Citation Nr: 21041943 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 15-44 395 DATE: July 10, 2021 ORDER For the entire period on appeal, an increased compensable evaluation for the Veteran's service-connected skin disability, diagnosed as dermatitis, is denied. For the entire period on appeal, an increased evaluation of 30 percent, but no greater, for the Veteran's service-connected gastrointestinal disability, diagnosed as intestinal amebiasis, is granted. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's service-connected skin disability, diagnosed as dermatitis, has involved characteristic lesions affecting less than 5 percent of the total body area and none of the exposed body area (face, neck, and hands), and has been treated with topical therapy, to include topical corticosteroids and bleach baths, but has not required systemic therapy during the past 12-month period. 2. For the entire period on appeal, the Veteran's service-connected gastrointestinal disability, diagnosed as intestinal amebiasis, manifested frequent gastrointestinal disturbances multiple times per day, to include lower abdominal cramps, gaseous distention and bloating, loss of appetite, and diarrhea. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for the assignment of a compensable evaluation for the Veteran's service-connected skin disability, diagnosed as dermatitis, have not been satisfied. 38 U.S.C. § 1101, 1110, 1131, 1155, 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.69, 4.118, Diagnostic Code 7806. 2. For the entire period on appeal, the criteria for the assignment of an increased evaluation of 30 percent, but no greater, for the Veteran's service-connected gastrointestinal disability, diagnosed as intestinal amebiasis, have been satisfied. 38 U.S.C. § 1101, 1110, 1131, 1155, 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.20, 4.21, 44.27, 4.110, 4.112, 4.113, 4.114, Diagnostic Codes 7321, 7323. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Marine Corps from February 1969 to July 1970, from October 1971 to October 1973, and from August 1974 to August 1976, including service in Vietnam, for which he was awarded the Gallantry Cross and the Combat Action Ribbon, among other decorations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in June 2018; a transcript of that hearing is of record. In April 2019, the Board remanded this appeal for further development, including scheduling the Veteran for an additional VA examination to evaluate his current skin disability. To the extent that the directed VA examination report was procured in November 2019, the Board finds that substantial compliance with its remand directives pertaining to the Veteran's claims has been accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). During the pendency of the appeal the AOJ granted an increased 10 percent rating for amebiasis effective January 7, 2019. A Veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation and a claim remains in controversy where less than the maximum available benefit is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). As such, the issue is entitlement to a compensable evaluation prior to January 7, 2019 and an evaluation in excess of 10 percent beginning January 7, 2019. Increased Rating Disability evaluations 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. See 38 U.S.C. § 1155; 38 C.F.R. § § 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. See 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991); 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other VA regulations, regardless of whether they were raised by the Veteran, as well as the entire history of the Veteran's disability. See 38 C.F.R. § § 4.1, 4.2; see also Schafrath, 1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran's disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). However, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Once the evidence has been assembled in the record, the Board shall consider all competent lay and medical evidence of record, analyze the credibility and probative value of the evidence, and provide reasons for rejecting any favorable material evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996); 38 U.S.C. § 7104(a). In addressing lay evidence and determining its probative value, the Board must assess both its competency, a legal concept determining whether testimony may be heard and considered, and its credibility, a factual determination regarding its probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall afford the claimant the benefit of the doubt, see 38 U.S.C. § 5107; 38 C.F.R. § § 3.102, 4.3, and where the evidence is in relative equipoise, the claimant shall prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must weigh against the claim in order to warrant its denial. See Alemany, 9 Vet. App. at 519-20. 