Citation Nr: 21042515 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-52 261 DATE: July 13, 2021 ORDER Entitlement to an initial 40 percent rating, but not higher, for thoracolumbar spine degenerative disc disease with spondylosis (lumbar spine disability) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial 20 percent rating, but not higher, for right ankle closed fracture status post ORIF (right ankle disability) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating higher than 10 percent from October 1, 2014, for bilateral foot plantar fasciitis with pes planus (bilateral foot disability) is denied, but a higher 20 percent rating from February 7, 2021, for bilateral foot disability is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating higher than 10 percent for right elbow lateral epicondylitis (right elbow disability) is denied. Entitlement to an initial compensable rating for hemorrhoids is denied. Entitlement to an initial 10 percent rating, but not higher, for gastroesophageal reflux disease with hiatal hernia (GERD) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial 60 percent rating for mast cell activation syndrome with facial flushing and skin rash (mast cell activation syndrome) is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to a separate initial compensable rating for mast cell activation under Diagnostic Code (DC) 6522 is denied. Entitlement to an initial compensable rating for scars of the trunk and extremities is denied. Entitlement to a higher initial rating for right shoulder status post subacromial decompression (right shoulder disability), currently evaluated as 20 percent disabling, is denied. REMANDED Entitlement to an initial rating higher than 20 percent for left shoulder partial tear supraspinatus tendon with bursitis (left shoulder disability) is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine back disability symptomatology more nearly approximates forward flexion of the thoracolumbar spine to 30 degrees or less, but does not more nearly approximate unfavorable ankylosis of the thoracolumbar spine, or incapacitating episodes. 2. The evidence is at least evenly balanced as to whether the Veteran's right ankle disability symptomatology more nearly approximates marked limitation of motion, but not right ankle ankylosis. 3. From October 1, 2014, the Veteran's bilateral foot disability does not more nearly approximate a severe bilateral condition; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, or characteristic callosities, but from February 7, 2021, does more nearly approximate disability with no relief from both non-surgical and surgical treatment. 4. The Veteran's right elbow disability symptomatology did not more nearly approximate limitation of extension to 75 degrees. 5. The Veteran's service connected hemorrhoid symptomatology does not more nearly approximate hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, and evidencing frequent recurrences. 6. The evidence is at least evenly balanced as to whether the Veteran's GERD symptomatology more nearly approximates hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, productive of a considerable impairment of health. 7. The Veteran's mast cell activation syndrome symptomatology more nearly approximates constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, required during the past 12-month period. 8. The Veteran's mast cell activation syndrome symptomatology does not more nearly approximate allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides, or complete obstruction on one side. 9. The Veteran's scars are not unstable or painful, do not affect an area of at least 39 cm (6 square inches), and do not cause functional impairment of the affected areas. 10. The Veteran's right shoulder disability symptomatology does not more nearly approximate motion limited to 25 degrees from the side for the minor joint. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to an initial rating of 40 percent, but not higher, for lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71, DC 5242. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 20 percent, but not higher, for right ankle disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71a, DC 5271. 3. For the period from October 1, 2014, the criteria for an initial rating higher than 10 percent for bilateral foot disability have not been met, but from February 7, 2021, the criteria for a higher, 20 percent rating for bilateral foot disability have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71a, DCs 5276, 5269. 4. The criteria for an initial rating higher than 10 percent for right elbow disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.45, 4.59, 4.71a, DC 5207. 5. The criteria for entitlement to an initial compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.114, DC 7336. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial 10 percent rating, but not higher, for GERD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.114, DC 7346. 7. The criteria for an initial 60 percent rating for mast cell activation syndrome have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.118, DC 7806. 8. The criteria for a separate initial compensable rating for mast cell activation syndrome have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.97, DC 6522. 9. The criteria for an initial compensable rating for scars of the trunk and extremities have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.118, DCs 7801-7805 (in effect prior to and since August 13, 2018). 10. The criteria for an initial disability rating higher than 20 percent for right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, DC 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1988 to August 1988, November 1990 to July 1991, and November 1993 to September 2014. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California which, inter alia, granted service connection for lumbar spine disability, left shoulder disability, bilateral plantar fasciitis, evaluating each as 10 percent disabling, right shoulder disability, right elbow disability, scars, GERD, mast cell activation syndrome, hemorrhoids, and right ankle disability, evaluating each as noncompensable. In April 2015, the Veteran filed his notice of disagreement with, among other things, the ratings assigned, was issued a statement of the case in September 2016, and, in October 2016, perfected his appeal to the Board. In a September 2016 rating decision, the RO, among one other thing, granted a 20 percent rating for left shoulder disability, and a 10 percent rating for right ankle disability. The Veteran requested a videoconference hearing with a Veterans Law Judge which was scheduled for October 15, 2019. However, in a September 2019 letter, the Veteran's attorney notified the Board that the Veteran wished to withdraw the hearing request. Therefore, the Board considers the hearing request withdrawn, and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704(d). In January 2020, the Board, among other things, remanded the Veteran's claims for increased initial ratings to obtain outstanding treatment records. In a November 2020 rating decision, the RO, among one other thing, granted an increased 20 percent rating for right shoulder disability, a 10 percent rating for right elbow disability, and a 30 percent rating for mast cell activation syndrome. 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. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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). 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). When evaluating a disability under VA's General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis, i.e., functional loss consistent with that contemplated by ankylosis. See Chavis v. McDonough, No. 18-2928 (Vet. App. Apr. 16, 2021). 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. Lumbar Spine Disability The Veteran's lumbar spine disability is currently rated 10 percent disabling under DC 5242-5237. