Citation Nr: 21040169 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-27 615A DATE: July 2, 2021 ORDER Entitlement to an increased 20 percent rating, but not higher, for left knee patellofemoral syndrome is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial 10 percent rating, but not higher, for left knee instability is granted, subject to the laws and regulations controlling the award of monetary benefits. Restoration of a 10 percent rating for pseudofolliculitis barbae and folliculitis (PFB) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an effective date of January 17, 2017 for an increased rating of 20 percent for cervical spine degenerative disc disease (neck disability) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an effective date of January 17, 2017 for an increased rating of 30 percent for lumbar spine degenerative disc disease (lumbar spine disability) is granted, subject to the laws and regulations controlling the award of monetary benefits. REMAND Entitlement to an increased rating for PFB, currently rated 10 percent disabling, is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's left knee patellofemoral syndrome symptomatology more nearly approximates flexion limited to 30 degrees, but it does not more nearly approximate flexion limited to 15 degrees. 2. The Veteran's left knee instability more nearly approximates slight, but not moderate, recurrent lateral instability. 3. The reduction in the disability rating from 10 percent to noncompensable for PFB was not based on improvement in the Veteran's ability to function under the ordinary conditions of life. 4. The Veteran underwent a surgical procedure indicating an increase in his lumbar spine and neck disabilities in January 17, 2017, and filed a claim for an increase rating within a year of that procedure. CONCLUSIONS OF LAW 1. The criteria for an increased 20 percent rating, but not higher, for left knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, diagnostic code (DC) 5260. 2. The criteria for an initial 10 percent rating, but not higher, for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 3. The reduction of the disability rating for PFB from 10 percent to noncompensable was not proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.105(e), 3.344. 4. The criteria for an increased rating of 20 percent for neck disability have been met from January 17, 2017. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.3, 4.71A, DC 5242. 5. The criteria for an increased rating of 30 percent for lumbar spine disability have been met from January 17, 2017. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.3, 4.71A, DC 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1996 to March 2010. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which continued a 10 percent rating for left knee disability, and reduced its rating for PFB, evaluating it as noncompensable; and a July 2017 rating decision that, inter alia, granted a rating increase for lumbar spine disability, evaluating it as 20 percent disabling from May 22, 2017, and neck disability, evaluating it as 30 percent disabling from May 22, 2017. In March 2015, the Veteran filed his notice of disagreement with the ratings assigned for PFB, and left knee disability, and in July 2018 filed his notice of disagreement with, among other things, the effective dates assigned for neck and back disability, was issued statements of the case in June 2016 and March 2020, and in June 2016 and April 2020, perfected his appeals to the Board. In March 2021, the Veteran appeared at a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. 1. Left knee patellofemoral syndrome During the Veteran's virtual Board hearing, his attorney stated that considering the medication the Veteran takes and various functional losses, he is entitled to a rating higher than 10 percent. The Veteran testified that he cannot ride in a car for over an hour, and he has to sit down after walking less than half a block due to his knee pain. He also stated that the pain stops him from getting out of his bed, reporting that the swelling is unbearable. The Veteran stated that at times when his knee pain flares-up, he needs help to get out of his bed, and put on socks and shoes. He reported that he suffers from these types of flare-ups 3 or 4 days a week, that they last for about three-fourths of the day, and that when it happens, he can barely move his knee forwards or backwards due to the excruciating pain. The Veteran testified that if he were not taking medications for his left knee disability, his symptoms would be much worse. The Veteran also testified that he has not fallen due to his knees giving out, but indicated that if he did not use his cane or brace, he would most definitely fall. The Veteran's disability is currently rated 10 percent disabling under Diagnostic Code 5299-5261. 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. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using "99" for the last 2 digits. Id. Portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021. However, this diagnostic code was not changed. While the Veteran is currently in receipt of a 10 percent rating pursuant to DC 5299-5261, the Board has also considered other potentially relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). DC 5256 assigns a 30 percent evaluation for knee ankylosis with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees; a 40 percent rating for knee ankylosis in flexion between 10 and 20 degrees; a 50 percent rating for knee ankylosis in flexion between 20 and 45 degrees; and a 60 percent rating for extremely unfavorable knee ankylosis in flexion at an angle of 45 degrees or more. The Board notes that during the pendency of the appeal, and as previously mentioned, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to February 7, 2021, DC 5257 assigns a 10 percent evaluation for slight recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. As of February 7, 2021, under the amended criteria, DC 5257 assigns a 10 percent rating for recurrent subluxation or instability for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device, or bracing for ambulation; a 20 percent evaluation for sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or unrepaired or failed repair of complete ligament tear causing persistent instability, and medical provider prescribes either an assistive device or bracing for ambulation; and a 30 percent evaluation for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device and bracing for ambulation. Under DC 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. Under DC 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, limitation of extension of the leg, a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. VA General Counsel provided guidance in VAOPGCPREC 23-97 (July 1997) that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under DC 5257, the Veteran must also have limitation of motion under DC 5260 or 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also clarified, if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under DC 5003 in light of sections 4.40, 4.45, 4.59 must be considered. Absent x-ray findings of arthritis, limitation of motion should be considered under DCs 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004. Id. Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. The limitation of flexion and extension must be compensable in both planes in order to warrant separate ratings. Id. There is no prohibition of separate evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5257 or 5261 and a meniscal Diagnostic Code, i.e., Diagnostic Codes 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). An August 2013 VA examination report reflects that the Veteran reported that his knee pain is getting worse, and that he has pain with kneeling. He reported increased pain in the left knee, on both the medial and lateral sides of both knees, and stated that he wears bilateral knee braces. The Veteran did not report flare-ups of the left knee, and his range of motion was as follows: flexion to 120 degrees, with objective evidence of painful motion at 120 degrees; extension with objective evidence of painful motion to 0 degrees. The Veteran was unable to perform repetitive-use testing with 3 repetitions, reported pain on movement, and interference with sitting, standing, and weight-bearing, and tenderness or pain to palpation for joint line or soft tissue of the left knee. Muscle strength and joint stability tests were normal, there was no evidence or history of recurrent patellar subluxation/dislocation, the Veteran did not have, and had never had any tibial or fibular impairment, and had not had any meniscal conditions or surgical procedures for a meniscal condition. The examiner reported that the Veteran had not had a total knee joint replacement, or arthroscopic or other knee surgery. A June 2014 VA examination report indicated that the Veteran reported worsening pain in the left knee described as shooting anterior knee pain, and throbbing popliteal knee pain, which was worse with cold weather, bending, standing, or sitting. The Veteran reported flare-ups of the left knee. Left knee flexion was to 115 degrees with no objective evidence of painful motion, and extension was to 0 degrees with no objective evidence of painful motion. There was no change in range of motion with repetitive use testing. The examiner noted less movement than usual in the left knee, and reported that the Veteran had tenderness or pain to palpation for joint line or soft tissues of the left knee. Muscle strength and joint stability tests were normal, there was no evidence or history of recurrent patellar subluxation/dislocation, the Veteran had not had any tibial and/or fibular impairment, and had not had any meniscal conditions, or a total knee joint replacement. The Veteran reported regular use of a brace due to knee pain. Diagnostic testing uncovered no degenerative or traumatic arthritis and no evidence of patellar subluxation. The examiner noted that she was unable to opine as to what degree further repetitive use or flare-ups could significantly limit functional ability without mere speculation. An April 2017 VA examination report reflected that the Veteran reported that currently he can walk several hundred feet, but stops frequently due to left knee pain on both sides. He also reported that his knee hurts "with the cold", and stated that the pain is too excruciating to walk up and down stairs. The Veteran did not report flare-ups of the left knee. Left knee flexion was to 130 degrees, and extension was to 0 degrees. The examiner noted pain with flexion and extension that did not result in or cause functional loss. There was evidence of pain with weight-bearing, pain with passive flexion and extension, and crepitus which was described as mild and normal for the Veteran's age. There was no change in range of motion with repetitive use testing. The examiner noted no muscle atrophy, muscle strength and joint stability tests were normal, there was no evidence or history of