POSTTRAUMATIC STRESS DISORDER (PTSD)

TANYA SMITH · 2026 · Case ID: A26039672

MIXED

Summary

The veteran, who served from October 1970 to May 1972, appeals decisions regarding increased ratings for PTSD with OCD, hypothyroidism, psoriasis, psoriatic arthritis with back pain, right heel psoriatic arthritis, and entitlement to TDIU, Dependents Educational Assistance (DEA), and Special Monthly Compensation (SMC) at the housebound rate. The Board granted an increased rating for psoriasis from 10% to 60% effective March 5, 2020, and denied higher ratings for PTSD/OCD, hypothyroidism, psoriatic arthritis with back pain, and right heel psoriatic arthritis. The Board found the veteran's PTSD with OCD symptoms warranted a 70% rating, not the requested 100%, as the criteria for total occupational and social impairment were not met. Hypothyroidism was found to be adequately treated and controlled, not meeting criteria for higher ratings. Psoriatic arthritis claims were denied as the veteran's range of motion and symptom severity did not meet criteria for ratings above 10%. The Board granted TDIU effective September 2, 2016, based on a private vocational consultant's opinion that the veteran's PTSD with OCD precluded substantially gainful employment. Consequently, DEA benefits were granted effective September 2, 2016, and SMC at the housebound rate was granted effective March 5, 2020, based on the TDIU and the 60% rating for psoriasis, respectively.

Rationale

VA examiners estimated impairment consistent with 70% rating.; Symptoms did not meet criteria for total occupational and social impairment.; No symptoms enumerated for 100% rating were demonstrated.

Special Benefit

SMC - HOUSEBOUND; TDIU

Diagnostic Code

7903

Docket No.

251125-620141

Full Decision Text

Citation Nr: A26039672
Decision Date: 04/28/26 Archive Date: 04/28/26

DOCKET NO. 251125-620141
DATE: April 28, 2026

ORDER

Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with obsessive compulsive disorder (OCD) is denied.

Entitlement to an initial rating in excess of 10 percent for hypothyroidism is denied.

Entitlement to an initial rating of 60 percent, but no higher, for psoriasis (increased from 10 percent disabling from March 5, 2020, through June 13, 2022, and from 30 percent disabling from June 14, 2022, through April 18, 2023) is granted.

On and after April 19, 2023, entitlement to an initial rating in excess of 60 percent for psoriasis is denied.

Entitlement to an initial rating in excess of 10 percent for psoriatic arthritis with back pain is denied.

Entitlement to an initial rating in excess of 10 percent for right heel psoriatic arthritis is denied.

Effective September 2, 2016, entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected PTSD with OCD is granted.

Entitlement to an effective date of September 2, 2016, for Dependents Educational Assistance (DEA) benefits under 38 U.S.C. Chapter 35 based on permanent and total disability status is granted.

Effective March 5, 2020, entitlement to special monthly compensation (SMC) at the housebound rate is granted.

FINDINGS OF FACT

1. The Veteran's PTSD with OCD does not manifest in total occupational and social impairment.

2. The Veteran's hypothyroidism has been controlled through medication; it does not manifest in constipation, mental sluggishness, muscular weakness, weight gain, cold intolerance, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), brachycardia (less than 60 beats per minute), or sleepiness due to his hypothyroidism; on and after December 10, 2017, the Veteran's hypothyroidism has not manifested in myxedema or any other compensable residuals.

3. Resolving reasonable doubt in the Veteran's favor, for the period prior to April 19, 2023, the Veteran's psoriasis has affected greater than 40 percent of his total body area.

4. On and after April 19, 2023, the Veteran is already in receipt of the maximum schedular rating for his psoriasis.

5. Even when considering functional impairment caused by factors such as pain, weakness, fatigability, incoordination, or pain on movement of a joint, including after repeated use over time and on flare-up, the Veteran's psoriatic arthritis with back pain did not manifest in flexion to 60 degrees or less or combined range of motion to 120 degrees or less; it did not result in muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; nor did it result in incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12-month period.

6. The Veteran's right heel psoriatic arthritis corresponds to foot injury of no more than moderate severity.

7. Effective September 2, 2016, the Veteran's PTSD with OCD has been shown to prevent him from securing and following substantially gainful employment.

8. Since September 2, 2016, the Veteran has had a permanent and total disability rating.

9. Since March 5, 2020, the Veteran has had a single, permanent service-connected disability rated 100 percent disabling and additional service-connected disabilities independently rated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems.

