Citation Nr: 21030246 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-38 332 DATE: May 18, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right knee meniscal disability is denied. Entitlement to a separate initial rating of 10 percent for right knee degenerative arthritis, based on limitation of flexion, is granted. Entitlement to an initial rating in excess of 10 percent for urticaria is denied. Prior to February 28, 2013, entitlement to a finding of total disability based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran is assigned the maximum rating under Diagnostic Code 5259 for right knee meniscal disability; there is no locking or effusion related to the meniscal damage. 2. There is evidence of limited flexion of the right knee and a diagnosis of degenerative arthritis. There is no evidence of flexion limited to 30 degrees or less. 3. The Veteran's urticaria is not shown to have resulted in recurrent debilitating episodes occurring at least four times during a 12-month period; nor has the condition required second-line treatment for control. 4. Prior to February 28, 2013, the Veteran's service-connected disabilities render her unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee meniscal disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259. 2. The criteria for a separate initial 10 percent rating for right knee degenerative arthritis, based on limitation of flexion, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260. 3. The criteria for an initial rating in excess of 10 percent for urticaria have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code 7825. 4. Prior to February 28, 2013, the criteria for TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from August 1991 to August 2011. These matters come before the Board of Veterans' Appeals (Board) from a January 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Board remanded the Veteran's case for additional development. The case has now been returned to the Board for review. For the sake of clarity, the issues have been recharacterized to identify the disability manifestation at issue. Concerning TDIU, the RO granted TDIU from February 28, 2013. Because this is not a complete grant of the benefit sought and the issue of TDIU was raised during the pendency of the initial rating claims on appeal, the issue of entitlement to TDIU prior to February 28, 2013, remains on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. The Veteran filed a pre-discharge compensation claim in May 2011. A pre-discharge notice response, signed by the Veteran in May 2011, stated that the Veteran had been provided a notice about the evidence and information to support her claims. The RO associated the Veteran's service, VA, and Social Security Administration (SSA) records with the claims folder. A request for updated VA treatment records was made in accord with the Board's March 2019 remand. The most recent VA treatment records are dated in 2017. In November 2019, the Veteran was asked to identify any relevant private treatment records and did not respond. Accordingly, the Board finds that the March 2019 remand directives were completed concerning the request for updated VA treatment records and for the Veteran to identify any relevant private treatment records. See Stegall v. West, 11 Vet. App. 268 (1998). Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. Though the 2013 VA examination report for the right knee disability did not include adequate range of motion findings for rating purposes, an adequate VA examination was provided in 2020. As such, VA has satisfied its duty to assist. The Veteran's representative has requested that if the claims are not granted in full, that the claims be remanded for new VA examinations to evaluate the current severity of the disabilities. However, the Veteran was provided VA examinations in 2020 and neither the evidence nor the Veteran has alleged that her disabilities have worsened in severity since those examinations. Accordingly, remand is not required. Neither the Veteran nor her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings In General Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Right knee disability Concerning Diagnostic Code 5257, the Board notes that the rating criteria have been revised effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Where the law or regulations governing a claim are changed while the claim is pending, the version most favorable to the claimant applies (from the effective date of the change), absent Congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the old Diagnostic Code 5257, a 10 percent rating is warranted for slight instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The new rating criteria provides that for recurrent subluxation or lateral instability, a 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g. cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g. cane(s), crutch(es), walker) for ambulation or (b) unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes either an assistive device (e.g, cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g. cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability, a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1) to the criteria states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under the old criteria, Diagnostic Code 5010 provides that arthritis