteran reported intermittent irritability in the context of dealing with a bank refinance. See April 2015 VA treatment record. The treatment provider noted that this “does not sound like he was out of control, but he had trouble letting go of it.” Id. In March 2015, the Veteran reported increased anxiety, suspiciousness, and angry outburst. The March 2015 VA provider determined that the Veteran was not a danger to himself or others. Following a review of the evidence of record, the Board does not find the Veteran to be a persistent danger to himself or others. As to hallucinations, the Veteran reported “seeing and hearing things that are not really there but not often.” See February 2021 Correspondence. During the January 2015 SSA evaluation, the Veteran reported hearing someone scream in the house. He also reported seeing jellyfish when he was not at the ocean. The Veteran explained that this happened after he was in surgery and still on medication. The examiner determined that the Veteran did not show any current signs of psychosis. In letters dated in March 2017, the Veteran’s brother and sister reported memory loss and jellyfish hallucinations. The August 2014 VA examiner found no evidence of hallucinations, delusions, or psychoses. During VA treatment in October 2020, the provider noted that hallucinations and delusions were not endorsed or observed. See also November 2018 VA treatment record. The Board does not find the Veteran’s report of hallucinations tantamount to persistent delusions or hallucinations. Additionally, the Veteran has endorsed bad hygiene. See February 2021 Correspondence. The Veteran’s brother described the Veteran’s beard as “long and mangy.” The August 2014 VA examiner described the Veteran as well-dressed. The January 2015 SSA examiner described the Veteran as neatly and appropriately dressed. Additionally, a review of VA treatment records reveal that the Veteran is often described as neatly dressed and well groomed. See, e.g., June 2015, March 2016 VA treatment record. The June 2017 DBQ examiner noted that the Veteran handles his household finances, but becomes overwhelmed with chores. The Veteran reported that his girlfriend reminds him to shave and to shower on a daily basis. The Board finds that the Veteran’s periods of neglect of personal appearance and hygiene are contemplated by a 70 percent rating, as he does not show intermittent inability to perform activities of daily living that is characteristic of a 100 percent rating. The Board has considered the evidence of record, including the August 2014 VA examination report, the June 2017 private DBQ, medical records, and lay statements. Even with a holistic analysis, the Board does not find that the criteria for a 100 percent rating for PTSD are met. As such, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine therefore does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Accordingly, a higher rating is not warranted. 7. Entitlement to an initial compensable rating for PFB is denied. The Veteran asserts that he is entitled to an initial compensable disability rating. The Veteran has a noncompensable (zero percent) rating for PFB under Diagnostic Codes (DCs) 7899-7806. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen). VA amended DC 7806, but claims pending on August 13, 2018 may be considered under the pre-amended and amended criteria, whichever is more favorable. 83 Fed. Reg. 32592 (August 13, 2018). Under pre-amended DC 7806 (prior to August 13, 2018), a noncompensable disability rating was assigned when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period. A 10 percent rating requires that at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas be affected, or intermitted systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs be required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. VA published a final rule amending its regulations on skin disabilities effective August 13, 2018. The amendment, in pertinent part, added a “General Rating Formula for the Skin” for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended Diagnostic Codes 7801,7802,7817,7819,7825, 7826, 7827,7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Under the new General Rating Formula for the Skin, pursuant to Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, a noncompensable rating is assigned when no more than topical therapy is required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected, or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. This rating instruction does not apply to Diagnostic Code 7824. A 10 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets 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; 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 will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. Also, under the new General Rating Formula for the Skin, the rating criteria notes that for the purposes of that section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. The Federal Circuit Court has held that within the purview of Diagnostic Code 7806 in effect prior to August 13, 2018, systemic therapy meant “treatment pertaining to or affecting the body as a whole,” whereas topical therapy meant treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it