CONCLUSIONS OF LAW

1. The criteria for entitlement to a rating in excess of 70 percent for PTSD with OCD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 4.130, Diagnostic Code 9411.

2. The criteria for entitlement to an initial rating in excess of 10 percent for hypothyroidism have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.119, Diagnostic Code 7903.

3. The criteria for entitlement to an initial rating of 60 percent, but no higher, for ps
OF LAW

1. The criteria for entitlement to a rating in excess of 70 percent for PTSD with OCD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 4.130, Diagnostic Code 9411.

2. The criteria for entitlement to an initial rating in excess of 10 percent for hypothyroidism have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.119, Diagnostic Code 7903.

3. The criteria for entitlement to an initial rating of 60 percent, but no higher, for psoriasis (increased from 10 percent disabling from March 5, 2020, through June 13, 2022, and from 30 percent disabling from June 14, 2022, through April 18, 2023) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7816.

4. On and after April 19, 2023, the criteria for entitlement to an initial rating in excess of 60 percent for psoriasis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7816.

5. The criteria for entitlement to an initial rating in excess of 10 percent for psoriatic arthritis with back pain have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.321(b), 3.400, 4.71a, Diagnostic Code 5237.

6. The criteria for entitlement to an initial rating in excess of 10 percent for right heel psoriatic arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5284.

7. Effective September 2, 2016, the criteria for entitlement to a TDIU due to service-connected PTSD with OCD have been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.340, 3.341, 4.15, 4.16, 4.18, 4.25, 4.26.

8. Entitlement to an effective date of September 2, 2016, for DEA benefits under 38 U.S.C. Chapter 35 based on permanent and total disability status have been met. 38 U.S.C. §§ 3501, 5110; 38 C.F.R. §§ 3.807, 21.3021.

9. Effective March 5, 2020, the criteria for entitlement to SMC at the housebound rate have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 1970 to May 1972. This matter comes before the Board on appeal from an April 2025 Regional Office (RO) rating decision. The Veteran was notified of this decision in a letter dated April 4, 2025.

In November 2025, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement). He selected the Direct Review Docket.

The Board may only consider the evidence of record at the time of the rating decision notification letter. 38 C.F.R. § 20.301. Thus, the Board may only consider the evidence of record as of April 4, 2025. Any evidence submitted after the agency of original jurisdiction (AOJ) decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

Due to continuous pursuit, the periods for consideration of these issues precedes the November 12, 2024, VA Form 20-0995, Decision Review Request: Supplemental Claim. The period for consideration for the hypothyroidism, TDIU, DEA, and SMC housebound claims begins on September
letter. 38 C.F.R. § 20.301. Thus, the Board may only consider the evidence of record as of April 4, 2025. Any evidence submitted after the agency of original jurisdiction (AOJ) decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

Due to continuous pursuit, the periods for consideration of these issues precedes the November 12, 2024, VA Form 20-0995, Decision Review Request: Supplemental Claim. The period for consideration for the hypothyroidism, TDIU, DEA, and SMC housebound claims begins on September 2, 2016. The period for consideration for the psoriasis claim begins on March 5, 2020. The period for consideration for the back and right heel disability claims begins on April 12, 2021. The period for consideration for the PTSD with OCD claim begins on June 14, 2022.

Increased Ratings

Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).

Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995).

Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40).

Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Estimates of additional functional impairment during flare-ups, if any, are also to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017).

1. Entitlement to a rating in excess of 70 percent for PTSD with OCD is denied.

The Veteran is currently in receipt of a 70 percent rating for PTSD with OCD under 38 C.F.R. § 4.130, Diagnostic Code 9411. He contends that a 100 percent rating is warranted.

Disabilities that are evaluated under 38 C.F.R. § 4.130 are to be rated pursuant to VA's General Rating Formula for Mental Disorders. A 0 percent (noncompensable) evaluation is assigned when a mental health condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.

A 10 percent evaluation is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.

A 30 percent evaluation is warranted when there is 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
130 are to be rated pursuant to VA's General Rating Formula for Mental Disorders. A 0 percent (noncompensable) evaluation is assigned when a mental health condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.

A 30 percent evaluation is warranted when there is 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 conversation 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, recent events).

A 50 percent evaluation is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships.