due to trauma, substantiated by x-ray findings is rated as degenerative arthritis. Under the new criteria, Diagnostic Code 5010 pertains to post-traumatic arthritis and provides that it must be rated as limitation of motion, dislocation, or other specified instability under the affected joint. Diagnostic Code 5003, unchanged under the amendments to the criteria for evaluation of musculoskeletal disabilities, provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s) a 10 percent rating is for application for each major joint or group of minor joint affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. The amendments to the criteria for evaluation of musculoskeletal disabilities did not impact the substance of the Codes that follow. Diagnostic Code 5260 provides ratings based on limitation of flexion. A 0 percent rating is assigned for limitation of flexion of the leg to 60 degrees. A 10 percent rating is warranted for limitation of flexion of the leg to 45 degrees. A 20 percent rating is warranted for limitation of flexion to 30 degrees. A 30 percent rating is warranted for limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides the criteria for limitation of extension of the leg. A noncompensable (0 percent) rating is assigned for limitation of extension of the leg to 5 degrees. A 10 percent rating is assigned for limitation of extension to 10 degrees. A 20 percent rating is assigned for limitation of extension to 15 degrees. A 30 percent rating is assigned for limitation of extension to 20 degrees. A 40 percent rating is assigned for limitation of extension to 30 degrees. A 50 percent rating is assigned for limitation of extension to 45 degrees. 38 C.F.R. § 4.71a. Normal range of motion is from 140 degrees on flexion to 0 degrees on extension. See 38 C.F.R. § 4.71, Plate II. Under 38 C.F.R. § 4.59, functional loss due to painful motion is to be rated to at least the minimum compensable rating for a particular joint. If the limitation of motion is not compensable under the applicable Diagnostic Code, the minimum compensable rating is assigned. Further, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Correia v. McDonald, 28 Vet. App. 158, 168-70 (2017), the U.S. Court of Appeals for Veterans Claims held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In September 2011, the Veteran was provided a general VA examination. The Veteran reported pain with prolonged sitting and stairs. She used Voltaren 1%. The Veteran reported popping in the knees. The examiner noted impact on employment would be increased absenteeism, decreased mobility, problem with lifting and carrying, and decreased strength. The report indicated a report of swelling in the extremities including the knees. In September 2012, the Veteran stated that she was unable to put pressure on her knee without pain. In January 2013, the Veteran was provided a VA examination for her right knee. However, the range of motion findings are not considered adequate for rating purposes given that the examiner did not address any additional functional and impairment during periods of repeated use, passive range of motion or non-weight bearing testing. The Board will still address other relevant findings made on examination. The Veteran reported that she had right meniscus tear repair in 2011. There was constant, severe right knee grinding aggravated with climbing, bending, and alleviated by lying down and staying off of it. Muscle strength testing was normal and stability testing was normal. There was no history of subluxation or dislocation. The examiner determined that the Veteran had a meniscal condition characterized by frequent episodes of joint pain. As for impact on employment, the examiner explained that the right knee condition hindered functionality of employment by not being able to climb, lift greater than 50 pounds, or walk for long periods of time. In September 2013, the Veteran stated that she had constant right knee pain. She could not kneel on her right knee or bend without severe pain. She stated that she was unable to run or walk for long periods of time. She was woken up during the night with right knee pain. In the VA Form 9, received by VA in September 2015, the Veteran stated that she had pain in her legs and feet, pain woke her up at night, and pain increased with activity. In January 2020, the Veteran was provided an adequate examination for her right knee disability. The claims folder was reviewed. The report shows diagnoses of right knee strain, right meniscal tear, and degenerative arthritis. The Veteran reported that she had constant right knee pain that was worse with any bending including going upstairs or carrying things. She stated that she had physical therapy in the past few years and took Gabapentin and Voltaren for pain. She did not report flare-ups. As to functional impairment and loss, including but not limited to repeated use over time, the Veteran could not do most exercises, could not run or jump, and could not do repetitive bending, kneeling, or squatting. She had limited ability to go up or down stairs and perform heavy lifting, pulling or pushing. On examination, right knee flexion was 90 degrees and extension was 0 degrees. The range of motion itself contributed to functional loss. The examiner explained that decreased range of motion contributed to inability to do things. Pain was noted on examination on rest and non-movement and with flexion and extension. There was evidence of pain with weight-bearing and lateral tenderness on palpation of the joint or associated tissue. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion after three repetitions. The examiner found that pain would significantly limit functional ability with repeated use over time and estimated that flexion would remain at 90 degrees and extension at 0 degrees. There were additional contributing factors of disability including less movement than normal, swelling, disturbance of locomotion, and interference with standing. Muscle strength testing was normal. There was no ankylosis. There was no history of instability of subluxation. Stability testing was normal. The examiner noted that the Veteran had a meniscal tear and experienced frequent episodes of joint pain. There was a scar of the anterior right knee but the examiner noted that the scar was not painful, unstable, have a total area equal to or greater than 39 square centimeters (6 square inches) or located on the head, face, or neck. She did not use assistive devices. As to impact on work, the Veteran could not do exercises, run or jump, do heavy lifting, push, or pull. She had limited ability to go up or down stairs. She could not do repetitive bending, kneeling, or squatting. There was evidence of pain on passive range of motion testing and pain when the joint was used in non-weight bearing. The Veteran's right knee disability is rated at the maximum available rating under Diagnostic Code 5259 for cartilage, semilunar, removal of, symptomatic. Thus, a higher rating is not warranted under that Code for the right knee meniscal disability. Diagnostic Code 5258 also addresses meniscal disabilities, and provides a 20 percent rating for dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint. Though review of the evidence shows some notations involving swelling, the VA examination reports specific to the Veteran's knee are assigned great probative value as to what symptoms are attributable to the Veteran's meniscal condition. The VA examiners specifically addressed the nature of the meniscal condition finding that it causes frequent episodes of joint pain, but did not find that it resulted in frequent episodes of effusion or locking. Therefore, the Board finds that the criteria for a higher, 20 percent rating under Diagnostic Code 5258 are not met. As to ratings under other available codes, the Board finds that the Veteran is entitled to a separate 10 disability rating under Diagnostic Codes 5003 and 5260. The evidence shows a diagnosis of degenerative arthritis of the right knee and VA examination reports show that the Veteran's right knee flexion is less than the normal 140 degrees. Because flexion is less than normal, but not compensable under Diagnostic Code 5260, a 10 percent rating is warranted by application of Diagnostic Code 5003 as explained above. This rating is not assigned under 38 C.F.R. § 4.59, as there is a Diagnostic Code allowing a compensable rating. In doing so, the Board notes that the Veteran is compensated for episodes of joint pain as a symptom of her meniscal disability under Diagnostic Code 5259, but she has also reported pain that is worse with movement, described as bending, going up the stairs, and carrying things. Thus, the Board finds that a separate rating for painful limitation of flexion is not duplicative or overlapping with symptoms of the meniscal disability rated under Code 5259. 38 C.F.R. § 4.14; see Lyles v. Shulkin, 29 Vet. App. 107 (2017) (evaluation of a knee disability under the limitation of motion diagnostic codes does not, as a matter of law, preclude separate evaluation of a meniscal disability of same knee under Diagnostic Code 5258 or 5259, and vice versa). A rating in excess of 10 percent is not warranted under Diagnostic Code 5260 because there is no evidence that the right knee flexion was limited to 30 degrees or less. A separate rating is not warranted for limitation of extension under Diagnostic Code 5261. Right knee extension is normal, as per medical evidence. Even considering additional functional impairment and loss during periods of repeated use, the evidence does not reflect that the Veteran's flexion would be limited to 30 degrees or less, or extension limited to 5 degrees for a noncompensable rating. The January 2020 VA examiner estimated that right knee flexion would remain at 90 degrees and right knee extension to 0 degrees during repeated use. Accordingly, a higher rating under Diagnostic Code 5260 is not warranted and a separate compensable rating under Diagnostic Code 5261 is not warranted. With respect to instability of the right knee, a separate rating is not warranted under either the old criteria or the new criteria. The Veteran has not reported instability and there is no evidence of instability on testing or a history of instability or subluxation. Accordingly, a separate rating under Diagnostic Code 5257 is not warranted. There is no evidence of ankylosis, tibia/fibula impairment, or genu recurvatum. Therefore, those Diagnostic Codes are not for application. Finally, the evidence shows a right knee scar, but the Veteran is already service connected for that scar and rated under Code 7805. Moreover, there is no evidence of pain, instability, or area measurements that would warrant a compensable