was applied, and that nothing in Diagnostic Code 7806 displaced the accepted understanding of systemic therapy and topical therapy to permit a topical therapy that affected “only the area to which it [was] applied” to count as a systemic therapy under that code. Prior to August 13, 2018, the use of a topical corticosteroids could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. The use of topical corticosteroids did not automatically mean systemic therapy because Diagnostic Code 7806 distinguished between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (The use of “such as” in Diagnostic Code 7806 does not mean that all forms of treatment with “cortico-steroids and other immunosuppressive drugs,” no matter how narrowly localized in their impact, count as “systemic therapy.”). Regardless of which criteria are considered, the evidence does not support a finding that the Veteran’s disability warrants a compensable rating at any time during the appeal. The Veteran was afforded a VA examination in August 2014. He reported an onset of PFB during service as a result of deep shaving. He denied any current medication. No associated scarring or systemic manifestations were indicated. Clinical evaluation was notable for PFB affecting less than 5 percent of both total body area and exposed area. The examiner reported that the Veteran had papules in the beard and neck area. The Veteran reported itching and pain in the neck and beard area that was distracting. Based on the above, the Board finds that an initial compensable rating is not warranted. The Veteran’s PBF symptoms consist of skin irritation with shaving. The August 2014 VA examiner specifically reported that it affected an exposed skin surface area of less than 5 percent. The Board notes the Veteran’s report about increased PFB symptoms when he had to shave. However, his reports are vague and unclear as to the symptoms and affected area. Overall, there is no lay or medical report suggesting that PFB manifested with additional symptoms, a greater affected area, or use of medication to warrant consideration of a higher rating under DC 7806 or compensable rating under an alternative DC. Furthermore, regardless of which version of the criteria is applied, the Veteran’s PFB has not required any use of systemic therapy or covered a large enough area to assign a compensable rating for his skin disability. The evidence also shows that the disability is not disfiguring, so the diagnostic codes related to scars are not applicable. The Board is aware that the Veteran’s PFB is rated by analogy under Diagnostic Code 7806 and that other diagnostic codes related to skin disabilities can be considered if they would result in a higher rating. However, based on his symptoms, the area of skin affected, and the severity, the other diagnostic codes from 7800 to 7833 associated with 38 C.F.R. § 4.118 are either not applicable or would not result in a compensable rating. For the foregoing reasons, the preponderance of the evidence is against an initial compensable rating for service-connected PFB, the benefit of the doubt doctrine is not for application and this claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 8. Entitlement to a TDIU is granted from May 26, 2014. The Veteran asserts that he is entitled to TDIU benefits. As this matter has been raised on a derivative basis, as part and parcel of his claim for a higher rating for PTSD, this matter is considered to be before the Board from September 27, 2013. See Rice v. Shinseki, 22 Vet. App. 447 (2009). VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing or following “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). TDIU can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). Throughout the appeal period, beginning on September 27, 2013, the Veteran has met the minimum percentage requirements for a TDIU. 38 C.F.R. § 4.16(a). Thus, the main question before the Board is whether the Veteran’s service-connected disabilities render him unable to obtain substantially gainful employment. The Board acknowledges that SSA records reveal that he was deemed to be disabled due to osteoarthritis and allied disorder, as well as organic mental disorders, and noted he last worked full time on May 25, 2014. The Board notes that consideration may not be given to the impairment caused by nonservice-connected disabilities when determining whether an individual veteran is entitled to a TDIU. See 38 C.F.R. § 3.341, 4.16, 4.19. The question is whether the claimant is capable of performing the physical and mental acts required by employment, not whether he or she can actually find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran’s ability to secure or follow substantially gainful employment, including factors such as the veteran’s history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The Veteran reported on a July 2020 VA Form 21-8940 that he was last employed full time in May 2014, as a mechanical specialist. In a September 2020 VA Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192), the Veteran’s former employer indicated that the Veteran’s ending date of employment was May 25, 2014. The employer answered “N/A” when asked if any concessions were made to the Veteran by reason of age or