A 70 percent evaluation is warranted when there is 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; obsessional 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 work like setting); and the inability to establish and maintain effective relationships.

A 100 percent evaluation is warranted if there is 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; and memory loss for names of close relatives, own occupation, or own name.

The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held "that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In particular, the Federal Circuit has expressly rejected interpreting 38 C.F.R. § 4.130 in such a manner that would render specific symptomatology a secondary consideration at the 70 percent level. Id.

Turning to the evidence of record, the Veteran has undergone VA examinations in connection with this claim in July 2022 and March 2023. Both VA examiners estimated that the Veteran's PTSD with OCD was best summarized as producing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. These summaries correspond to a 70 percent disability rating.

Both the July 2022 and March 2023 VA examination reports diagnosed PTSD and OCD. With respect to symptoms that were noted at the examination, the July 2022 report noted that, for the Veteran's PTSD, "Rituals refer to hypervigilance, excessive safety-checking. Memory loss refers to low executive functioning inherent in posttraumatic anxiety. Speech reflects non-linear tangential thought process." With respect to the OCD, the July 2022 report noted that the Veteran "Counts keystrokes when typing, urge to do tasks bilaterally (i.e., using tools), time-consuming fixation on car repair rituals to decrease fears/obsessions, compulsively relocates his hat in exam."

With respect to recent history, the July 2022 VA examination report notes that the Veteran has been married for 43 years. He reported that he has a supportive home life but that "the instability has largely
PTSD, "Rituals refer to hypervigilance, excessive safety-checking. Memory loss refers to low executive functioning inherent in posttraumatic anxiety. Speech reflects non-linear tangential thought process." With respect to the OCD, the July 2022 report noted that the Veteran "Counts keystrokes when typing, urge to do tasks bilaterally (i.e., using tools), time-consuming fixation on car repair rituals to decrease fears/obsessions, compulsively relocates his hat in exam."

With respect to recent history, the July 2022 VA examination report notes that the Veteran has been married for 43 years. He reported that he has a supportive home life but that "the instability has largely come from me - I'm vulnerable and difficult to live with. It's had a profound effect on our relationship and our children." He reported that he is estranged from his middle daughter because "she thinks I'm toxic." It was noted that he "Has a small circle of friends." His wife reported that she retired from her work as a psychiatric nurse because her husband needed her to take care of him. She reported that "My husband needs a lot of attention, support.... It's mutating. It's changing from being angry to high, high anxiety. This need to control everything. He'll say, 'I can't take people.'"

With respect to recent history, the March 2023 VA examination report notes that the Veteran "is close with all of his children currently," reporting that he has "had some estrangement issues." It was noted that the Veteran remains married to his wife of 43 years, but that she "has left me for anger management issues and me threatening her." He reported that he has "a very difficult temper. I am getting better about managing my anger and temper and have learned not to respond. But the brunt of it is toward my wife. I have become very accusatory towards her." His past estrangement from his middle daughter was noted, and it was noted that "He has a very strained relationship with his wife."

The July 2022 VA examination report notes that the following symptoms apply to the Veteran's diagnosis: depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; circumstantial, circumlocutory, or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; and obsessional rituals which interfere with routine activities.

The March 2023 VA examination report notes that the following symptoms apply to the Veteran's diagnosis: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence.

With respect to behavioral observations, the July 2022 VA examination report notes the Veteran was well-dressed and groomed. His eye contact was normal. Behavior was cooperative and engaged, and it was noted that he "compulsively moves his hat back & forth on couch 3x until satisfied with placement." His mood was distressed and anxious. His affect was mildly limited in range and was congruent with his mood. His speech was well-articulated, verbose, and detail-heavy. His thought processes were circumstantial, non-linear, and tangential.

With respect to behavioral observations, the March 2023 VA examination report notes the Veteran arrived on time for the evaluation and was pleasant and engaging. He was articulate, and his speech was of normal pace and prosody. His mood was a bit anxious. His affect was congruent with his mood. He denied current suicidal or homicidal ideation.

The Veteran's VA medical records reflect that he has received mental health treatment through VA. The contents of these records do not reflect a greater degree of psychiatric impairment than that which is described in the VA examination reports.

Based on the above, the Board finds that the criteria for entitlement to a 100 percent rating for the Veteran's psychiatric disability have not been met. Neither VA examiner found that the Veteran's occupational and social impairment manifested in total occupational and social impairment, which is the standard that warrants a 100 percent rating. Rather, both examiners found that the Veteran's occupational and social impairment manifested in a level of impairment that warrants a 70 percent rating
his mood. He denied current suicidal or homicidal ideation.

