Citation Nr: 24009019 Decision Date: 02/23/24 Archive Date: 02/23/24 DOCKET NO. 20-01 940 DATE: February 23, 2024 ORDER Entitlement to an initial rating of 50 percent, but no higher, for major depressive disorder with alcohol abuse disorder is granted. Entitlement to a rating in excess of 20 percent for right upper extremity peripheral neuropathy is denied. Entitlement to a rating in excess of 20 percent for left upper extremity peripheral neuropathy is denied. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) of the neck is denied. Entitlement to service connection for hypertension is denied. REMANDED Entitlement to a rating in excess of 10 percent prior to October 13, 2020, and in excess of 40 percent thereafter for intervertebral disc syndrome (IVDS) of the lumbar spine is remanded. Entitlement to a rating in excess of 10 percent for right lower extremity sciatic radiculopathy is remanded. Entitlement to a rating in excess of 10 percent for left lower extremity sciatic radiculopathy is remanded. Entitlement to a compensable rating for residuals of a traumatically deviated septum prior to October 13, 2020, and in excess of 10 percent thereafter, is remanded. FINDINGS OF FACT 1. Prior to October 2020, the Veteran's depression manifested as occupational and social impairment due to symptoms of depressed mood, anxiety, flattened affect, impaired cognition, disturbances in motivation or mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including in a work or work-like setting. 2. Throughout the appeal period, the Veteran's right arm nerve impairment has manifested as pain, numbness, tingling, and some decreased sensation, with full reflexes and muscle strength, which more nearly approximates symptomatology contemplated by mild incomplete paralysis of the radicular groups; it does not more nearly approximate moderate incomplete paralysis. 3. Throughout the appeal period, the Veteran's left arm nerve impairment has manifested as pain, numbness, tingling, and some decreased sensation, with full reflexes and muscle strength, which more nearly approximates symptomatology contemplated by mild incomplete paralysis of the radicular groups; it does not more nearly approximate moderate incomplete paralysis. 4. The Veteran's PFB affects less than 5 percent of the entire body or exposed areas and requires no more than topical therapy; it is also not productive of deep acne affecting less than 40 percent of the face and neck, and does not exhibit a characteristic of disfigurement, or visible or palpable tissue loss with either gross distortion of assymetry of one feature. 5. The Veteran does not have a current diagnosis of hypertension, nor has he manifested such a diagnosis during or near the pendency of the appeal. CONCLUSIONS OF LAW 1. The criteria for an initial 50 percent rating, but no higher, for depression have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating in excess of 20 percent for right upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8513. 3. The criteria for a rating in excess of 20 percent for left upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8513. 4. The criteria for a compensable evaluation for PFB have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.118, DCs 7800, 7806, 7828. 5. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from September 1996 to September 1997, and in the Coast Guard from March 1998 to June 2017. This matter comes before the Board of Veterans' Appeals (Board) on appeal of September 2017 and March 2018 rating decisions issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Board previously remanded this matter to the AOJ for further development in May 2020. The Board observes that, on April 26, 2023, correspondence was received from Attorney Bryce Krampert indicating an intent to withdrawal the appeal. However, the Veteran has not authorized this individual to represent him in this appeal. By letter dated September 28, 2023, the Board requested clarification from the Veteran regarding his intent in this appeal. The Veteran has not responded, and the Board does not find a valid attempt to withdraw this appeal. In January 2024, the Veteran waived AOJ consideration of evidence received since the last supplemental statement of the case. Increased Rating In his notices of disagreement, the Veteran asserted entitlement to higher disability evaluations for his neuropathy and radiculopathy, lumbar spine disorder, major depressive disorder, deviated septum and PFB. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 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 civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. The Board must interpret various examination reports in light of the entire medical history, reconciling any contrary findings into a consistent picture. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). At the outset, the Board notes that the Veteran has not raised the issue of unemployability, and in fact was either attending school full time or gainfully employed during much of the appeal period. He has also completed VA Vocational Rehabilitation and successfully obtained gainful employment thereafter. 