recurrent patellar subluxation/dislocation, or lateral instability, but the Veteran reported a history of "severe" recurrent effusion, stating that his left knee swells every night. The Veteran had not had any tibial and/or fibular impairment, or any meniscal conditions. The Veteran reported regular use of a brace and cane due to knee pain. There was no evidence of pain on passive range of motion testing, or in non-weight bearing. Based on the foregoing, the Board finds that a higher, 20 percent rating is warranted for the Veteran's left knee patellofemoral syndrome under DC 5261. While the VA examination reports reflect flexion from 115 to 130 degrees, with no muscle atrophy, or reduction in muscle strength, the Veteran reported a "severe' history of knee swelling, and testified that his left knee patellofemoral syndrome prevents him from being able to ride in a car for over an hour, and requires that he sit down after walking for not even a half a block. He also testified that when the knee pain flares-up, he can "barely" move his knee forwards or backwards due to "excruciating pain", and that his symptoms would be much worse if not for the use of medication. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Board notes that the Veteran is competent to attest to the pain he suffers as a result of his left knee patellofemoral syndrome, and there is no indication in the evidence of record that he lacks credibility. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). Considering the Veteran's competent and credible descriptions of pain particularly during a flare-up, the Board finds that the Veteran's left knee patellofemoral syndrome symptomatology more nearly approximates flexion limited to 30 degrees as contemplated by a 20 percent disability rating under DC 5260. However, a rating higher than 20 percent for left knee patellofemoral syndrome is not warranted as the preponderance of the evidence does not suggest that his left knee patellofemoral syndrome symptomatology more nearly approximates flexion limited to 15 degrees, or extension limited to 20 degrees as contemplated by a higher, 30 percent rating under DCs 5260 and 5261. As previously discussed, the Veteran's extension has consistently been noted to 0 degrees, with flexion between 115 to 130 degrees. While the Veteran has described suffering from pain which results in functional limitation, particularly during a flare-up, the evidence provided by the VA examination reports reflects a considerable range of motion of the left knee. Therefore, the Veteran's overall impairment due to his left knee patellofemoral syndrome symptomatology, including during a flare-up as described by the Veteran, does not result in a reduction that more nearly approximate symptomatology contemplated by a higher 30 percent rating under DCs 5260 and 5261. Moreover, the examination reports reflect that the Veteran does not have or more nearly approximate ankylosis of the left knee, thus a higher rating under DC 5256 is not warranted. However, while joint stability tests reflected by the VA examination reports were normal, with the April 2017 examiner noting no history of lateral instability, the Veteran has competently and credibly reported, and the examination reports indicate, regular use of a brace, with the Veteran adding that while he has not fallen, if he did not use a brace or cane, he would "most definitely fall". Therefore, the evidence is at least evenly balanced as to whether the Veteran's left knee symptomatology more nearly approximates slight recurrent lateral instability, thus a separate 10 percent rating for left knee lateral instability under the former DC 5257 criteria, as there is no evidence of ligament tear, is warranted. However, given the normal stability test findings, a rating higher than 10 percent for moderate recurrent subluxation or lateral instability is not warranted. While the April 2017 examination report indicates that the Veteran suffers from mild left knee crepitus, the evidence of record does not reflect, and the Veteran does not otherwise contend, that his left knee patellofemoral syndrome more nearly approximates dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, or symptomatic removal of semilunar cartilage. In fact, the VA examiners each noted no evidence or history of recurrent patellar subluxation/dislocation. Therefore, separate ratings under DCs 5258, and 5259 are not warranted. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's left knee patellofemoral syndrome symptomatology warrants a 20 percent rating, but not higher, under DC 5260, and his left knee instability warrants a separate 10 percent rating, but not higher, under DC 5257. 2. Pseudofolliculitis barbae and folliculitis The Veteran's PFB is currently rated noncompensable under DC 7813-7806 from June 1, 2015. It was previously rated 10 percent disabling from March 29, 2010. There is no question that a disability rating may be reduced; however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by VA regulations. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). In any rating reduction case, it must be ascertained, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. 