disability. Further, it was noted that the Veteran worked 7.5 hours daily and 37.5 hours weekly and that it was unknown if the Veteran lost any time during the 12 months preceding the last date of employment (due to disability). It is also noted that the employer checked “yes” indicating that the Veteran was in receipt or entitled to receive retirement benefits through his employment. There is no evidence that the Veteran was engaged in substantial and gainful employment since May 26, 2014. This is in accord with the economic component of entitlement to a TDIU, beginning May 26, 2014. Regarding the noneconomic component, the Veteran’s educational background includes a bachelor’s degree in psychology and political science, with no additional training or education. Id. The Veteran has reported lack of motivation, memory loss, difficulty concentrating, mood swings, and irritability. See February 2021 Correspondence. Further, he reported that he dislikes being around people or attending gatherings or events as it causes him to hyperventilate. Id. He also reported using leave for mental health days but would report it as sick leave for knee, back, or foot pain. Similarly, the Veteran’s brother documented the Veteran’s difficulties with his memory loss and completing tasks, social impairments, and difficulties handling stress. The January 2015 SSA examiner determined that the Veteran would have difficulty in many job settings given his depression and memory impairment. In a June 2017 Residual Functional Capacity Evaluation, Dr. H.H.G. determined that more than once per month, the Veteran would respond in an angry manner but would not actually become violent. Further, she determined that the Veteran would miss more than three days per month of work due to his PTSD. Dr. H.H.G. determined that the Veteran “cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD.” In support of her conclusion, Dr. H.H.G highlighted the Veteran’s suspiciousness, difficulties with remembering details, his inconsistent mood, poor interpersonal skills, and workplace trust issues. In a January 2021 letter, following a review of the Veteran’s treatment records, Dr. M.B. opined that the Veteran would not be able to maintain substantially gainful employment due to his service-connected mental and physical disabilities. In support of her opinion, Dr. M.B. noted the Veteran’s periods of uncontrollable crying, sleep impairment, anxiety, mild memory loss, irritability, and outbursts of anger. Given these findings, including the Veteran’s competent and credible report, the Board finds that the overall severity of the Veteran’s psychiatric symptoms described above preclude substantially gainful employment, beginning May 26, 2014, which is the day following his last day of full time employment. Hence, entitlement to a TDIU is warranted from May 26, 2014. 38 U.S.C. §§ 1155, 5107(b). REASONS FOR REMAND 9. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for a left knee disability is remanded. 10. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for left knee scars is remanded. 11. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for PTSD is remanded. 12. Entitlement to an effective date earlier than September 27, 2013 for the award of service connection for pseudofolliculitis barbae is remanded. In December 2014, the Veteran filed a timely Notice of Disagreement (NOD) with a December 2014 rating decision assigning the effective date for the grant of service connection for a left knee disability, left knee scars, PTSD, and pseudofolliculitis barbae, requiring issuance of a statement of the case (SOC) on remand. Manlincon v. West, 12 Vet. App. 238 (1999). 13. Entitlement to a rating in excess of 10 percent for left knee disability is remanded. The Veteran reported that his left knee symptoms have worsened since his most recent VA examination in August 2014. See February 2021 Correspondence. Further, VA treatment records note that his left knee gave out in August 2020. As such, the Board finds that a new examination should be provided in order to assess the current nature and severity of his left knee disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). 14. Entitlement to a compensable rating for left knee scars is remanded. Because the knee examination that will be provided on remand may provide additional information regarding the Veteran’s left knee scars, the issues are inextricably intertwined. Therefore, a remand of the claim for entitlement for an initial compensable disability rating for left knee scars is required. 15. Entitlement to service connection for an upper gastrointestinal disorder, to include GERD and gastritis is remanded. The Veteran asserts that his upper GI disorder is due to his active service. A review of VA treatment records include a diagnosis of GERD and service treatment records (STRs) show the Veteran’s complaint of constipation with right upper quadrant pain in September 1977 and gastritis in December 1977. Accordingly, the Board finds that the low standard detailed in McLendon is met and a VA examination and medical nexus opinion is warranted and should be obtained on remand. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 16. Entitlement to service connection for a left ankle disorder is remanded. The Veteran was afforded a VA left ankle examination in August 2014. The examiner found no current diagnosis or functional loss for the left lower extremity. However, during VA treatment in March 2015, the Veteran reported ankle pain caused by walking long distances. The Board notes that pain that results in functional impairment may be considered a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As such, a remand is required to afford the Veteran a new examination to determine the functional impairment caused by the Veteran’s left ankle pain, and whether it is related to his March 1978 left ankle injury. 17. Entitlement to service connection for a back disorder is remanded. In an April 2014 statement, the Veteran reported chronic back pain for over 35 years. VA treatment record show a history of chronic back pain. The Veteran complained of pain between the scapula with no history of trauma in November 1977. He was assessed with a muscle strain. In his May 1980 separation Report of Medical History, the Veteran checked “yes” and “no” for recurrent back pain, but crossed out his “yes” response. No clarification was provided. Accordingly, the Board finds that the low standard detailed in McLendon is met and a VA examination and medical nexus opinion is warranted and should be obtained on remand. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 18. Entitlement to service connection for asthma is remanded. The October 2014 VA addendum report addressing the Veteran’s asthma is inadequate. Specifically, it is not clear from the report if there was “clear and unmistakable” evidence that the Veteran’s asthma pre-existed service and was not aggravated beyond the natural progress of the disease. Notably, the examiner did not comment on the December 1975 entrance examination that was completely normal with regard to asthma or the May 1980 separation report of medical history reflecting a history of asthma. Thus, an addendum opinion should be obtained on remand. 19. Entitlement to service connection for tinnitus is remanded. The Veteran’s DD Form 214 shows that the Veteran’s military occupational specialty (MOS) was an aerographer’s mate. The Duty MOS Exposure Listing lists aerographer’s mates as having a low probability of noise exposure. However, on the Veteran’s May 1980 separation Report of Medical History he noted that his usual occupation was that of a fire control technician on a F-16 aircraft. He also endorsed ear, nose, or throat trouble. The Board finds that in-service noise exposure has been established as consistent with the circumstances of his active service. The AOJ obtained an April 2015 medical opinion. However, this medical opinion is based solely on the fact that tinnitus was reported after service, and does not consider a theory of delayed onset tinnitus in relation to conceded acoustic trauma. 38 C.F.R. § 3.303(d). Therefore, an addendum VA opinion is necessary. 20. Entitlement to service connection for tinea of hands and feet is remanded. 21. Entitlement to service connection for a left ear cyst is remanded. 22. Entitlement to service connection for a left hip disorder is remanded. Any outstanding VA and private treatment records should be secured on remand. Finally, as the record does not demonstrate the presence of a current disability or functional impairment regarding a left ear cyst, tinea of the hands and feet, or a left hip disorder, action on these claims is deferred pending this development. The matters are REMANDED for the following action: 1. Issue a SOC with respect to the NOD filed as to the assignment of the effective date for the grant of service connection for a left knee disability, left knee scars, PTSD, and pseudofolliculitis barbae. The Veteran should additionally be informed that in order to perfect an appeal of these issues to the Board, he must file a timely and adequate substantive appeal following the issuance of the SOC. 2. Obtain any outstanding VA treatment records. 3. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his left knee disability. The claims file, to include a copy of this remand must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. The examiner is asked to address the following: Full range of motion testing must be performed where possible. The joints involved should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in nonweight-bearing. Please specify range of motion measurements in all areas outlined above. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Considering the Veteran’s reported history, please also provide an opinion describing functional impairment of the Veteran’s left knee due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. The examiner should also assess the severity of the Veteran’s left knee scars. A complete rationale shall be given for all opinions and conclusions expressed. 5. Schedule the Veteran for an appropriate VA examination to address the current nature and etiology of his upper GI disorders. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should address the following: a) Identify all digestive disorders diagnosed since September 2013, to include GERD, even if resolved. b) Then, the examiner should opine as to whether it is as least as likely as not (50 percent or greater probability) that any diagnosed digestive disorder, to include GERD, had its onset in or is otherwise related to service, to include as a continuation or the result of the December 1977 diagnosis of gastritis. c) In answering this question, the examiner must address the following: (1) the September 1977 report of constipation with right upper quadrant pain; (2) the December 1977 diagnosis of gastritis; and (3) the September 2019 report of occasional constipation The examiner is advised that the Veteran is competent to report symptoms and treatment, and these reports must be considered when formulating the requested opinion. The examiner should provide a complete rationale for any opinion given. The absence of evidence of treatment for specific digestive disorders in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion and any reliance on such will render any opinion inadequate. 6. Schedule the Veteran for an appropriate VA examination to address the current nature and etiology of his left ankle and back disorders. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. a) Identify each left ankle and back disorder diagnosed during the appeal period. If no diagnosis is rendered and only pain is identified, the examiner must indicate whether the Veteran’s reported ankle and back pain causes any functional impairment. b) For each left ankle and/or back disorder so diagnosed, or any functional impairment identified, please opine whether it is at least as likely as not (50 percent probability or more) that such disability/impairment had its onset in or are otherwise related to service? In addressing this question please discuss: (1) the service treatment record reflecting a left ankle sprain of two weeks duration in March 1978 and the November 1977 report of pain between the scapula; (2) the May 1980 separation Report of Medical History, wherein the Veteran checked “yes” and “no” for recurrent back pain; (3) the Veteran’s report as to back and left ankle problems starting during service; and (4) his reports of continuous back and left ankle pain since service. In addressing this question, the examiner must assume items 3-4 as true, even despite the absence of “objective documentation,” and determine whether a nexus to service is “medically plausible” based on the same. See April 2014 statement. A complete rationale shall be given for all opinions and conclusions expressed. 7. Then obtain an addendum opinion regarding the etiology of the Veteran’s asthma. No additional examination of the Veteran is necessary, unless the reviewing examiner deems otherwise. After a review of the claims file, the examiner is requested to provide a specific opinion as to: a) Did the Veteran’s asthma clearly and unmistakably (undebatably) pre-exist service and, if so, was the disability clearly and unmistakably not aggravated (permanently worsened) by active service beyond the normal progression of the disease? b) If the Veteran’s asthma did not clearly and unmistakably pre-exist service, or pre-existed service and was clearly and unmistakably not aggravated during service, is it at least as likely as not (50 percent probability or more) that such disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service? c) If not directly related to service on the basis of questions (a)-(b), is his asthma proximately due to, the result of, or caused by any service-connected disability, to include allergic rhinitis? d) If not caused by another medical condition, is his asthma aggravated (permanently worsened) by any service-connected disability, to include allergic rhinitis? In addressing secondary service connection, please note that the primary disability (service-connected disability) need not be diagnosed or service-connected at the time his asthma is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. A complete rationale shall be given for all opinions and conclusions expressed. 8. Obtain an addendum opinion concerning the etiology of the Veteran’s tinnitus. No additional examination is necessary, unless the reviewing examiner deems otherwise. After a review of the claims file, the examiner is requested to provide a medical opinion as whether it is at least as likely as not (50 percent or greater probability) that tinnitus had onset during or was caused by the Veteran’s service, including as a result of conceded exposure to hazardous noise therein. In addressing this question, the examiner must accept as true that the Veteran was exposed to acoustic trauma during service in conjunction with his duties as a fire control technician on a F-16 aircraft and determine whether a nexus to service is “medically plausible” based on the same. In addressing this question, please discuss whether it is medically plausible that the Veteran’s current tinnitus, which he reports onset in 2000, is related to conceded noise exposure during his active service. Please note that the absence of hearing loss pursuant to 38 C.F.R. § 3.385 during service cannot, standing alone, serve as a basis of a negative opinion, and please address the possibility of delayed-onset tinnitus. A complete rationale must be provided for all opinions expressed. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Forde, 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.