1. Entitlement to a rating in excess of 30 percent for major depressive disorder with alcohol abuse disorder prior to October 14, 2020, and in excess of 70 percent thereafter A March 2018 rating decision granted entitlement to service connection for an acquired psychiatric disorder, diagnosed as major depressive disorder with alcohol abuse disorder, assigning an initial rating of 30 percent. The Veteran disagreed, and after a Board remand for further development, the AOJ issued a December 2020 rating decision granting an increased rating of 70 percent from the date of an October 2020 VA examination. As this is less than the maximum benefit available, the claim of increased rating remains in controversy. See AB v. Brown, 6 Vet. App. 35 (1993). Depression is rated using the General Rating Formula for Mental Disorders. Under this Formula, a 30 percent rating for acquired psychiatric disorders is assigned where there is evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversational normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Codes 9201-9440. A 50 percent rating is assigned where there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned where there is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsession rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Evaluation under 38 C.F.R. § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. The Veteran submitted a December 2017 private examination conducted by a psychologist which included diagnoses of major depressive disorder and alcohol abuse disorder. The psychologist stated that the Veteran's depression manifested as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood due to symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation or mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting. The psychologist noted that the Veteran's disturbed sleep was due to his sleep apnea. Additional noted symptoms included irritability, fatigue, poor self-esteem, loss of job or academic opportunities, hopelessness, and kinesiophobia. The Veteran denied previous psychiatric treatment or medication and reported considering suicide "several years back," but did not develop a plan and denied current ideation. He described difficulty with daily life due to his chronic pain issues, with daily anxiety and depressed mood as well as occasional feelings of worthlessness. He also related cognitive function decline, indecisiveness and irritability "all the time," although he described his relationship with his children as "good." The Veteran reported having an associate degree but stated he dropped out of school because of back pain, although he described running a picture framing business in his garage. The Veteran was afforded a March 2018 VA psychiatric examination, wherein his diagnosis of major depressive disorder was confirmed. The examiner stated that his depression had been diagnosed but that his symptoms of depressed mood, anxiety and disturbances of motivation or mood were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran reported that his relationship with his wife was very strained, and that he sometimes snapped at his children, for which he felt guilty afterward. He described a good relationship with his mother and sister as well as two or three best friends, with occasional contact as they live in different states. He reported going to college full time, majoring in film and earning good grades as well as running a part time framing business in his garage. The Veteran related past incidents of "feeling down" with binge eating and purging related to Coast Guard "weigh-ins," though this behavior was not current. He described being irritable and anxious often with his children, with additional anxiety regarding his physical health and future. He also reported occasional sleep difficulties but attributed this to sleep apnea and physical pain. Upon examination he was appropriate in appearance, fully oriented and cooperative, with normal speech and thought processes. His mood was euthymic with congruent affect, although he was occasionally tearful when discussing his difficulties with depression. He denied suicidal or homicidal ideations and his insight and judgment were intact. In compliance with the Board remand, the Veteran was afforded an additional VA psychiatric examination in October 2020. The examiner stated that his depression manifested as occupational and social impairment with reduced reliability and productivity due to symptoms of depressed mood, anxiety, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, mild memory loss, disturbances of motivation or mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, neglect or personal appearance and hygiene, and intermittent inability to perform the activities of daily living. The Veteran reported living with his brother's family, which "is good, nice here," but that he was homeless for a period of 2019 and 2020, renting a hotel room when his children would visit. He reported seeing his children on the weekends but lacks motivation and the physical ability to participate in activities with them. He related speaking to his mother and sister every few weeks on the phone but denied significant friendships, spending most of his time at home, sleeping. He reported earning a bachelor's degree in digital photography but was unable to find a job in the field due to going through a divorce as well as lack of motivation. However, he indicated he was currently working full time as an avionics contractor at Jacksonville airport, although he often avoided interacting with coworkers. The Veteran reported briefly undergoing substance abuse treatment at VA in 2020, wherein he was prescribed Sertraline. He denied suicidal ideation because of his children but described feelings of hopelessness and depression, occasional