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The Board notes that while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, including DC 5242, the changes were primarily to include degenerative disc disease under the diagnostic code, and does not have any significant impact on this matter. Disabilities of the spine are rated under the General Rating Formula for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Under the General Rating Formula for Diseases and Injuries of the Spine applied by DC 5242, the disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A 20 percent rating requires thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the thoracolumbar spine warrants a 50 percent evaluation, and unfavorable ankylosis of the entire spine is rated 100 percent disabling. 38 C.F.R. § 4.71a. The IVDS Rating Formula provides a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. 38 C.F.R. § 4.71a, DC 5237, Note 2. Further, all measured ranges of motion should be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, general rating formula, Note 4. Ankylosis is a condition in which an entire spinal segment is immobile and fixed in position. Unfavorable ankylosis exists where the fixation is in flexion or extension, and the ankylosis results in difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; and/or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) is considered favorable ankylosis. 38 C.F.R. § 4.71a, general rating formula, Note 5. An October 2014 VA examination report indicates that the Veteran reported pain from the mid-shoulder blades down to the lower part of his back, sometimes into his neck. He stated that he has a constant ache in his back he rated as a 3 to 4 out of 10, but reported that the pain increased to a 6 to 7 out of 10 during cold weather, or when he does too much activity. The Veteran stated that he cannot sit too long in a chair, and that he takes Naproxen twice per day for his back pain. The examination report indicates that the Veteran did not suffer from flare-ups which impact the function of his lumbar spine, flexion was to 65 degrees with objective evidence of painful motion at 65 degrees, and extension to 30 degrees with no objective evidence of painful motion. Right and left lateral flexion and rotation were each to 30 degrees or greater with no objective evidence of painful motion. There was no change in range of motion testing with repetitive use, but the examiner noted less movement than normal, and pain on movement after repetitive use. The Veteran did not have localized tenderness or pain to palpation for joints and/or soft tissue, muscle spasms, or guarding of the thoracolumbar spine, no muscle atrophy, and muscle strength was normal. The examiner noted that the Veteran did not have any radicular pain or other signs or symptoms due to radiculopathy, and had no ankylosis of the thoracolumbar spine. The examination report reflects that the Veteran does not have IVDS, does not use any assistive devices for locomotion, and does not have a thoracic vertebral fracture with loss of 50 percent or more of height. The examiner reported that the Veteran's lumbar spine disability impacted his ability to work as he cannot sit in a chair for longer than an hour, or do manual labor where he would have to lift things like loading trucks. In a May 2016 VA examination report, the Veteran reported constant pressure, and stiffness which ranged from between his shoulder blades to his lower back which he treated with gentle stretching and Naproxen. The Veteran did not report flare-ups of his lumbar spine disability, and range of motion was recorded as flexion to 80 degrees, extension, right and left lateral flexion, and right and left lateral rotation each to 30 degrees. Pain was noted with each range of motion that did not result in or cause functional loss, and there was no evidence of pain with weight bearing, or objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. There was no additional loss of function or range of motion with repetitive use testing, the Veteran did not have guarding or muscle spasm, and the examiner noted less movement than normal due to ankylosis, adhesions, etc. Muscle strength was normal, there was no muscle atrophy, and no ankylosis of the spine. The Veteran did not have radicular pain or other signs or symptoms due to radiculopathy, and the examiner noted that the Veteran did not have IVDS, or use an assistive device. The Oswestry Low Back Pain Disability Index reflected minimal disability due to the Veteran's low back disability. The examiner reported that the Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of height, and his lumbar spine disability did not impact his ability to work. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine symptomatology more nearly approximates forward flexion of the thoracolumbar spine 30 degrees or less. While the previously discussed VA examination reports reflect flexion to 65 and 80 degrees, normal muscle strength, and no muscle atrophy, the Veteran has provided competent and credible evidence that he suffers from increased pain during cold weather or with too much activity, and that he treats his pain with medication. He has also reported an inability to sit in a chair for longer than an hour, or lift things due to his back pain. The Veteran is competent to report the symptoms associated with his service connected lumbar spine disability, and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337. Therefore, while the Veteran did not report flare-ups of the lumbar spine pain, it is reasonable to conclude that the pain and overall functional impairment caused by his lumbar spine disability during cold weather, with too much activity, or when not treated by medication is more severe than indicated by the VA examination reports. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Considering these contentions in light of the evidence of record and the applicable law, the orthopedic manifestations of the Veteran's low back disability are best evaluated as 40 percent disabling. However, a higher 50 percent rating is not warranted. The Veteran does not contend, and the evidence does not demonstrate that the Veteran's lumbar spine disability has resulted in symptomatology that more nearly approximates unfavorable ankylosis of the thoracolumbar spine. While the May 2016 examiner noted less movement than normal due to ankylosis, adhesions, etc., both he and the October 2014 examiner reported that the Veteran did not have ankylosis of the spine. Additionally, the Veteran has demonstrated an ability to perform range of motion testing with substantial motion in each direction, including with repetitive use. Therefore, the evidence of record indicates that the Veteran does not suffer from unfavorable ankylosis of the thoracolumbar spine. Additionally, the Veteran has not been diagnosed with IVDS. Both examiners specifically reported that the Veteran did not have IVDS, and the evidence does not suggest that the Veteran had any acute signs and symptoms due to IVDS that required bed rest by a physician, and treatment by a physician in the past 12 months. Therefore, the Veteran's lumbar spine disability symptomatology does not more nearly approximate symptomatology contemplated by a rating higher than 40 percent under either the rating schedule for IVDS or the general rating formula schedule. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to a rating of 40 percent, but not higher, is warranted for the Veteran's low back disability for the entire appeal period. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. Right Ankle The Veteran's right ankle disability is currently rated 10 percent disabling under DC 5271. During the pendency of the appeal, 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 the regulatory change, under DC 5271, ankle disability with moderate limitation of motion warrants a 10 percent rating. A 20 percent rating is assigned for marked limitation of motion. 38 C.F.R. § 4.71a, DC 5271. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from zero to 45 degrees. See 38 C.F.R. § 4.71, Plate II. Under the pre-February 7, 2021, regulations, "slight," "moderate," and "marked" were 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," and all evidence must be evaluated in deciding rating claims. 