rating. Finally, consideration has been given to the possibility of assignment of an extraschedular evaluation under 38 C.F.R. § 3.321. Extraschedular consideration involves a three-step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In her NOD, the Veteran reported that she woke up due to her right knee pain. The Board finds that being awakened due to pain is not considered exceptional or unusual impairment associated with a musculoskeletal disability. Even if this could be considered an exceptional or unusual disability, the evidence does not reflect marked interference with employment. The Veteran has functional impairments that may impact employment because she cannot run or jump, do heavy lifting, push, or pull. She also has limited ability to go up or down stairs and cannot do repetitive bending, kneeling, or squatting. However, again, limitations on physical activity including exercises, does not represent a marked interference with employment in this case. The Veteran has not worked since she separated from military service. There is no evidence of frequent hospitalization. Referral for extraschedular consideration is not warranted. Entitlement to an initial rating in excess of 10 percent for urticaria The Veteran contends that an evaluation in excess of 10 percent is warranted for her service-connected urticaria. The Veteran's urticaria is rated under 38 C.F.R. § 4.118, Diagnostic Code 7825, pertaining to urticaria. In 2018, VA amended the criteria for rating the skin. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). Under the former version of Diagnostic Code 7825, a 10 percent rating was warranted for recurrent episodes occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics. A 30 percent rating was warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. A maximum 60 percent rating was warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. Under the new criteria, the terms "systemic" and "debilitating" have been removed from Diagnostic Code 7825. Instead, the criteria were revised to address chronic urticaria, which is defined as continuous urticaria at least twice per week, off treatment, for a period of six weeks or more. Under the revised version of Diagnostic Code 7825, a 10 percent rating is warranted for chronic urticaria that requires first-line treatment (antihistamines) for control. A 30 percent rating is warranted for chronic urticaria that requires second-line treatment (e.g., corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil inhibitors, or thyroid hormone) for control. A maximum 60 percent rating is warranted for urticaria that requires third-line treatment for control (e.g., plasmapheresis, immunotherapy, and or immunosuppressives) due to ineffectiveness with first- and second-line treatments. With regard to the effective date governing the new criteria, VA indicated in the Supplementary Information to the Final Rule that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Veteran's claim in this case was pending prior to the effective date of the new criteria. Therefore, the Board will consider both the old and new criteria and apply the more favorable. The Veteran's treatment records reflect that she had been prescribed Lidocaine, a numbing cream. The most recent VA treatment records are dated in 2017 (printed in 2019) with no mention of the Veteran's skin condition. In September 2011, the Veteran was provided a general VA examination. She had pruritic hives from being outside and avoided sitting in the front seat of car. It was noted that she currently used Doxepin that made her tired. The physical examination showed manifestations on her face, back, and chest, but those have been separately service connected under Diagnostic Code 7828. The impact on employment was that the Veteran was assigned different duties and was unable to do outside duties. There was a problem with usual daily activities as she was unable to be outside for any length of time and unable to drive any distance. In September 2012, the Veteran was provided a VA examination. The report shows a diagnosis of solar urticaria. The Veteran reported that in 2003 or 2004, she developed itching and hives over sun exposed areas. She was on profile to cover entire body and avoid the sun. She was advised to stay out of the sun, cover skin from sun exposure, and use sunscreen. She reported that she developed hives and itching on hands, arms, and face when exposed to the sun. It usually subsided within one to one and a half hours. There was no scarring or disfigurement. The examiner noted that treatment consisted of sunscreen. The examiner found that the Veteran did not have any debilitating episodes due to her solar urticaria, but did experience non-debilitating episodes. The non-debilitating episodes were described as itching and hives when exposed to the sun and subside in one and a half hours. Regarding impact on work, the examiner explained that the Veteran would not be able to work where exposure to sun could not be avoided. The examiner also remarked that there was no skin condition on examination as the Veteran only developed skin lesions when exposed to the sun and lasts for one- and one-half hours. In September 2013, the Veteran stated that she suffered daily breakouts and that the symptoms were debilitating. She reported breakouts with hives and severe itching on exposed skin. She