neglect of personal hygiene, difficulty concentrating as well as fatigue and low energy. Upon examination he was appropriate in appearance and fully oriented with logical speech and thought processes, adequate judgment and insight, flat affect and "down" mood. He denied harmful ideations as well as hallucinations or delusions. As noted above, the Board must interpret various examination reports in light of the entire medical history, reconciling any contrary findings into a consistent picture. This task is complicated by the widely divergent disability pictures painted by the December 2017 private and March 2018 VA psychiatric evaluations, even though they occurred only four months apart. There are factual differences such as the Veteran reporting he dropped out of school as a result of back pain in December 2017 but was attending school full time and performing well by March 2018, as well as the obvious difference in the level of functional impairment each examiner attributed to his depression. However, there are also several factual similarities, to include the Veteran's good relationship with his children despite often being irritable with them, his ability to run a business out of his garage, as well as occasional feelings of hopelessness with regular anxiety, depression and disturbances of motivation or mood. After review of the evidence of record, the Board finds that, for the entire appeal period, the Veteran's depression most closely approximates the 50 percent rating criteria's occupational and social impairment due to symptoms of depressed mood, anxiety, flattened affect, impaired cognition, disturbances in motivation or mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including in a work or work-like setting. A higher rating of 70 percent is not warranted, as the Veteran's depression did not more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Although the Veteran later reported neglect of personal appearance and hygiene, this symptom was not noted by either the private or VA examiner. Similarly, although both noted past suicidal ideation, the Veteran has consistently denied experiencing this symptom during the appeal period. Finally, although his psychiatric symptoms undoubtedly interfered with his social and work life, he was able to maintain a good relationship with his children, mother and sister, and was able to run a part time business and participate in school full time. As such, he did not exhibit occupational and social impairment with deficiencies in most areas, and a rating in excess of 50 percent is not warranted. The Board also finds that throughout the appeal period, the Veteran's depression did not manifest as the total occupational and social impairment contemplated by the 100 percent rating criteria. As noted above, the Veteran was gainfully employed and/or in school full time for much of the appeal period, and recently completed VA vocational rehabilitation. He also sees his children on weekends, maintains a cordial relationship with their mother, his ex-wife, and is able to live with his brother and his family without reported incident. Although the October 2020 examiner noted that he sometimes neglects his personal hygiene, he was well groomed and appropriate in appearance during the examination, and there is no indication he was unable to complete the activities of daily living during the appeal period. Additionally, although he has reported some cognitive decline during the appeal period, there is no indication it is so severe as to approximate an inability to remember his own name, occupation, or close family members. As such, the Board finds that this symptom represents, at worst, the 50 percent rating criteria's impairment of short- or long-term memory and impairment of abstract thinking. The Veteran's suicidal ideations and lack of personal hygiene are less frequent, less severe and of less duration as contemplated by the criteria for a rating higher than 50 percent. Therefore, a rating in excess of 50 percent is not warranted for any time during the appeal period. 2. Entitlement to a rating in excess of 20 percent for right upper extremity peripheral neuropathy 3. Entitlement to a rating in excess of 20 percent for left upper extremity peripheral neuropathy The Veteran's bilateral upper extremity neuropathy was granted service connection in the September 2017 rating decision on appeal, which assigned an initial rating of 10 percent for each limb. After a Board remand and further development, the AOJ issued a December 2020 rating decision granting entitlement to a 20 percent rating for each limb throughout the appeal period utilizing DC 8513, which rates paralysis of all upper spine radicular groups. Under this DC, a 20 percent rating is assigned for mild incomplete paralysis of either limb, while 40 and 30 percent ratings are assigned for moderate incomplete paralysis of the dominant and non-dominant limb, respectively. The Veteran is right-handed. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, a disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Descriptive words such as "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. However, VA's Adjudication Manual does provide guidance in evaluating the severity of nerve paralysis. According to the Manual, "mild" incomplete paralysis is demonstrated by subjective symptoms or diminished sensation. "Moderate" incomplete paralysis is manifested by the absence of sensation confirmed by objective findings. "Severe" incomplete paralysis is manifested when more than sensory findings are demonstrated, such as atrophy, weakness, and diminished reflexes. M-21, III.iv.4.G.4.b. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.124a. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate, incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes as noted above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.124. The Veteran was afforded a May 2017 VA nerve examination, during which he was diagnosed with bilateral peripheral neuropathy of the upper extremities originating from an inservice electrical shock. He also reported a comorbid diagnosis of bilateral carpel tunnel syndrome. The Veteran described mild constant pain in the right upper extremity, moderate intermittent pain in the left upper extremity, as well as severe and moderate paresthesias and/or dysesthesias and numbness in the right and left upper extremities, respectively. Muscle strength testing was all normal, as was a reflex examination. Sensory examination revealed decreased light touch sensation in the inner/outer forearm and hand/fingers, although it was normal in the shoulder area. There were no trophic changes. The examiner stated that the Veteran manifested bilateral mild incomplete paralysis of the median nerve. June 2017 private treatment records indicate that the Veteran complained of numbness in his hands, worse when performing extended word processing. A neuropathy workup was negative. In July 2018 correspondence, the Veteran described frequent shooting pain, numbness, tingling sensation running from his forearm to his fingers in both arms. He reported weekly flareups lasting for a day or two with more severe symptoms, brought on by overusing his arms, to include reaching above his head, driving, performing chores and yard work, and typing on a keyboard. A private registered nurse opined in July 2018 that the Veteran's upper extremity neuropathy symptoms were mild and intermittent. The Veteran was afforded an additional VA nerve examination in October 2020, wherein his bilateral upper extremity neuropathy diagnosis was continued. The Veteran described moderate constant pain, paresthesias and/or dysesthesias as well as numbness in both upper extremities. Upon examination he exhibited full muscle strength and normal reflexes. Sensory testing revealed normal light touch sensation in the inner/outer forearm and shoulder area, with decreased sensation in the hands/fingers bilaterally. There were no trophic changes. The examiner recorded moderate incomplete paralysis of the median, radial and ulnar nerves. Upon review of the evidence, the Board finds that a rating in excess of 20 percent for either right or left upper extremity radiculopathy is not warranted. Throughout the appeal period, the Veteran has reported symptoms of pain, numbness and tingling in both arms, and has manifested decreased light touch sensation in the middle and/or lower radicular group. However, when considering that he has described his symptoms as generally intermittent, and has manifested full muscle strength and intact reflexes, without evidence of atrophy, trophic changes, the Board finds that his paralysis is mild in nature. Therefore, a 20 percent rating for each limb is warranted under the criteria for impairment of all radicular groups. The Board also notes that throughout the appeal period the Veteran was able to work gainfully as an aircraft mechanic, build picture frames, and/or go to school for art full time, indicating that his bilateral upper extremity neuropathy caused no significant functional impairment beyond the aforementioned pain, numbness and tingling. As such, his impairment does not more closely approximate moderate incomplete paralysis, and a higher rating is not warranted. 4. Entitlement to a compensable rating for PFB The September 2017 rating decision on appeal established service connection for PFB and assigned an initial noncompensable rating. PFB is rated by analogy under DC 7806, the criteria for dermatitis or eczema, which utilizes the General Formula for the Skin. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) 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. 38 C.F.R. § 4.118. A 30 percent rating is assigned at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) 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 assigned for at least one of the following: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) 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. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Id. In evaluating skin and scar residuals, the Board notes that during the appeal period, changes were made to certain DCs under 38 C.F.R. § 4.118. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's 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. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). As the Veteran filed his claim before the August 13, 2018, effective date, the Board will consider whether either the old or new rating criteria are more favorable to the Veteran. Id. Prior to August 13, 2018, under DC 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for 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 affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body, or more than 40 percent of exposed areas affected, or constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Id. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a Veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). The Veteran was afforded a VA skin examination in May 2017, wherein he was diagnosed with PFB. The examiner noted that around June 2000 the Veteran first experienced a rash on the back of his neck that has persisted since. The Veteran indicated that the condition fluctuated, some days light, others heavier. The examiner recorded the presence of multiple papules on the back of the neck, covering less than 5 percent of total body area, and included color photographs confirming the same. The Veteran was afforded an additional VA skin examination in February 2020, wherein his PFB diagnosis was confirmed. He reported that every time he receives a haircut, the PFB at the back of his neck flares up for approximately three weeks. He indicated he had seen a dermatologist for the condition and used multiple topical ointments for less than six weeks, but without improvement. These included tea tree oil, over the counter razor bump and antibiotic treatments. The examiner indicated that the Veteran manifested erythematous raised papules along the base of the hairline at the back of neck, covering less than 5 percent of his exposed and total body area. There was no scarring associated with PFB. After review of the evidence of record, the Board finds that a compensable evaluation is not warranted for the Veteran's PFB, to include when considering his flareups following haircuts. The evidence does not indicate, nor does the Veteran allege, that he manifests disfigurement of the head, face, or neck nor was there evidence of visible or palpable tissue loss, gross distortion or asymmetry of one feature or paired set of features, acne, or hyperpigmentation. Although he manifests papules on the back of the neck lasting up to three weeks at a time, they are not present in an area of at least six square inches, and as such do not constitute a characteristic of disfigurement. Further, multiple VA examinations have indicated that his PFB manifests as characteristic lesions but does not cover at least 5 percent of his exposed or total body area, and which are contemplated by the rating criteria. PFB is a bacterial disorder occurring chiefly in beards, especially in the submandibular region of the neck, with characteristic lesions being erythematous papules and sometimes postules. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 1377 (28th Ed. 1994). Finally, the only medicine given to the Veteran to treat PFB is topical, and not systemic, in nature. As such, a compensable rating is not warranted under either the pre- or post-2018 rating criteria for the skin. 5. Entitlement to service connection for hypertension The Veteran asserts that he manifests hypertension as a result of his active service. To establish service connection, the evidence must show competent evidence of (1) a present disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b). A valid service connection claim requires competent evidence of a current disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). However, the presence of a disability at any time during the claim process or relatively close thereto can justify a grant of service connection, even where such disability has become asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). A claimant bears the evidentiary burden to establish all elements of a service connection claim. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) The Veteran was afforded a VA hypertension examination in May 2017, wherein the examiner noted that he had not previously been diagnosed with the disorder. During the examination, his three blood pressure readings were 128 over 80, 128 over 82, and 128 over 82, for an average of 128 over 81. After a physical examination, the examiner noted that there was no pathology with which to render a hypertension diagnosis. According to August 2016 VA treatment records, the Veteran's primary care physician noted that his blood pressure, recorded at 138 over 86, was at the "upper limits of normal, do not think he requires medications." The remainder of the Veteran's VA and submitted private treatment records are silent with regard to complaints of or treatment for hypertension. Hypertension for VA purposes means that the diastolic blood pressure (bottom number) is predominantly 90 or more, or systolic blood pressure (top number) is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, DC 7101, Note (1). In this case, there is no evidence that the Veteran has exhibited either diastolic blood pressure over 90 or systolic blood pressure over 160. As such, he has not manifested a current hypertension disability at or near the pendency of the appeal, there is no reasonable doubt left to resolve in his favor, and entitlement to service connection must be denied. 38 U.S.C. § 5107. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent prior to October 14, 2020, and in excess of 40 percent thereafter for a lumbar spine IVDS is remanded. The September 2017 rating decision on appeal granted entitlement to service connection for lumbar spine disorder and bilateral lower extremity radiculopathy, assigning an initial rating of 30 percent for his lumbar spine disability. After a Board remand and further development, the AOJ issued a December 2020 rating decision granting an increased rating of 40 percent from the date of an October 2020 VA examination. The Veteran was first afforded a VA spine examination in May 2017, during which he reported flareups occurring sporadically after too much movement, lasting anywhere from several days to weeks. However, the VA examiner declined to estimate the extent of the Veteran's limitation of motion during flareups and after repeated use over time. The May 2017 VA examination is inadequate under Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017), which requires that an examiner estimate functional loss during flareups based on all procurable information. In order to properly determine a rating prior to the October 2020 VA examination, the Board requires an accurate picture of the severity of the Veteran's lumbar spine disability, to include during flareups and after repetitive use. As such, remand for an addendum retrospective opinion is required. 