38 C.F.R. § 3.344 (a). Moreover, not only must it be determined that an improvement in a disability has actually occurred, but also that any improvement in a disability reflects an improvement in a veteran's ability to function under the ordinary conditions of life and work. Id.; Brown v. Brown, 5 Vet. App. 413, 420-22 (1993). The burden of proof is on VA to establish that a reduction is warranted by a preponderance of the evidence. The Court has stated that both decisions by the RO and by the Board that do not apply the provisions of 38 C.F.R. § 3.344, when applicable, are void ab initio and will be set aside as not in accordance with the law. Kitchens v. Brown, 7 Vet. App. 320 (1995). Where a rating reduction was made without observance of law, the reduction must be vacated, and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). A June 2014 VA examination report reflected that the Veteran's PFB was stable, causing no functional limitations. The Veteran reported shaving 1 to 2 times a week, and stated that he does not use medication. The Veteran's PFB did not cause scarring or disfigurement of the head, face, or neck, he did not have any benign or malignant skin neoplasms, and did not have any systemic manifestations due to any skin diseases. The examiner noted that the Veteran had not been treated with oral or topical medications in the past 12 months, had not had any treatments or procedures other than systemic or topical medications in the past 12 months, and had not had any debilitating, or non-debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examination report indicated that the Veteran did not have any visible skin conditions. During his March 2021 virtual Board hearing, the Veteran, through his attorney, indicated that his PFB warrants at least a 10 percent disability rating, noting that in June 2018 he suffered from slight flare-ups due to a close shave. He testified that he has a mark on his face which occurred while on active duty that burns at times, and which he treats with different creams. He stated that he was advised not to take an oral antibiotic to treat his PFB due to the other medications he was taking for other disabilities. The Veteran stated that when his PFB flares up, it is like sunburn, with burning and itching, and that the bumps are painful. He also stated that the scarring on his face, which started in service, "throbs every now and then." The Veteran stated that shaving close to the scar caused the sunburned feeling and pain. The Veteran reported that he has to plan several weeks in advance to go out so that he can grow facial hair to wear a mask to comply with COVID-19 protocols. In light of the previously discussed evidence including the June 2014 VA examination report and the Veteran's virtual Board hearing testimony, the Board finds that the reduction in the disability rating for the Veteran's PFB was not proper. Overall, the evidence does not reflect that there was any improvement in the Veteran's ability to function under the ordinary conditions of life and work considering his PFB at the time of the March 2015 reduction. While the June 2014 VA examination report indicates that the Veteran's PFB is stable, causing no functional limitations, the Veteran has competently and credibly testified that his PFB "burns" when it flares up, and that he treats it with different creams. He has stated that when he shaves, he suffers from slight flare-ups. While the June 2014 VA examination report reflects no pain or use of medication to treat PFB, it is unclear as to whether the Veteran reported that he no longer suffers from discomfort due to flare-ups, or was just not experiencing flare-ups at the time of the examination. Additionally, it is reasonable to conclude that at the time the Veteran was not using creams and medication to treat his PFB, but has since found it necessary to do so. The Board will resolve any such discrepancy in the light most favorable to the Veteran considering the pro-claimant nature of Veterans law, and concludes that the Veteran suffers from flare-ups of his PFB, but was not experiencing discomfort at the time of the June 2014 VA examination. Considering the recent testimony provided by the Veteran and his attorney discussed above, it is reasonable to conclude the functional impact of the Veteran's PFB had not improved to the point where a rating reduction would be warranted based on improvement in the Veteran's ability to function under the ordinary conditions of life and work. For the foregoing reasons, the reduction in the disability rating for the Veteran's PFB was not proper. This renders the reduction from 10 percent to noncompensable void ab initio. Accordingly, under these circumstances, restoration of the previously assigned 10 percent rating for the Veteran's PFB is warranted. Effective Date 3. Cervical and Lumbar Spine The Veteran's cervical spine degenerative disc disease is currently rated 30 percent disabling from May 22, 2017 under DC 5242, and his lumbar spine degenerative disc disease is rated 20 percent disabling under DC 5242 also from May 22, 2017, the date the Veteran filed his VA 21-526b Supplemental Claim for an increased rating for a lumbar spine disability. The Board will now determine whether an earlier effective date for both the lumbar, and cervical spine rating increase, is warranted. In a June 2020 letter, the Veteran's attorney reported that the Veteran's back disability had worsened to the point that his physicians scheduled him for back surgery in January 2017, and prior to that, his VA treatment records show deterioration in the Veteran's condition which led to the need for surgery. Therefore, the Veteran's attorney stated that the Veteran is entitled to an earlier effective date of May 22, 2016, a year prior to his claim for an increased rating. The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Except as otherwise provided, the effective date of an evaluation and an award of compensation will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. The words "claim" and "application" are defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1 (p). "Date of receipt" generally means the date on which a claim, information, or evidence was received by VA. 38 C.F.R. § 3.1 (r). For increased rating claims, if the evidence shows that the increase in disability occurred prior to the date of receipt of claim, the RO may assign the earliest date as of which it is ascertainable that the increase occurred as long as the claim for the increased disability rating was received within a year of the date that the increase occurred. 