1. For the entire period on appeal, an increased compensable evaluation for the Veteran's service-connected skin disability, diagnosed as dermatitis, is denied. In March 2013, the Veteran was awarded service connection for his current skin disability, diagnosed as dermatitis of the right ankle, and assigned a noncompensable evaluation effective May 31, 2011. Subsequently, a January 2021 rating decision also awarded service connection for the Veteran's dermatitis of the lateral groin area, combined that award with his award for his service-connected dermatitis of the right ankle, and continued the Veteran's noncompensable evaluation for his service-connected skin disability, now diagnosed as dermatitis of the lateral groin area and right ankle. In March 2013, the Veteran filed a Notice of Disagreement (NOD) and the instant claim for an increased compensable evaluation; however, after careful review, the Board finds that, for the entire period on appeal, an increased compensable evaluation for the Veteran's service-connected skin disability is not warranted in this case. Disability evaluations 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. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. See 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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. See 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence of record indicates fluctuations in the severity of symptoms during the course of the rating period on appeal, an assignment of staged ratings is permissible. See Fenderson v. West, 12 Vet. App. 119 (1999). As noted above, the Veteran's service-connected skin disability is currently evaluated as 0 percent disabling under the criteria of Diagnostic Code 7806 for dermatitis. The Board notes that on July 13, 2018, VA issued a final rule amending its regulations governing skin disabilities, which had been in effect since 2008 (the 2008 Regulations). The regulations amended in 2018 became effective on August 13, 2018 (the 2018 Regulations). Therefore, claims filed on or after August 13, 2018, must be evaluated under the 2018 Regulations; however, claims pending prior to August 13, 2018, must be evaluated under both the 2008 Regulations and the 2018 Regulations, and the most favorable set of criteria must be applied to the claims on appeal. See 83 Fed. Reg. 32592-32601 (July 13, 2018). Because the Veteran's claim for an increased rating for his service-connected skin disability was pending prior to August 13, 2018, his claims must be evaluated under both the 2008 Regulations and the 2018 Regulations, and the most favorable set of criteria must be applied in this case. However, because the 2018 Regulations made no substantive changes to Diagnostic Code 7806, the application of these criteria does not modify the Board's analysis of the Veteran's claim in any appreciable manner. Under the 2008 Regulations, Diagnostic Code 7806 provides as follows: (1) a 60 percent evaluation is warranted upon evidence of more than 40 percent of the entire body or more than 40 percent of exposed areas being affected, or the condition must require constant or near-constant systemic therapy during the prior 12-month period; (2) a 30 percent evaluation is warranted upon evidence of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas being affected, or the condition must require systemic therapy for a total duration of six weeks or more, but not constantly, during the prior 12-month period; (3) a 10 percent evaluation is warranted upon evidence of 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 being affected; or the condition must require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the prior 12-month period; and (4) a noncompensable evaluation is warranted upon evidence of less than 5 percent of the entire body or less than 5 percent of exposed areas being affected, and no more than topical therapy required during the past 12-month period. The 2008 Regulations also provide that dermatitis or eczema may also be evaluated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Under the current 2018 Regulations, Diagnostic Code 7806 provides that dermatitis shall be evaluated under the General Rating Formula for the Skin, which provides as follows: (1) a 60 percent evaluation is warranted upon evidence of at least one of the following: (a) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (b) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period; (2) a 30 percent evaluation is warranted upon evidence of at least one of the following: (a) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (b) 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; (3) a 10 percent evaluation is warranted upon evidence of at least one of the following: (a) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; (b) at least 5 percent, but less than 20 percent, of exposed areas affected; or (c) 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; and (4) a 0 percent evaluation is warranted upon evidence of no more than topical therapy required over the past 12-month period and at least one of the following: (a) characteristic lesions involving less than 5 percent of the entire body affected; or (b) characteristic lesions involving less than 5 percent of exposed areas affected. See 38 C.F.R. § 4.118, General Rating Formula for the Skin for Diagnostic Code 7806 (2020). The 2018 Regulations also provide that dermatitis or eczema may also be evaluated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Some