stated that she did not have access to phototherapy or light therapy and was told to avoid sunlight, cover at all times, and wear sunscreen. She stated that going to the hospital was not an option because treatment did not exist. The Veteran reported that she was unable to sit by a window during the day and missed family activities because of her conditions. She was given Doxepin to help with symptoms which improved but did not alleviate symptoms. She took Vitamin D and B6 daily because she was deficient due to an inability to go out in the sun without cover and sunblock. In the VA Form 9, received by VA in September 2015, the Veteran stated that she had daily episodes of urticaria, and it was constant. She explained that she was covered regardless of the time of year and her condition did not respond to treatment. The Veteran stated that her condition required her to take Vitamin D, B6, and made her depression worse. She requested reevaluation of her urticaria. In January 2020, the Veteran was provided a VA examination for her solar urticaria. The report shows review of the claims folder and lists a diagnosis of solar urticaria. The Veteran stated that any exposure to the sun caused diffuse itchy urticaria in areas exposed to the sun. The symptoms tended to last for hours at a time. She stated that this occurred multiple times per week. The Veteran explained that she tried to avoid the sunlight as much as possible and took Benadryl as needed. The examiner stated that the Veteran used oral antihistamines for 6 weeks or more but not constant. The Veteran had a break in treatment and experienced symptoms at least twice a week for six weeks or more. The examiner stated that the Veteran had first-line treatment of antihistamines. The Veteran did not have a visible rash due to urticaria at the time of the examination. Regarding impact on work, the Veteran needed to avoid any sunlight including direct and indirect. The Board finds that a rating in excess of 10 percent is not warranted for the Veteran's urticaria under the old criteria, which is more favorable to the Veteran. Though the Veteran has stated that hospital treatment would not help her disability and that she experienced debilitating episodes, the Board finds that the symptoms of her disability do not rise to the level of debilitating episodes for a higher rating. The 2013 VA examiner specifically addressed the Veteran's symptoms and found that she did not experience debilitating episodes and that her symptoms abated after a few hours. The medical evidence demonstrates that the Veteran's disability has not required hospitalization, emergency room visits, urgent care at clinics, or prescribed bed rest. Accordingly, a rating in excess of 10 percent is not warranted. Further, though the new criteria are not more favorable to the Veteran, application of the criteria would not warrant a higher rating from its effective date. The evidence does not show that the Veteran's urticaria requires second-line treatment for control. The 2020 VA examiner determined that the Veteran was prescribed an antihistamine for first-line treatment. Therefore, a rating in excess of 10 percent is not warranted under the new criteria from its effective date. 38 C.F.R. § 4.118, Diagnostic Code 7825. The Board has considered the Veteran's statements regarding the severity of her service-connected urticaria. The Board sympathizes with the Veteran's condition and her symptoms; however, the Board finds the medical evidence of record more probative. Significantly, the VA examinations and records do not show that she suffers debilitating episodes sufficient to warrant an increased rating under the former criteria of Diagnostic Code 7825 or that she has second-line treatment to warrant a higher rating under the new criteria from its effective date. For the above reasons, the Board finds the evidence does not support a rating in excess of 10 percent. Thus, the benefit-of-the-doubt doctrine is not for application, and the claim for a higher rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Consideration has been given to the possibility of assignment of an extraschedular evaluation under 38 C.F.R. § 3.321. See also Thun v. Peake, 22 Vet. App. 111 (2008). In her NOD, the Veteran reported depression as a result of her urticaria and missed family activities. In a February 2019 brief, the Veteran's representative stated that she was bothered by the discomfort and appearance. However, the Veteran is already service connected for major depression and compensated under the rating schedule. The Board finds that the evidence does not reflect exceptional or unusual disability and that the schedular criteria reasonably describe the Veteran's disability level and symptomatology. Referral for extraschedular consideration is not warranted. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340(a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is not whether the Veteran can find employment generally, but whether the Veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. For the appeal period prior to February 28, 2013, the Veteran meets the percentage requirements for TDIU. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Prior to February 28, 2013, the Veteran was service connected for major depression, rated as 50 percent disabling; lumbar strain rated as 10 percent disabling; right knee disability rated as 10 percent disabling; right ankle strain rated as 10 percent disabling; retinopathy rated as 10 percent disabling; solar urticaria rated as 10 percent disabling; carpal tunnel syndrome of the right upper extremity rated as 10 percent disabling; plantar fasciitis of the left foot rated as 0 percent disabling; plantar fasciitis of the right foot rated as 0 percent disabling; strain, right thigh muscle rated as 0 percent disabling; chronic sinusitis rated as 0 percent disabling; allergic rhinitis rated as 0 percent disabling; hemorrhoids rated as 0 percent disabling; residual vaginal soreness and cramping rated as 0 percent disabling; residual scarring, left thigh, rated as 0 percent disabling; residual scarring of right knee rated as 0 percent disabling; residual scarring of right thigh rated as 0 percent disabling; onychomycosis rated as 0 percent disabling; acne of face, back, and chest rated as 0 percent disabling; hyperpigmentation of skin of thighs and genital region rated as 0 percent disabling; carpal tunnel syndrome of the left upper extremity rated as 0 percent disabling; sciatica of the right lower extremity rated as 0 percent disabling; and sciatica of the left lower extremity rated as 0 percent disabling. Her combined evaluation is at least 70 percent for the entire period. An August 2011 VA mental disorders examination report shows that the Veteran had one year of college at Central Texas College and University of Maryland. She was currently treated with an anti-psychotic and anti-depressant for her psychiatric symptoms. The Veteran reported that she was unable to concentrate, would lose her train of thought, experienced crying spells, and felt that she could not cope. Her mood was severely depressed, and she could not adapt her behavior to fit social situations. She felt hopeless, worthless, and helpless. The Veteran had a flat affect and was also tearful at times. She had mildly impaired recent memory and immediate memory. Concerning employment, the Veteran worked in computer support in the military and lost two weeks of work for inability to stop crying. The examiner found that her symptoms of decreased concentration, difficulty following instructions, increased absenteeism, and poor social interaction posed problems with occupational functioning. The examiner determined that the Veteran's symptoms resulted in deficiencies in judgment, family relations, thinking, work, mood, or school. The examiner found that her symptoms of major depression significantly impaired her social, occupational, and interpersonal functioning. In September 2012, the Veteran stated that she was an IT specialist by trade but her inability to recall information, appear pleasant, and communicate with people left her unable to gain employment. She stated that her depression controlled her life. She also reported that she had to take higher doses of pain medications to function due to increased pain in her hands and elbows. She stated that she could not lift, work with small tools, or solve complex problems. The Veteran also stated that the pain in her knees caused her to avoid pressure on the knees at all costs. She reported that her plantar fasciitis caused her to be unable to stand longer than 20 minutes. The Veteran reported that she had sinusitis and had headaches, runny nose, and pain up the back of her neck. The January 2013 VA examination report for the right knee shows that the Veteran reported constant severe right knee sprain. The examiner explained that the right knee condition hindered functionality of employment by not being able to climb, lift greater than 50 pounds, or walk for long periods of time. The Board finds that the Veteran was unable to secure or follow a substantially gainful occupation as a result of her service-connected disabilities, in combination, prior to February 28, 2013. The evidence shows that the Veteran's major depression symptoms significantly impaired occupational functioning. In addition, the Veteran's service-connected back disability hindered functionality of employment by not being able to climb, lift greater than 50 pounds, or walk for long periods of time, the September 2011 general VA examination report shows that the Veteran's carpal tunnel syndrome worsened with use of her hands, and the September 2011 general VA examination report shows decreased activity due to headaches and that her bilateral knee strain impacted her mobility, lifting and carrying, and strength. The Board finds that the Veteran's symptoms associated with her service-connected disabilities would pose significant barriers to obtaining and maintaining substantially gainful employment. See Ray v. Wilkie, 31 Vet. App. 58, 72 (2019) (holding that the phrase "unable to secure and follow a substantially gainful occupation" in § 4.16 has economic and noneconomic components, the latter of which focuses on the individual veteran's ability to perform the physical and mental acts necessary for such an occupation). Resolving reasonable doubt in the Veteran's favor, the Board finds that she is entitled to an award of TDIU prior to February 28, 2013. 38 C.F.R. § 4.16. As the total disability is not due to a single condition, consideration of special monthly compensation is not warranted. Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Seay, 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.