38 C.F.R. § 4.6. As of February 7, 2021, under the amended criteria for DC 5271, moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) warrants a 10 percent rating; marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) warrants a 20 percent rating. In an October 2014 DBQ, the examiner noted that the Veteran had a diagnosis of closed fracture of the right fibula/tibia which the Veteran reported felt arthritic and sore, especially with change in the weather, running, or walking. He rated the pain as a 5 out of 10, but reported that if he hits his ankle on something, he can have sharp pain up to 10. The Veteran did not report flare-ups that impact the function of his ankle, or functional loss or impairment of the joint. Range of motion was normal, there was no evidence of pain with weight bearing, and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no additional loss of function or range of motion with repetitive use testing, muscle strength testing was normal, and there was no muscle atrophy or ankylosis of the right ankle. The examiner reported no ankle instability or dislocation, and the Veteran had not had shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, or malunion of calcaneus or talus, and had never had a talectomy. The Veteran did not report use of any assistive devices as a normal mode of locomotion due to his right ankle disability, there was no evidence of crepitus, and the examiner noted that the Veteran's right ankle disability impacted his ability to work as it would slow him down if he had a manual labor job requiring that he climb anything. A May 2016 VA examination report reflects that the Veteran reported that his right ankle "does not work like it used to," and that he fatigues easier now and will start to limp after prolonged weight-bearing. He reported feelings of instability in the ankle especially after walking on uneven terrain, and tenderness to the touch "over the hardware and where hardware used to be." The Veteran described the pain as a 4 out of 10 with stiffness, and dull ongoing pain, at worst a 6 out of 10 with throbbing pain. He reported that he is no longer able to run or fast walk, and stated that he has problems with stairs and with squatting. The examiner noted that the Veteran reported flare-ups of the ankle and lack of endurance, but the examination was not administered during a flare-up. Dorsiflexion was to 15 degrees, and plantar flexion to 35 degrees. Pain was noted on examination, but it did not result in or cause functional loss. There was no evidence of pain with weight-bearing, but there was tenderness to palpation of the lateral ankle where hardware is palpable under the skin. There was no objective evidence of crepitus, and no additional functional loss or range of motion with repetitive use testing. The examiner noted that there was less movement than normal due to ankylosis, adhesions, etc., and instability of station. There was no muscle atrophy, ankylosis, or reduction in muscle strength. The examiner reported that ankle instability or dislocation was suspected, and noted a lateral right ankle scar measuring 10.0 cm by 0.5 cm, and a medial right ankle scar measuring 4.5 cm by 1.0 cm that were not painful or unstable. The Veteran reported occasional use of an ankle brace for stability. The examiner noted that the Veteran's right ankle disability did not impact his ability to work. The evidence of record reflects that during the entire period on appeal, the Veteran's right ankle disability more nearly approximates the symptomatology contemplated by a higher, 20 percent rating under both the old and revised versions of DC 5271. The VA examination reports indicate that the Veteran suffers from right ankle pain, reflect functional loss and/or functional impairment of the ankle with pain and stiffness, and the Veteran has competently and credibly reported that he is no longer able to run or walk fast, and stated he has difficulty with stairs and with squatting. The Veteran also reported occasional use of an ankle brace for stability. While the Veteran's dorsiflexion was noted to 15 degrees, and plantar flexion to 35 degrees in the May 2016 VA examination, the examination was not administered during a flare-up. Therefore, it is reasonable to conclude that the Veteran's range of motion would be significantly decreased during a flare-up, as he has described increased throbbing pain of the right ankle with flare-ups. Therefore, the Board finds that the evidence is at least evenly balanced that the Veteran's right ankle disability symptomatology more nearly approximates that contemplated by a 20 percent rating, the maximum schedular evaluation assignable for the Veteran's right ankle disability under DC 5271. Remand for an estimate of motion loss in terms of degrees for compliance with Sharp is unnecessary, and no prejudice accrues to the Veteran, as the Veteran is being awarded the highest available rating under DC 5271. Moreover, there is no evidence of ankle ankylosis, and the absence of ankylosis was specifically noted during the October 2014 and May 2016 examinations. Also, there is no evidence of any malunion of the os calcis or astragalus or any astragalectomy, thus, no separate and/or higher ratings are warranted on the basis of any such impairments at any time during the claim period. See 38 C.F.R. § 4.71a, DCs 5270, 5272-5274. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b) (1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board" (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to a rating of 20 percent for right ankle disability, but not higher, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Bilateral Foot Disabilities The Veteran's bilateral foot disability is currently rated 10 percent disabling under DC 5276. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Under DC 5276, a 10 percent rating is warranted for moderate flat foot; weight-bearing over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent rating is warranted where the bilateral condition is severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 50 percent rating is warranted where the bilateral condition is pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. In addition to pes planus, the Veteran has a diagnosis of plantar fasciitis which could be separately rated under DC 5269. Relevant to the present case, 38 C.F.R. § 4.71a was amended effective February 7, 2021, which assigns a new diagnostic code for plantar fasciitis under DC 5269. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). Under DC 5269, a 10 percent rating is warranted for unilateral or bilateral plantar fasciitis, otherwise; a 20 percent rating is warranted when there is no relief from both non-surgical and surgical treatment; a 30 percent rating is warranted when there is no relief from both non-surgical and surgical treatment, bilateral. With regard to rating the foot, "Under Copeland [v. McDonald, 27 Vet. App. 333 (2015)] and Yancy [v. McDonald, 27 Vet. App. 484 (2016)], the Board is obligated to consider analogous DCs when rating unlisted conditions, despite the presence of listed conditions." Scott v. Wilkie, 920 F.3d 1375, 1379 (Fed. Cir. 2019). However, the Veteran has been diagnosed with both bilateral pes planus and plantar fasciitis which are specifically listed in the Rating Schedule. Thus, rating by analogy is not appropriate in this case. See Copeland, 27 Vet. App. at 337 ("when a condition is specifically listed in the Schedule, it may not be rated by analogy"). An October 2014 VA examination report reflects that the Veteran reported that surgery performed in 2013 on his right foot helped, but stated if he stands on it or walks for a prolonged period of time, or mows, it becomes sore which he rated as a 2 or 3 out of 10. The Veteran stated that he still has plantar fasciitis on the left foot with pain he described as a 4 to 5 out of 10 when it aches. He stated that it hurts in the morning, during and after mowing, and after prolonged periods of rest, lasting a few hours. He also reported wearing arch supports. The examiner noted that the Veteran did not report flare-ups, or