applications of topical corticosteroids may constitute systemic therapy under Diagnostic Code 7806, and this determination should be made based on the facts of each individual case. See Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir 2017); see also Burton v. Wilkie, 30 Vet. App. 286 (2018). The Board is required to consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the 2008 version of Diagnostic Code 7806. See id. First, the Board must determine whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition. Then, if the treatment is clearly systemic, the Board also must determine whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. See id. The questions of whether a specific topical treatment affects the body as a whole and whether a treatment is "like" a corticosteroid or immunosuppressive drug are factual questions which may require medical evidence, including a VA opinion or referral to medical dictionaries. See id. In February 2013, the Veteran was afforded a VA skin examination which culminated in a report diagnosing dermatitis of the right ankle and finding as follows: (1) the Veteran reported that the condition began during service in 1974 with insect bites on his right ankle that caused local swelling and a "blackish" skin discoloration that has remained ever since; (2) the Veteran's skin disability does not result in scarring or disfigurement of the head, face, or neck; (3) in the prior 12 months, the Veteran was prescribed topical corticosteroids (triamcinolone cream) to treat the "very itchy" rash on his right ankle, with constant/near-constant use for the prior 12 months; (4) the Veteran's skin disability affects less than 5 percent of his total body area and zero percent of his total exposed body area (including the face, neck, and hands); and (5) the Veteran's skin disability has no impact on his ability to work. In February 2019, the Veteran was afforded a second VA skin examination which culminated in a report diagnosing dermatitis of the right ankle and finding as follows: (1) the Veteran reported that his skin condition has manifests itching, irritation, dryness, flaky skin, redness, and swelling with flare ups, which he treats with a topical corticosteroid (triamcinolone); (2) the Veteran's service-connected dermatitis affects less than 5 percent of his total body area; (3) the Veteran's service-connected dermatitis affects zero percent of his exposed body area (including the face, neck, and hands); (4) the Veteran's dermatitis occurs on his right ankle and presents as a darkened and discolored patch; and (5) the Veteran's dermatitis negatively impacts his ability to work as forklift operator and results in decreased productivity and concentration due to itching and irritation that can cause a safety hazard while operating machinery. In November 2019, the Veteran was afforded a third VA skin examination which culminated in a report confirming his dermatitis diagnosis and finding as follows: (1) the Veteran reported that his skin condition manifests dryness, itching, irritation, and "scaling" with flareups, which he treats with a topical corticosteroid (triamcinolone); (2) he reported flareups with worsened symptoms during the summer (such as darkened discoloration) but reports constant itching, dryness, and irritation daily to the groin and right ankle area; (3) the Veteran's service-connected dermatitis affects less than 5 percent of his total body area; (4) the Veteran's service-connected dermatitis affects zero percent of his exposed body area (including the face, neck, and hands); (5) the Veteran's dermatitis occurs on his right ankle and groin and presents as a darkened and discolored patch; (6) he is currently treating his dermatitis with topical corticosteroids (clobetasol propinate cream) and bleach baths, as needed, to include for six weeks or more during the prior 12 months, but not constantly; and (7) the Veteran's dermatitis negatively impacts his ability to work and results in decreased productivity due to his dermatitis causing the need for breaks due to intense itching and medication application. In November 2019, VA obtained an addendum medical opinion opining that the Veteran's use of a topical corticosteroid (triamcinolone cream) does not qualify as systemic treatment. In June 2018, the Veteran testified at his Board hearing before the undersigned as follows: (1) his ankle rash is worse during the summer, growing to the size of a silver dollar, and gets irritated "every once in a while"; (2) he sometimes treats his dermatitis symptoms with over-the-counter calamine lotion, which can make it swell up; (3) prescription medication has not alleviated his symptoms; (4) he sometimes bathes his ankle and groin in bleach; (5) he sometimes scratches his rash until bloody; (6) the rash in his groin area is the same as the rash in his ankle area but worse; and (7) the rash in his groin area does not respond to treatment, to include the topical cream prescribed as treatment for both his right ankle and groin. However, after careful review of the relevant evidence of record, and in light of the foregoing, the Board concludes that a preponderance of the evidence weighs against the award of an increased evaluation in excess of the 0 percent currently awarded under Diagnostic Code 7806 as the Veteran's service-connected dermatitis has not been found to manifest the symptoms required by both the 2008 and the 2018 rating criteria, as it does not (1) involve at least 5 percent of his total body area or exposed body area, or (2) require systemic therapy, as indicated by the February 2019 VA examination report and November 2019 VA addendum opinion report. See Johnson, 862 F.3d at 1354-56. Therefore, the Board finds that an increased evaluation for the Veteran's service-connected skin disability is not warranted in this case. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an evaluation in excess of the rating assigned herein for the Veteran's disability. See Schafrath, 1 Vet. App. at 593. In addition, the Board is not required to address additional issues unless specifically raised by the Veteran or reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). Accordingly, in light of the foregoing, the Board hereby finds that the preponderance of the evidence of record weighs against a finding that the Veteran's service-connected skin disability warrants a compensable evaluation under Diagnostic Code 7806 or any other Diagnostic Code under either the 2008 Regulations or the 2018 Regulations. Therefore, the benefit of the doubt doctrine does not apply in this case, and the Veteran's claim for an increased evaluation for his service-connected skin disability must be denied. See Gilbert, 1 Vet. App. at 53-54. 2. For the entire period on appeal, an increased evaluation of 30 percent, but no greater, for the Veteran's service-connected gastrointestinal disability, diagnosed as intestinal amebiasis, is granted. In March 2013, the Veteran was awarded service connection for his current gastrointestinal disability, diagnosed as intestinal amebiasis and claimed as a stomach condition and diarrhea, and assigned a 0 percent evaluation under Diagnostic Code 7321, effective May 31, 2011. Subsequently, a March 2019 rating decision increased the Veteran's evaluation to 10 percent, effective January 7, 2019. The Veteran contends that his service-connected gastrointestinal disability is entitled to an increased evaluation in excess of 10 percent, and for the reasons set forth below, the Board agrees and finds that, for the entire period on appeal, an increased evaluation of 30 percent is warranted in this case. Diagnostic Code 7321 applies to digestive conditions diagnosed as amebiasis and provides as follows: (1) a 10 percent evaluation is warranted where the record contains evidence of mild gastrointestinal disturbances, lower abdominal cramps, nausea, gaseous distention, and chronic constipation interrupted by diarrhea; and (2) a 0 percent evaluation is warranted where the record contains evidence that the Veteran's diagnosed of amebiasis is asymptomatic. See 38 C.F.R. § 4.114, Diagnostic Code 7321. In addition, amebiasis with or without liver abscess is parallel in symptomatology with ulcerative colitis and should be rated on the scale provided for the ulcerative colitis (Diagnostic Code 7323). See id. Diagnostic Code 7323 applies to digestive conditions diagnosed as ulcerative colitis and provides as follows: (1) a 10 percent rating is warranted upon evidence of moderate symptoms with infrequent exacerbations; (2) a 30 percent rating is warranted for moderately severe symptoms with frequent exacerbations; (3) a 60 percent rating is warranted for severe symptoms with numerous attacks a year and malnutrition, with health only fair during remissions; and (4) a 100 percent rating is warranted for pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as liver abscess. See 38 C.F.R. § 4.114, Diagnostic Code 7323. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities; thus, rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. See 38 C.F.R. § 4.6. Moreover, use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue as all evidence must be evaluated in connection with the adjudication of an increased rating claim. See 38 C.F.R. §§ 4.2, 4.6. For purposes of evaluating gastrointestinal conditions under Section 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. See 38 C.F.R. § 4.112. Certain diseases of the digestive system, particularly within the abdomen, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding, which must be avoided. See 38 C.F.R. §§ 4.14, 4.113. In addition, certain diseases of the digestive system, corresponding to Diagnostic Codes 7301 to 7329, 7331, 7342, and 7345 to 7348, may not be combined with each other; rather a single rating must be assigned under the diagnostic code indicating the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability so warrants. See 38 C.F.R. § 4.114. After careful review, the Board finds that, for the entire period on appeal, the Veteran's service-connected gastrointestinal disability warrants an increased evaluation of 30 percent under Diagnostic Code 7323 for moderately severe symptoms with frequent exacerbations, as the Veteran's predominant symptomatology involves the following: gastrointestinal disturbances at least three times per day; bloating; lower