38 U.S.C. § 5110 (b)(3); 38 C.F.R. § 3.400 (o)(2); see also Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (stating that section 5110(b) (2), now section 5110(b)(3), requires that "an increase in a veteran's service-connected disability must have occurred during the one year prior to the date of the veteran's claim... to receive the benefit of an earlier effective date"). March 2016 VA treatment records reflect that the Veteran reported suffering from postsurgical back pain following an October 2015 laminectomy, and reported trying physical therapy which worsened the pain. January 2017 VA treatment records reflect the Veteran underwent back surgery for a diagnosis of intervertebral disc displacement. The Veteran, through his attorney, has reported, and the evidence including VA treatment records reflect, that the Veteran's lumbar spine disability, and associated neck disability, worsened prior to the current May 22, 2017 effective date. As reported by the Veteran's attorney, the Veteran underwent back surgery in January 2017, indicating that his lumbar spine disability symptomatology had worsened to the point that he found surgical intervention necessary to alleviate the symptoms. Additionally, the March 2016 VA treatment records indicate that the Veteran's pain had worsened since his October 2015 procedure. The Court has held that an "effective date should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that [the veteran's disability] first manifested." Swain v. McDonald, 27 Vet. App. 219, 224 (2015) (quoting DeLisio v. Shinseki, 25 Vet. App. 45, 58 (2011); Hazan v. Gober, 10 Vet. App. 511, 521 (1997) (noting that for increased ratings claims, section 5110(b)(2) requires VA to "review all the evidence of record"). Here, the evidence reflects that the earliest date as of which it is ascertainable that an increased occurred was October 2015, as reported in the March 2016 VA treatment records, but the claim for an increased rating was not received within a year of the date that the increase occurred. However, the January 17, 2017 records indicate that the Veteran's lumbar spine disability underwent an increase which resulted in the Veteran undergoing a surgical procedure, and the Veteran filed a claim for an increase rating within a year of that procedure. Based on the foregoing, the Board finds that January 17, 2017 is the proper effective date for the grant of the 20 percent rating for neck disability, and the 30 percent rating for lumbar spine disability. REASONS FOR REMAND The Veteran contends that his PFB symptomatology warrants higher than a 10 percent rating. VA has amended the criteria for rating the skin, 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 the new regulations, systemic therapy is defined as "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." In Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017), the Federal Circuit found that "systemic" is defined as "pertaining to or affecting the body as a whole" and "therapy" is defined as "treatment of diseases. In Burton v. Wilkie, 30 Vet. App. 286, 291 (2018), the Court discussed two ways that a treatment could be shown to be systemic: (1) The method by which the treatment works to treat the medical condition and (2) the side effects that are possible or actually experienced as a result of the treatment. Finally, in Warren v. McDonald, 28 Vet. App. 194, 197 (2016), the Court held that the types of systemic treatment that are compensable under DC 7806 are not limited to "corticosteroids or other immunosuppressive drugs;" rather, compensation is available for "all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs. Here, the Veteran has indicated that he uses creams to treat his PFB and stated that he has a "mark" on his face as well as slight "flare-ups" with shaving. However, the evidence of record does not address whether the Veteran treats his PFB with systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs, and no examiner has made any determination as to the percentage of the Veteran's body affected by his PFB. Therefore, a remand is necessary for a new VA examination report to adequately assess the severity of the Veteran's PFB. The matter is thus REMANDED for the following action: Schedule the Veteran for a medical examination, to include via telehealth if feasible, by an appropriately qualified physician to evaluate the current nature and severity of his service connected PFB. The physician must address whether the Veteran's disability requires systemic therapy as that term was defined prior to and after the regulatory change discussed above. Specifically, the physician must consider whether any topical therapy such as skin cream is systemic in its scale, method, or side effects, and must address the percentage of exposed area affected by PFB. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.