functional loss or impairment of either foot. The examiner also indicated that the Veteran's bilateral pes planus impacts his ability to work, as if he had a warehouse which required a lot of walking, he would suffer from pain in his feet. A May 2016 VA examination report reflects that the Veteran reported that his right foot is 75 percent better, but that he still gets some cramping in the morning. He described minor aches and pains in his right foot, but noted that the pain in his left foot is worse. He reported right foot pain as between 0 and 3 out of 10, and left foot pain as between 3 and 10 out of 10. He reported using orthotics, a left boot brace while sleeping, a roller to the bottom of his feet, and stretching. The Veteran stated that his plantar fasciitis reduces his ability to run and workout like he used to. The Veteran reported flares on the left foot regularly which he notices when he first steps out of bed and with prolonged weight-bearing activities. The Veteran had pain on use of his feet which was accentuated on use, but no pain on manipulation, no swelling on use, and no characteristic calluses. Orthotics provided relief on the right side but not the left side. The examination report indicated that the Veteran did not have extreme tenderness of plantar surfaces on one or both feet or marked deformity of one or both feet, but had decreased longitudinal arch height of one or both feet on weight-bearing. There was no marked pronation of one or both feet, the weight-bearing line did not fall over or medial to the great toe, there was no lower extremity deformity other than pes planus causing alteration of the weight-bearing line, the Veteran did not have "inward" bowing of the Achilles tendon, and did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation of one or both feet. There was no pain in either foot upon examination, but there was pain noted on weight-bearing on the left foot, and lack of endurance affecting both feet. There was pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time in the left foot, but not the right foot. The examiner reported that it is not possible without mere speculation to estimate either loss of range of motion or describe loss of function during flares because there is no conceptual or empirical basis for making such a determination without directly observing function under these circumstances. The examination report reflected a right medial heel scar measuring 4 by 0.2 cm which was not painful or unstable. The examiner noted that the Veteran's right and left foot disabilities did not impact his ability to perform any occupational task. Based on the evidence of record, the Veteran's bilateral pes planus and plantar fasciitis symptomatology does not more nearly approximate a severe bilateral condition with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities as contemplated by a higher, 30 percent rating under DC 5276. While the Veteran has described left foot pain of up to a 10 out of 10, he reported minor aches and pain in his right foot of up to a 3 out of 10. Additionally, the May 2016 VA examiner noted no pain on manipulation, no swelling on use, and no characteristic calluses. The Veteran did not have extreme tenderness of plantar surfaces on one or both feet, or marked deformity on one or both feet, and the weight-bearing line did not fall over or medial to the great toe. Therefore, while the Veteran has competently and credibly described severe pain of the left foot, his overall bilateral foot disability symptomatology does not more nearly approximate that contemplated by a higher, 30 percent rating under DC 5276. However, as previously noted, the Veteran has a diagnosis of plantar fasciitis which, effective February 7, 2021, was assigned DC 5269 under 38 C.F.R. § 4.71a. Here, the Board finds that the Veteran's bilateral foot disability symptomatology more nearly approximates disability with no relief from both non-surgical and surgical treatment. The Veteran competently and credibly explained during his May 2016 examination that while his right foot pain has improved, his left foot pain is worse despite use of orthotics, a left boot while sleeping, a roller to the bottom of his feet, and stretching. He stated that his left foot continued to flare regularly, and the examiner noted pain on weight-bearing on the left foot. The Veteran thus continues to suffer from significant left foot pain with no relief from non-surgical treatment, therefore his bilateral foot disability symptomatology more nearly approximates the criteria contemplated by a higher 20 percent rating under DC 5269. As the revised version of the regulation is more favorable, and the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change, a higher 20 percent rating for the Veteran's bilateral foot disability is warranted from February 7, 2021, creating a staged rating. However, as the Veteran's bilateral foot pain is considered under both DC 5276 and 5269 for separate time periods, the Veteran is not entitled to a separate, concurrent ratings as it would constitute pyramiding. 38 C.F.R. § 4.14 ("[t]he evaluation of the same disability under various diagnoses," a practice called "pyramiding," "is to be avoided"). The Veteran does not have a diagnosis of weak foot, claw foot, bilateral hallux valgus with bunion formation, or hammertoes, and the record contains no evidence of any malunion or nonunion of the tarsal or metatarsal bones, or unilateral or bilateral metatarsalgia, so evaluation under DCs 5277, 5278, 5279, 5280, 5281, 5282 and 5283 is not warranted. Therefore, the Board finds that for the period from October 1, 2014, an initial rating higher than 10 percent for bilateral foot disability is not warranted under DC 5276, and from February 7, 2021, a higher 20 percent rating under DC 5269 is warranted. 4. Right Elbow The Veteran's right elbow disability is currently rated 10 percent disabling under DC 5207. The evidence of record indicates that the Veteran is left hand dominant. Under DC 5207, a 10 percent rating is warranted for the minor elbow where extension of the elbow is limited to 60 degrees; a 20 percent rating is assigned where extension of the minor elbow is limited to 75 degrees; a 30 percent rating is assigned where extension of the minor elbow is limited to 100 degrees; and a 40 percent rating is assigned where extension of the minor elbow is limited to 110 degrees. The Board has also considered other potentially relevant diagnostic codes. 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). Under DC 5206, a noncompensable rating is warranted for the minor elbow where there is limitation of flexion of the forearm to 110 degrees; a 10 percent rating is warranted for the minor elbow where flexion is limited to 100 degrees; a 20 percent rating is warranted for the minor elbow where flexion is limited to 90 degrees; a 30 percent rating is warranted for the minor elbow where flexion is limited to 55 degrees; a 40 percent rating is warranted for the minor elbow where flexion is limited to 45 degrees. Under Diagnostic Code 5213, impairment of supination and pronation of the minor forearm is assigned a 10 percent evaluation for limitation of supination to 30 degrees or less. A 20 percent evaluation is warranted for limitation of pronation with motion lost beyond the last quarter of the arc and where the hand does not approach full pronation. For the minor elbow, a 30 percent rating is assigned when the hand is fixed in supination or hyperpronation. When motion is lost beyond the middle arc for the minor elbow, a 20 percent rating is assigned. A 20 percent evaluation is also assigned for loss of supination or pronation (bone fusion) where the hand is fixed near the middle of the arc or moderate pronation in the minor elbow. When the hand is fixed in full pronation, a 20 percent rating is warranted for the minor elbow. Normal ranges of motion of the elbow are zero degrees of extension to 145 degrees of flexion. See 38 C.F.R. § 4.71, Plate I. Normal ranges of motion of the forearm are 80 degrees of pronation and 85 degrees of supination. An October 2014 VA examination report reflects that the