Based on the above, the Board finds that the criteria for entitlement to a 100 percent rating for the Veteran's psychiatric disability have not been met. Neither VA examiner found that the Veteran's occupational and social impairment manifested in total occupational and social impairment, which is the standard that warrants a 100 percent rating. Rather, both examiners found that the Veteran's occupational and social impairment manifested in a level of impairment that warrants a 70 percent rating. The Board notes that the 70 percent rating contemplates considerable impairment. Both of the VA examiners found that the Veteran's PTSD with OCD does not manifest in any of the enumerated symptoms of the 100 percent psychiatric rating criteria.

The Board, however, finds that the criteria for entitlement to a 100 percent rating under Diagnostic Code 9411 are not met. The Veteran's thought processes and communication are not "grossly" impaired. He has not demonstrated delusions or hallucinations, much less persistent ones. His behavior has not been grossly inappropriate. He has not demonstrated suicidal or homicidal ideation, plan, or intent, and is thus not a persistent danger of hurting himself or others. He was properly groomed and appropriately dressed on both examinations, and there is no indication that he is intermittently unable to perform activities of daily living. He has not demonstrated disorientation to time or place. He has not experienced memory loss of such a severity that he is unable to remember the names of close relatives, his own occupation, or his own name. The Board finds that the Veteran's psychiatric disability symptoms are contemplated by the 70 percent rating criteria. Therefore, entitlement to a 100 percent rating under Diagnostic Code 9411 is not demonstrated.

Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to an initial rating in excess of 10 percent for hypothyroidism is denied.

The Veteran's hypothyroidism is currently assigned a 10 percent evaluation, pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7903. During the pendency of the appeal, the rating criteria for evaluating hypothyroidism under 38 C.F.R. § 4.119 were amended effective December 10, 2017.

When regulations are revised during the course of an appeal, as here, the Board is required to consider the claim in light of both the former and revised schedular criteria and to apply the regulation more favorable to the claimant. However, if an increased rating is warranted under the revised criteria, that award may not be made effective before the effective date of the change; there is no prohibition against assigning a rating under the older criteria for the entire period on appeal. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003).

Prior to December 10, 2017, Diagnostic Code 7903 provided a 10 percent rating for hypothyroidism with fatigability, or continuous medication required for control. A 30 percent rating was warranted for hypothyroidism with fatigability, constipation, and mental sluggishness. A 60 percent rating was warranted for hypothyroidism with muscular weakness, mental disturbance, and weight gain. A 100 percent rating was warranted for hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), brachycardia (heartbeat less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903.

The current version of the criteria, effective December 10, 2017, assigns a 30 percent rating for hypothyroidism without myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)) for six months after initial diagnosis. Thereafter, residuals of disease or medical treatment are rated under the most appropriate diagnostic code(s) within the appropriate body system (e.g., eye, digestive, mental disorders). A 100 percent rating is warranted for hypothyroidism manifesting as myxedema for a period of six months after an examiner has determined the condition is stabilized. Thereafter, the residual effects of hypothyroidism shall be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). 38 C.F.R. § 4.119, Diagnostic Code 7903.

The United States Court of Appeals for Veterans Claims (Court) has addressed the specific application of the rating criteria for Diagnostic Code 7903 and found that all the symptoms listed for a particular disability rating are not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms meeting some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 and resolved based on the evidence of record. The Court also stated that the rating criteria for Diagnostic Code 7903 are not successive. See Tatum, 23 Vet. App. at 155. A claimant could potentially establish all the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156.

Turning to the evidence of record, the Veteran has undergone four VA examinations in connection with this claim. These examinations occurred in February 2021, June 2022, October 2022, and April 2023.

The February 2021 VA examination report notes a date of diagnosis in 2000, while the October 2022 report notes a date of diagnosis in October 2009.

The February 2021 VA examination report notes that the Veteran "Takes Levothyroxine, continues to feel fatigued and has difficulty losing weight which he attributes to his hypothyroidism." The Veteran had not had any radioactive iodine treatment. The Veteran did not currently have any findings, signs, or symptoms due to a thyroid condition, including musculoskeletal, respiratory, cardiovascular, gastrointestinal, genitourinary, reproductive, skin, eye, neurological, mental and psychological, and dental and oral symptoms. There were no findings, signs, or symptoms attributable to a hypothyroid condition, to include myxedema or mental disturbance. The examiner opined that the Veteran's hypothyroidism does not impact his ability to work.