abdominal cramps with diarrhea; gaseous distention with abdominal bloating and full feeling; loss of appetite; and weight loss. See 38 C.F.R. § 4.114, Diagnostic Code 7323. In February 2019, the Veteran was afforded a VA examination which culminated in a report diagnosing his gastrointestinal condition as intestinal amebiasis and finding as follows: (1) the Veteran reports that he is not currently treating his gastrointestinal condition with any medication, but that the condition has worsened over time, manifesting the following symptoms: (a) mild gastrointestinal disturbances at least three times per day; (b) constant bloating; (c) lower abdominal cramps with diarrhea; (d) gaseous distention with abdominal bloating and full feeling; (e) weight loss attributable to an infectious intestinal condition; (f) occasional episodes of bowel disturbance with abdominal distress and diarrhea; and (g) needing to void his bowels approximately three times per day; (2) the Veteran reports that he is not currently treating his intestinal condition with medication; (3) upon examination, no malnutrition, serious complications, or other general health effects were noted that are attributable to the intestinal condition; (4) an August 2018 blood test, including a complete blood count (CBC) indicated the following: (a) hemoglobin: 14.5; (b) hematocrit: 42.3; (c) white blood cell count: 7.1; and (d) platelets: 167; and (4) the Veteran's intestinal condition negatively impacts his ability to work resulting in decreased productivity due to frequent breaks for toileting and abdominal distress. In June 2018, the Veteran also testified at a Board hearing before the undersigned that his service-connected gastrointestinal disability results in the following symptoms: loss of appetite; bloating, congestion, and cramping even after only eating small portions; stomach aches every time he eats; and abdominal cramping and voiding almost every time he eats. The Veteran further testified that the medication he was prescribed to increase his appetite was ineffective. Accordingly, in light of the foregoing and resolving all reasonable doubt in the Veteran's favor, the Board finds that an increased evaluation of 30 percent under Diagnostic Code 7323 is warranted in this case, as the Veteran's service-connected gastrointestinal disability more nearly approximates the criteria for a 30 percent evaluation under Diagnostic Code 7323, including moderately severe symptoms with frequent exacerbations. However, in so finding, the Board further finds that a preponderance of the evidence of record weighs against a finding that an increased evaluation in excess of 30 percent is warranted in this case, as the competent evidence of record does not indicate that the Veteran's gastrointestinal disability manifests severe symptoms resulting in malnutrition, anemia, or general debility with only fair health during remission, or serious complications, such as a liver abscess. See 38 C.F.R. § 4.114, Diagnostic Code 7323. The Board has considered whether any other diagnostic codes would allow for a higher or separate rating but finds that no other higher or separate ratings are warranted under any of the other diagnostic codes pertaining to the digestive system, and notes that disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) may not be combined. See 38 C.F.R. § 4.114; Esteban v. Brown, 6 Vet. App. 259 (1994). Moreover, although the February 2019 VA examination report reflects that the Veteran has lost weight (35 pounds from his baseline weight of 160 pounds), the evidence does not reflect a finding of clinical malnutrition at any time during the period on appeal, and the February 2019 VA examination report does not indicate that the Veteran suffers from malnutrition, serious complications, or other general health effects attributable to the intestinal condition. See 38 C.F.R. § 4.114, Diagnostic Code 7323. In addition, the Board is not required to address additional issues unless specifically raised by the Veteran or reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). (Continued on the next page) Accordingly, in light of the foregoing and resolving all reasonable doubt in the Veteran's favor, the Board hereby finds that, for the entire period on appeal, the Veteran's service-connected gastrointestinal disability warrants a 30 percent evaluation under Diagnostic Code 7323, but no greater, as the Veteran's gastrointestinal symptoms more nearly approximate the criteria for a 30 percent evaluation under Diagnostic Code 7323, including moderately severe symptoms with frequent exacerbations. However, in so finding, the Board also finds that the preponderance of the evidence of record weighs against an award of an increased evaluation in excess of 30 percent, because, as stated above, the Veteran's service-connected gastrointestinal disability does not more closely approximate the criteria required for a 60 percent evaluation. Accordingly, because the preponderance of the evidence weighs against the award of any additional increased evaluations, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Marsdale 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.