Veteran reported occasional right forearm pain 3 to 4 times a day for the last 8 months to a year. The examination report indicates that the Veteran is left hand dominant, and did not report flare-ups of the right elbow pain. Flexion was to 145 degrees, and extension to 0 degrees with no objective evidence of painful motion, and no change in range of motion with repetitive use testing. There was no localized tenderness or pain on palpation of the joints/soft tissue of either elbow or forearm noted, no ankylosis, muscle strength was normal, and the Veteran did not have flail joint, joint fracture, and/or impairment of supination or pronation. The examiner noted that the Veteran had not had joint replacement or any other surgical procedure of the right elbow, but stated that the right elbow disability impacts his ability to work as it bothers the Veteran when lifting, typing, and opening and closing doors. In a May 2016 VA examination report, the Veteran reported discomfort in the muscles of his forearm, and that he notices the pain primarily when he is lifting, mowing, or with prolonged keyboarding. He rated the pain as between 2 and 5 out of 10, and stated that it limits his ability to do things on a normal day to day basis. The Veteran did not report flare-ups of the elbow or forearm. Range of motion was normal with flexion to 145 degrees, extension to 0 degrees, supination to 85 degrees, and pronation to 80 degrees. There was no evidence of pain with weight bearing, objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. The examiner noted that there was no reduction in muscle strength, no muscle atrophy, and the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. The Veteran reported occasional use of an elbow compression strap, and the examiner noted that the Veteran's right elbow disability did not impact his ability to work. For the following reasons, an initial rating higher than 10 percent is not warranted for the Veteran's right elbow disability. The October 2014 and May 2016 VA examination reports indicated that the Veteran did not report of flare-ups of the right elbow, but reflected his reports of pain primarily when lifting, or keyboarding, and the examiners noted normal range of motion with flexion to 145 degrees, and extension to 0 degrees. While the Veteran reported increased pain and discomfort with certain activities, the above statements reflect that the severity of his right elbow pain and discomfort was not such that they would result in additional loss of motion more nearly approximating the criteria for a higher rating. The evidence of record therefore does not indicate that the Veteran's right elbow disability symptomatology more nearly approximates limitation of extension to 75 degrees as contemplated by a 20 percent rating under DC 5207. Thus, an initial rating higher than 10 percent is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. A separate, compensable rating is also not warranted for limitation of flexion even with consideration to functional impairments under DC 5206. For the entire period on appeal, the Veteran's right elbow flexion measured to 145 degrees, thus his right elbow disability symptomatology does not more nearly approximate that contemplated by at least a 10 percent rating under DC 5206. Therefore, a separate, compensable rating under DC 5206 for limitation of extension is not warranted. The Board has also considered whether a higher rating is warranted under DC 5213 for impairment of supination and pronation. There is no evidence that the Veteran's right elbow disability symptomatology more nearly approximated limitation of supination to 30 degrees or less as contemplated by a 10 percent rating under DC 5213. In fact, the Veteran's May 2016 VA examination report reflected supination to 85 degrees, and the October 2014 and May 2016 VA examiners noted no impairment of supination or pronation, thus a separate, compensable rating under DC 5213 is not warranted. As to other potentially applicable DCs, the Veteran does not have, nor does her disability picture more nearly approximate ankylosis, flail joint, nonunion of the radius and ulna, impairment of the ulna, or impairment of the radius. 38 C.F.R. § 4.71a, DCs 5205, 5208, 5209, 5210, 5211, and 5212). Therefore, these DCs are inapplicable in this case. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Overall, the Board finds that the evidence of record reflects that the Veteran's right elbow disability does not more nearly approximate extension of the elbow limited to 75 degrees, therefore an initial rating higher than 10 percent is not warranted under DC 5207. 5. Hemorrhoids The Veteran's service connected hemorrhoids are currently evaluated as noncompensable under DC 7336, governing external or internal hemorrhoids. Under DC 7336, a 10 percent rating is warranted for internal or external hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, and evidencing frequent recurrences. The maximum 20 percent schedular rating is warranted for internal or external hemorrhoids with persistent bleeding, and with secondary anemia, or with fissures. The terms "frequent," "mild," "moderate," "excessive" and "large" are not defined in the regulations. 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. An October 2014 VA examination report reflects that the Veteran reported 10 to 15 flare-ups of hemorrhoids over the last 10 to 15 years, with the most recent flare-up six months prior. He also reported a "strain" feeling in his rectum. His treatment plan did not include taking continuous medications, and the examination report indicated that the Veteran's hemorrhoids were mild or moderate. The examiner noted that the rectal/anal examination was normal, and that the Veteran's hemorrhoids did not impact his ability to work. A May 2016 VA examination report indicates that the Veteran reported no current hemorrhoids, but suffered from intermittent flares with the last flare about one month prior to the examination. He stated his hemorrhoids self-resolve, and that they occur once every several months and seem to occur when he is more active. Based on the preponderance of the evidence, the Veteran's hemorrhoid symptomatology does not more nearly approximate large or thrombotic, irreducible, with excessive redundant tissue, and evidence frequent recurrences as contemplated by a 10 percent disability rating under DC 7336. The October 2014, and May 2016 examiners each noted that the Veteran had no hemorrhoids at the time of the examinations, and the October 2014 examiner described the Veteran's hemorrhoids as "mild or moderate." There is no evidence suggesting that the Veteran's hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue and evidence frequent recurrences. Frequent is defined as "happening at short intervals: often repeated or occurring" see Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/frequent (last visited June 16, 2021). Here, the Veteran has indicated that his hemorrhoids are intermittent, occurring "once every several months." As the Veteran has described hemorrhoid flare-ups that occur only a few times per year, the occurrences fall short of meeting the definition of frequent for purposes of DC 7336. The Veteran also reported that his hemorrhoids self-resolve, and the October 2014 examiner noted that they did not impact the Veteran's ability to work. While the Veteran contends that he is entitled to a compensable rating due to the severity of his hemorrhoids, his contention is outweighed by the evidence of record which indicates that his hemorrhoid symptomatology is mild or moderate, with no significant functional impairment or disability. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those contemplated by the rating criteria. Doucette, 28 Vet. App. at 369-70. For the foregoing reasons, a compensable rating for the Veteran's service connected hemorrhoids is not warranted. As the preponderance of the evidence is against a compensable rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 6. GERD The Veteran's GERD with hiatal hernia is currently rated noncompensable under DC 7399-7346. The use of DC 7346 reflects that there is no diagnostic code specifically applicable to the Veteran's service connected GERD, and that this disability has been rated by analogy to hiatal hernia under DC 7346. See 38 C.F.R. § 4.20 (allowing for rating of unlisted condition by analogy to closely related disease or injury). Under DC 7346, a 10 percent rating is warranted for hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity; a 30 percent rating is warranted for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of a considerable impairment of health; and a 60 percent rating is warranted for hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. In an October 2014 VA examination report, the Veteran reported that he felt like he "had stuff in his throat" when he was diagnosed with GERD in 2001. He had a sore throat and was scoped and found to have a hiatal hernia. His symptoms improved and he was taken off of medication, but reported that he has recently had episodes of waking up at night with acid in his mouth. Currently, the Veteran takes Nexium as needed. The examiner noted symptoms of pyrosis, reflux, and sleep disturbance caused by esophageal reflux, with the Veteran reporting symptom recurrence four or more times a year, lasting less than one day. The Veteran did not have an esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. The examiner noted that the Veteran's GERD did not impact his ability to work. A May 2016 VA examination report indicates that the Veteran reported symptoms of reflux in the night, and heartburn periodically during the day. He reported that this GERD is aggravated by alcohol ingestion and spicy foods, and that his GERD sometimes interferes with his sleep. The Veteran does not take continuous medication to treat his GERD, and reported symptoms including pyrosis, reflux, and sleep disturbance. The symptoms occur four or more times a year, and last less than a day. The examiner noted that the Veteran did not have an esophageal stricture, spasm of the esophagus, or an acquired diverticulum of the esophagus. He also noted that the Veteran's GERD did not impact his ability to work. The evidence is at least evenly balanced as to whether the Veteran's GERD symptomatology more nearly approximates hiatal hernia with pyrosis, and regurgitation productive of a considerable impairment of health. The October 2014 VA examination report reflects a diagnosis of hiatal hernia, and the examiner noted symptoms including pyrosis, reflux, and sleep disturbance due to esophageal reflux. While the Veteran reported symptoms of pyrosis, reflux, and sleep disturbance occurring four or more times a week, he also competently and credibly reported suffering from heartburn periodically during the day, and stated that alcohol ingestion and spicy food aggravate his GERD, suggesting that these symptoms occur much more frequently. However, the evidence does not reflect, nor does the Veteran suggest, that his GERD symptomatology more nearly approximates hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of a considerable impairment of health. While the Veteran has provided evidence of impairment of health due to his GERD as it causes sleep disturbance, there is no evidence that his symptomatology is accompanied by substernal or arm or shoulder pain. Therefore, the Veteran's GERD symptomatology does not more nearly approximate that contemplated by a 30 percent rating under 7346. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to an initial 10 percent rating, but not higher, for service connected GERD is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 7. Mast Cell Activation Syndrome The Veteran's mast cell activation syndrome to include facial flushing and skin rash is currently rated 30 percent disabling under DC 7806, and the Board notes a separate, noncompensable rating for mast cell activation syndrome under DC 6599-6522. Notably, mast cell activation syndrome is a disability that is not listed under VA's rating schedule. As previously discussed, where a particular disability is not listed, it may be rated by analogy to a closely related disease by not only the functions affected, but also where the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27; cf. Copeland, 27 Vet. App. at 337. In this regard, the RO has evaluated such disability as analogous to dermatitis or eczema pursuant to 38 C.F.R. § 4.118, DC 7806, and as analogous to allergic or vasomotor rhinitis pursuant to 38 C.F.R. § 4.97, DC 6522. The criteria provide that allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, is rated 10 percent disabling. Allergic or vasomotor rhinitis with polyps is rated 30 percent disabling, which is the maximum rating pursuant to DC 6522. VA amended DC 7806, but claims pending on August 13, 2018, may be considered under the pre-amended and amended criteria, whichever is more favorable. 83 Fed. Reg. 32592 (August 13, 2018). Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, "systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin." DC 7806 continues to apply to dermatitis or eczema, but is rated under the general rating formula for the skin. The Federal Circuit's interpretation of the term "systemic therapy" in the revised criteria applies throughout the entire period prior to the August 13, 2018, effective date of the new criteria. Jordan v. Nicholson, 401 F.3d 1296, 1298-99 (Fed. Cir. 2005) (noting that a new interpretation of a statute retroactively affects decisions still open on direct review). Under pre-amended DC 7806, a 10 percent rating requires that at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas be affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs be required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. Under the general rating formula, a 10 percent rating is warranted where at least one of the following is present: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted where at least one of the following is present: Characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or 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. In this case, the pre-amended version is more favorable and will be applied. Id.; 38 C.F.R. § 4.118, DC 7806 (2017). An October 2014 VA examination report indicates that the Veteran suffers from symptoms of facial flushing, heart palpitations, problems with memory, and hot flashes. He also reported daily sneezing. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, or other obvious disfigurement. The examiner noted that the Veteran's mast cell activation disability impacts his ability to work, as he has less attention to detail, has to take good notes due to memory lapses, and believes his attention span is diminished. A May 2016 VA examination report indicates that the Veteran stated that he has random facial rash and facial flushing. He also reported a lot of sneezing, mild tingling in his hands a couple times a month, brain fuzz, and fatigue. He reported improvement with Singulair, Allegra, Doxepin, and Flonase. The examiner noted that the Veteran did not have anemia or thrombocytopenia, any signs and symptoms due to a hematologic or lymphatic disorder, recurrent infections, sickle cell anemia, or polycythemia vera. The Veteran's May 2016 VA examination report reflects continuous medication, including the use of Allegra and Flonase, for control of his mast cell activation syndrome symptoms which includes a facial rash. Flonase is a prescription nasal spray corticosteroid used to treat sneezing, runny nose, and itchy or watery eyes, (see https://www.rxlist.com/flonase-drug.htm), while Allegra is an antihistamine used to relieve itchy or watery eyes, sneezing, and hives. (see https://www.rxlist.com/allegra-drug.htm#indications). The Veteran has provided competent and credible evidence that he uses oral medications like Allegra and Flonase which constitutes systemic therapy as described above, and the May 2016 examiner indicated that the usage is continuous. Therefore, the evidence is at least evenly balanced as to whether the Veteran's mast cell activation symptomatology and treatment more nearly approximates constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Therefore, an initial 60 percent rating under DC 7806 is warranted for the Veteran's mast cell activation syndrome. This is the highest available schedular rating under DC 7806. However, an initial compensable rating is not warranted for the Veteran's mast cell activation syndrome under DC 6522. While the Veteran has competently and credibly reported a lot of sneezing, and facial flushing, the October 2014 VA examination report indicates that the Veteran does not have loss of part of the nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, or other obvious disfigurement. The Veteran did not report, and the evidence of record does not otherwise suggest, that he suffers from symptomatology that more nearly approximates allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, or allergic or vasomotor rhinitis with polyps. Thus, the Veteran's mast cell activation syndrome does not more nearly approximate the criteria for a compensable rating under DC 6522, and a higher compensable rating is not warranted. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those contemplated by the rating criteria. Doucette, 28 Vet. App. 366, 369-70 (2017). Therefore, referral for extraschedular consideration is not warranted. 8. Scars The Veteran's service-connected scars are currently rated noncompensable under DC 7802. The diagnostic codes 7801-7805 (for scars) were revised effective October 23, 2008. The regulatory changes pertaining to the rating of scars apply only to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 54708 (Sept. 23, 2008). As the Veteran's application for an increased rating was received after that date, the revised criteria are applicable. The Board notes that VA again amended the criteria for rating skin disabilities during the claim period, effective from August 13, 2018. With regard to the effective date of 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 August 13, 2018, effective date of the new criteria, and therefore, the Board will consider both the old and new criteria and apply the more favorable criteria. In order to warrant a compensable rating under DC 7804 under either the old or new rating criteria, scarring would need to involve one or two scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804 (in effect prior to and since August 13, 2018). In order to warrant a compensable rating under other applicable diagnostic codes under the old rating criteria, scarring would need to involve the head, face or neck and be associated with at least once characteristic of disfigurement (DC 7800); be deep and nonlinear and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (DC 7801); be superficial and nonlinear and involve an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); or have some other disabling effects (DC 7805). 38 C.F.R. § 4.118, DCs 7800-7803, 7805 (in effect prior to August 13, 2018). In order to warrant a compensable rating under other applicable diagnostic codes under the new rating criteria, scarring would need to involve the head, face or neck and be associated with at least one characteristic of disfigurement (DC 7800); be associated with underlying soft tissue damage and affect an area or areas of at least 6 square inches (39 square centimeters) (DC 7801); not be associated with underlying soft tissue damage and affect an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); or have some other disabling effects (DC 7805). 38 C.F.R. § 4.118, DCs 7800-7803, 7805 (in effect since August 13, 2018). As a preliminary matter, the Board notes that the evidence of record, as will be discussed, indicates that the Veteran has no scars or disfigurement of the head, face, or neck. Therefore, DC 7800 (scars of the head, face, or neck) is not applicable. An October 2014 VA examination report reflected that the Veteran had scars on the trunk or extremities, but no scars or disfigurement of the head, face, or neck. The examiner noted scars from shoulder and foot surgeries, as well as from moles taken off of his back. The examination report indicated that none of the scars of the trunk or extremities were painful, unstable with frequent loss of cover of skin over the scar, or both painful and unstable. None of the scars were due to burns. The examination report reflects linear scars on the right shoulder measuring 1 by 0.2 cm, 0.8 by 0.1 cm, 2.0 by 0.1 cm; linear left shoulder scars measuring 2 by 0.2 cm, 1 by 0.2 cm, 2 by 0.1 cm, and 1.5 by 0.5 cm. Right lower extremity linear scars measured 2 by 0.2 cm, 3.5 by 0.2 cm, and 11.2 by 0.3 cm. The Veteran's posterior trunk linear scars measured 2.75 by 0.2 cm, and superficial non-linear scars measured 1.2 by 1.5 cm, 1.5 by 1.5 cm, 0.8 by 0.5 cm, and 0.3 by 0.3 cm. There were no deep non-linear scars, and the examiner noted that the Veteran's scars did not result in limitation of function, or impact his ability to work. In a May 2016 VA examination report, the examiner noted multiple scars on the trunk and extremities, but no scars or disfigurement of the head, face, or neck. The scars were noted to not be painful, unstable, or due to burns. The right shoulder scars measured 1 cm by 0.2 cm, 0.8 by 0.1cm, and 2 by 0.1 cm; his left shoulder scars measured 2 cm by 0.2 cm, 1 cm by 0.2 cm, 2 cm by 0.1 cm, and 1.5 cm by 0.5 cm. The right lower extremity linear scars measured 2 cm by 0.2 cm, 3.5 cm by 0.2 cm, and 11.2 cm by 0.3 cm. Finally, the Veteran's posterior trunk linear scar measured 2.75 cm by 0.2 cm, and his superficial non-linear scars measured 1.2 cm by 1.5 cm, 1.5 cm by 1.5 cm, 0.8 cm by 0.5 cm, and 0.3 cm by 0.3 cm. The examiner noted that the Veteran's scars did not result in limitation of function, and did not impact his ability to work. Based on the preponderance of the evidence, a compensable rating for the Veteran's scars is not warranted under either the old or new rating criteria. The October 2014 and May 2016 examiners noted that the Veteran's scars are not painful or unstable, and did not cover a total area equal to or greater than 39 square cm. There was also no evidence that the scars caused disabling effects or other complications as the examiners specifically reported that the Veteran's scars did not result in limitation of function, or impact his ability to work. The examiners provided the Veteran with a thorough examination prior to reporting their findings, thus the examination reports are afforded significant probative weight. The Veteran has not provided any additional evidence which would suggest that his scars are painful or unstable, exceed an area of 39 square cm, or cause limitation of motion. Hence, there is no basis upon which to grant a compensable rating for the Veteran's scars under any applicable diagnostic code pertaining to scars under either the old or new rating criteria at any time during the claim period. Overall, the record neither shows that the evidence is so evenly balanced as to warrant a compensable rating for the Veteran's scars, nor does the evidence show that the Veteran's scars more nearly approximate the criteria for a compensable rating at any time during the claim period. Therefore, a compensable rating for scars of the trunk and extremities is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.118, DCs 7800-7805 (in effect prior to and since August 13, 2018). 9. Right Shoulder Disability The Veteran's right shoulder disability is currently rated 20 percent disabling under DC 5201 based on limitation of motion. The Veteran's left shoulder is considered his major joint for rating purposes. Under DC 5201, limitation of the arm at the shoulder level warrants a 20 evaluation whether it is the major or minor extremity. When motion is limited to midway between the side and shoulder level, a 30 percent evaluation is warranted for the major extremity and 20 percent for the minor extremity. When motion is limited to 25 degrees from the side, a 40 percent evaluation is warranted for the major extremity and 30 percent for the minor extremity. Normal flexion (forward elevation of the arm) and normal abduction (movement of the arm away from the side) of the shoulder are to 180 degrees. Normal internal rotation and external rotations of the shoulder are to 90 degrees. 