The same symptoms were reported and findings were made on the June 2022 VA examination report.

The October 2022 VA examination report notes that the Veteran's current symptoms are "Malaise, fatigue, low thyroid levels." It was noted that he was using Levothyroxine daily. He described the impact of his condition as follows: "Struggles to get up and going, complete tasks, stay active, maintain physical condition." The Veteran had not had any radioactive iodine treatment. The Veteran did not currently have any findings, signs, or symptoms due to a thyroid condition, including musculoskeletal, respiratory, cardiovascular, gastrointestinal, genitourinary, reproductive, skin, eye, neurological, mental and psychological, and dental and oral symptoms. There were no findings, signs, or symptoms attributable to a hypothyroid condition, to include myxedema or mental disturbance. The examiner opined that the Veteran's hypothyroidism does not impact his ability to work.

The April 2023 VA examination report notes that the Veteran reported that he currently experiences fatigue due to his hypothyroidism. He reported that he was still taking Levothyroxine. The Veteran had not had any radioactive iodine treatment. The Veteran did not currently have any findings, signs, or symptoms due to a thyroid condition, including musculoskeletal, respiratory, cardiovascular, gastrointestinal, genitourinary, reproductive, skin, eye, neurological, mental and psychological, and dental and oral symptoms. There were no findings, signs, or symptoms attributable to a hypothyroid condition
xedema or mental disturbance. The examiner opined that the Veteran's hypothyroidism does not impact his ability to work.

The April 2023 VA examination report notes that the Veteran reported that he currently experiences fatigue due to his hypothyroidism. He reported that he was still taking Levothyroxine. The Veteran had not had any radioactive iodine treatment. The Veteran did not currently have any findings, signs, or symptoms due to a thyroid condition, including musculoskeletal, respiratory, cardiovascular, gastrointestinal, genitourinary, reproductive, skin, eye, neurological, mental and psychological, and dental and oral symptoms. There were no findings, signs, or symptoms attributable to a hypothyroid condition, to include myxedema or mental disturbance. The examiner opined that the Veteran's hypothyroidism does not impact his ability to work.

Review of the Veteran's VA and private medical records does not reveal symptoms that contradict those of the VA examinations. They reveal that the Veteran has been taking thyroid medication since at least October 2009.

Based on the above, the Board finds that the criteria for entitlement to a rating in excess of 10 percent under the former rating criteria were not met during any portion of the appeals period. The medical evidence of record reveals that the Veteran has been taking medication to control his hypothyroidism since at least October 2009. It does not suggest that the Veteran was experiencing constipation, mental sluggishness, muscular weakness, weight gain, cold intolerance, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), or sleepiness due specifically to his hypothyroidism. Therefore, the Board finds that the criteria for a rating in excess of 10 percent were not met under the former rating criteria.

The Board will now consider whether a rating in excess of 10 percent is warranted under the revised rating criteria at any point since the December 10, 2017, change in rating criteria.

As noted above, the current version of the criteria, effective December 10, 2017, assigns a 30 percent rating for hypothyroidism without myxedema for six months after initial diagnosis. The Veteran's medical records reflect that he had a hypothyroidism diagnosis in October 2009. Therefore, the Veteran's initial diagnosis far preceded the six-month period prior to the September 2, 2016, grant of service connection.

All four VA examination reports expressly found that the Veteran has no findings, signs, or symptoms of hypothyroidism. The Veteran's mental health issues are compensated under the rating for the service connected psychiatric disability; to assign a rating under Diagnostic Code 7903 for the same symptoms would constitute an impermissible pyramiding of benefits. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Therefore, no separate ratings of residuals are necessary.

In the absence of evidence of myxedema, entitlement to a 100 percent rating under the revised Diagnostic Code 7903 is not warranted.

In short, the Board finds that a rating in excess of 10 percent is not warranted for hypothyroidism during any portion of the appeals period, under either the former or the revised rating criteria.

3. Entitlement to an initial rating of 60 percent, but no higher, for psoriasis (increased from 10 percent disabling from March 5, 2020, through June 13, 2022, and from 30 percent disabling from June 14, 2022, through April 18, 2023) is granted.