2. Entitlement to a rating in excess of 10 percent for right lower extremity sciatic radiculopathy is remanded. 3. Entitlement to a rating in excess of 10 percent for left lower extremity sciatic radiculopathy is remanded. A review of the claims file indicates that the Veteran has been diagnosed with IVDS, and he has claimed that his condition requires periods of bedrest. As such, the issue of entitlement to higher ratings for lower extremity radiculopathy are intertwined with the issue of a higher rating for a lumbar spine disability being remanded for further development. Issues are considered to be inextricably intertwined when a determination on one issue could have a significant impact on the outcome of another. Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, the Board defers consideration of these issues at this time. 4. Entitlement to a compensable rating prior to October 13, 2020, and in excess of 10 percent thereafter is remanded. The September 2017 rating decision on appeal granted entitlement to service connection for a traumatically deviated septum, assigning an initial noncompensable rating. The Veteran appealed, and after a Board remand and further development, the AOJ granted an increased rating of 10 percent from the date of an October 2020 VA examination. This grant was predicated on the examiner finding that the Veteran's traumatically deviated septum manifested as at least a 50 percent obstruction of both nasal passages, although neither side was completely obstructed. Traumatically deviated septum is rated under 38 C.F.R. § 4.97, DC 6502, which provides a maximum 10 percent rating for 50 percent obstruction of the nasal passage on both sides or complete obstruction of one side. A previous May 2017 VA examiner noted the Veteran's deviated septum but left blank the examination section regarding nasal passage obstruction. Neither the Veteran's private medical records nor lay statements give an accurate picture of his level of nasal obstruction. The Board is not competent to determine the level of nasal obstruction caused by the Veteran's deviated septum prior to the October 2020 VA examination, and the only prior VA examination of record during this period is silent on the matter. As such, remand for a retrospective addendum opinion is warranted in order to determine the severity of his traumatically deviated septum prior to October 2020. The matters are REMANDED for the following action: 1. Associate any updated VA and relevant private treatment records with the claims file. 2. Forward the Veteran's claims file to a qualified VA examiner for a retrospective opinion on the nature and severity of his lumbar spine disability from July 2017 to October 2020. The need for an additional examination is left to the discretion of the examiner. Based upon the VA examination, clinical medical records, and lay statements of the Veteran, the examiner is asked to estimate the extent of motion loss during flareups and after repetitive use for the VA examination occurring in May 2017 through October 2020, if medically feasible. If not medically feasible, the examiner should explain in detail why (e.g., the inability to provide the needed opinion is due to the limits of the examiner's medical knowledge; the limits of the knowledge of the medical profession in general; or whether there is specific additional evidence, which if obtained, would enable the examiner to provide the needed opinion). The examiner's attention is directed to the May 2017 VA examination, the Veteran's September 2018 description of his lumbar spine symptoms, and his April 2017 clinical records attached to the claims file in July 2020. 3. Forward the Veteran's claims file to a qualified VA examiner for a retrospective opinion on the nature and severity of his deviated septum from July 2017 to October 2020. The need for an additional examination is left to the discretion of the examiner. After reviewing the claims file, the examiner is asked to opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's traumatically deviated septum manifested as 50 percent obstruction of both nasal passages or complete obstruction of one side prior to October 13, 2020. If so, and if medically feasible, the examiner is asked to identify the date this first occurred. If not medically feasible, the examiner should explain why in detail (e.g., the inability to provide the needed opinion is due to the limits of the examiner's medical knowledge; the limits of the knowledge of the medical profession in general; or whether there is specific additional evidence, which if obtained, would enable the examiner to provide the needed opinion). 4. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Schumacher, Kyle C. 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.