38 C.F.R. § 4.71, Plate 1. Other potentially relevant diagnostic codes include DC 5200 (ankylosis of the scapulohumeral articulation), DC 5202 (impairment of the humerus), DC 5203 (other impairment of the clavicle or scapula), and DC 5203 (impairment of function of the contiguous joint). 38 C.F.R. § 4.71a. In an October 2014 VA examination report, the Veteran reported that his right shoulder "pops and clicks" occasionally, and that he suffers from achiness during and after overuse for 12 to 24 hours. He also reported issues with his left shoulder, including pain he rated a 4 out of 10, and stated that he has pain and stiffness when he reaches overhead or sleeps on it. The Veteran stated that the pain goes up to 6 or 7, and that he cannot reach around his back without pain. The Veteran did not report flare-ups of either shoulder, but did report functional loss or functional impairment as he cannot ride a motorcycle, keep his left arm elevated for any length of time, and stated it hurt shampooing his hair or showering when he lifts his arms up. Left shoulder flexion was to 135 degrees, abduction to 180 degrees, and external and internal rotation was to 90 degrees. Pain was noted on examination with flexion that caused functional loss, but there was no evidence of pain with weight bearing, or localized tenderness or pain on palpation of the joint or associated soft tissue. Right shoulder range of motion was normal with flexion and abduction to 180 degrees, and external and internal rotation both to 90 degrees. No pain was noted on examination, and there was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no additional functional loss or range of motion with repetitive use testing in the right shoulder, but there was with left shoulder flexion to 135 degrees due to pain. There was no reduction in muscle strength, muscle atrophy, or ankylosis noted, there was no shoulder instability, dislocation, or labral pathology suspected, and no clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint condition suspected. The Veteran did not have loss of head, nonunion, or fibrous union of the humerus, malunion of the humerus with moderate or marked deformity, and there was no evidence of crepitus. The examiner reported that the Veteran's shoulder disabilities impacts his ability to work as he cannot type for a long period of time due to arm stiffness and the pain of having his arms up. The Veteran also stated that he cannot lift things that weigh more than a few pounds up over his head. A May 2016 VA examination report indicated that the Veteran is left hand dominant, that the Veteran's right shoulder has arthritic soreness and pain with lifting and working overhead, and that this left shoulder was much worse with pain, no endurance, and inability to do any heavy lifting or lifting overhead. He stated he also cannot do push-ups anymore due to the left shoulder disability. The Veteran reported right shoulder pain of between 2 and 4 out of 10, and left shoulder pain of between 5 and 7 out of 10. The Veteran indicated that he suffers from flare-ups in his left shoulder with reaching, and lifting overhead. Right shoulder flexion was to 170 degrees, abduction to 165 degrees, external rotation to 75 degrees, and internal rotation to 90 degrees. There was no evidence of pain with weight bearing, objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or crepitus. Left shoulder flexion was to 130 degrees, abduction to 130 degrees, external rotation to 75 degrees, and internal rotation to 90 degrees. Pain was noted with flexion and abduction, but it did not result in or cause functional loss. There was also evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. No additional functional loss or range of motion was noted with repetitive use testing in either joint, and there was less movement than normal due to ankylosis, adhesions, etc. in both joints. There was no reduction in muscle strength, no muscle atrophy, and no ankylosis of either shoulder. Right shoulder instability, dislocation, or labral pathology was suspected, but there was no history of mechanical symptoms or recurrent subluxation of the glenohumeral joint in the right shoulder. The Veteran did not have loss of head, nonunion, or fibrous union of the humerus, or malunion of the humerus with moderate or marked deformity. The examination report indicated that the Veteran had scars related to his right and left shoulder disabilities, but they were not painful or unstable, have a total area equal to or greater than 39 cm, and were not located on the head, face, or neck. The Veteran's anterior right shoulder scar, lateral right shoulder scar, and posterior right shoulder scar each measured 1 cm by 0.1 cm; and anterolateral left shoulder, posterior left shoulder, and 2 anterior left shoulder scars each measured 1 cm by 1 cm. The examiner reported that the Veteran's shoulder disabilities would impact his ability to work as they would limit his ability to work in occupations which required repetitive heavy lifting or working overhead. Based on the evidence above, the Board finds that a rating higher than 20 percent is not warranted for the right shoulder disability. As previously noted, the Veteran's left shoulder is considered his major joint for rating purposes. Here, the aforementioned VA examination reports reflect that the Veteran does not suffer from flare-ups in the right shoulder, but the Veteran reported flare-ups in his left shoulder with reaching and lifting overhead. Limitation of motion was noted in flexion between 170 degrees and 180 degrees, and abduction between 165 and 180 degrees for the right shoulder, and flexion between 130 degrees and 135 degrees, and abduction between 130 degrees and 180 degrees for the left shoulder. These limitations of motion are primarily above shoulder level or slightly below. The Board has also considered the Veteran's statements concerning the severity of his disability. However, there is no indication in the evidence of record that the Veteran's right shoulder pain, including with lifting and working overhead, causes additional limitation of motion of a degree that would have resulted in limitation of motion to 25 degrees from the side warranting a higher 30 percent rating for the minor extremity under DC 5201. The examination reports have overwhelmingly and consistently noted that the Veteran does not suffer from ankylosis, impairment of the humerus, clavicle or scapula, or the contiguous joint, and the Veteran has not provided evidence to the contrary. Therefore, separate disabilities ratings under DCs 5200, 5202, and 5203 are not for application. The above determinations are based on consideration of the applicable provisions of VA's rating schedule. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to this claim. See Doucette, 28 Vet. App. at 369-70. For the foregoing reasons, the preponderance of the evidence is against a rating higher than 20 percent for the right shoulder disability. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND With regard to the Veteran's claim for an initial rating higher than 20 percent for a left shoulder disability, the May 2016 examiner noted that the Veteran suffered from flare-ups of the left shoulder, particularly with lifting and reaching overhead. As no examiner in this case attempted to estimate additional loss of motion during flare-ups or explain why an estimate cannot be given, a remand for a new VA examination is warranted to determine the present level of the Veteran's left shoulder disability, to include consideration of flare-ups as indicated in Sharp. The matter is thus REMANDED for the following action: Schedule the Veteran for an examination, to include via telehealth if feasible, to determine the current severity of his left shoulder disability. The examination should be conducted in accordance with the current disability benefits questionnaire. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran's left shoulder disability alone and discuss their effects on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Jenna Brant Acting 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.