4. On and after April 19, 2023, entitlement to an initial rating in excess of 60 percent for psoriasis is denied.

The Veteran's psoriasis is rated under 38 C.F.R. § 4.118, Diagnostic Code 7816. (The Board notes that this rating contemplates the Veteran's skin symptoms. His psoriatic arthritis has been assigned separate ratings for each of the involved joints. The disability ratings for the Veteran's psoriatic arthritis of the back and right heel will be discussed separately, below.)

Disabilities rated under Diagnostic Codes 7806, 7809, 7813-16, 7820-22, and 7824 are to apply the General Rating Formula for the Skin.

Under the General Rating Formula for the Skin
an initial rating in excess of 60 percent for psoriasis is denied.

Disabilities rated under Diagnostic Codes 7806, 7809, 7813-16, 7820-22, and 7824 are to apply the General Rating Formula for the Skin.

Under the General Rating Formula for the Skin, 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: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected.

A 10 percent rating is assigned for at least one of the following: 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, psoralen with long-wave ultraviolet-A light (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 assigned for at least one of the following: characteristic lesions involving more than 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 assigned for at least one of the following: 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, PUVA, or other immunosuppressive drugs required over the past 12-month period.

Or the disability is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating Formula for the Skin.

As it pertains to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824, 38 C.F.R. § 4.118(a) explicitly states 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."

The Veteran has undergone VA skin conditions examinations in connection this claim in July 2020, April 2021, June 2021, October 2022, and April 2023. He has also received medical treatment through VA for his psoriasis.

A March 2020 VA medical record notes that there were active signs of flare-ups on examination.

A June 2020 VA medical record notes that the Veteran's "psoriasis is better with the exception to his legs. They are flared."

The July 2020 VA examination report notes that the Veteran reported the following current symptoms: "rash, itchiness, scaling, constant irritation/aggravation, and pain. Scalp, face, elbows, toes, behind ears, chest, fingernails, legs, toes (severe fungus), and groin/buttocks.... The symptoms are getting more severe as the skin ages." Treatment consisted of "Calcipotriene cream-alternating 2-3 times per day depending on the severity, and Clobetasol Proriamate Cream." He has described the impact of this condition as "constant." He noted increased problems when soaking in a hot tub. It was noted that "He is unable to wear short sleeve shirts, as his forearms and elbows are so unattractive." He reported that "The cosmetic aspect ha[s] been very adverse." It noted that "It compromises physical activities that he is able to do.
ernails, legs, toes (severe fungus), and groin/buttocks.... The symptoms are getting more severe as the skin ages." Treatment consisted of "Calcipotriene cream-alternating 2-3 times per day depending on the severity, and Clobetasol Proriamate Cream." He has described the impact of this condition as "constant." He noted increased problems when soaking in a hot tub. It was noted that "He is unable to wear short sleeve shirts, as his forearms and elbows are so unattractive." He reported that "The cosmetic aspect ha[s] been very adverse." It noted that "It compromises physical activities that he is able to do. He is constantly scratching/itching the skin. He states that he wears long sleeve shirts, hats, gloves, long pants, and socks. He stated that he mostly does not go out in hot temperatures."

With respect to treatment, the July 2020 VA examination report notes that the Veteran has been treated with topical corticosteroids or other immunosuppressive medication constantly or nearly constantly. No other treatments were noted.

On examination, the July 2020 VA examination report notes that the Veteran's psoriasis affects at least 5 percent but less than 20 percent of his total body area and less than 5 percent of his exposed areas. The examiner specified that "about 1% exposed, 5% nonexposed" areas were affected. The examiner noted that the Veteran "has about 3 by 3 inch patch on chest. [A] few scattered patches on both legs, dryness behind both ears, scaly patches on both elbows."

The July 2020 VA examination report found that the Veteran's skin condition impacts his ability to work in that it "Can be socially unacceptable if he has visible outbreaks on arms or ears or scalp that makes it difficult to be in the midst of public."

The July 2020 VA examiner notes that the Veteran "has had other skin issues including basal cell carcinoma and squamous cell carcinoma and dermatophytosis but these are not on the claim and this is a focused exam request so not addressed and Veteran may follow up with the VA and PCP as needed."

The April 2021 VA skin diseases examination report describes the same symptoms that were reported in July 2020 and the same treatment. On physical examination, the Veteran's psoriasis was estimated to cover at least 5 percent but less than 20 percent of his total body area and none of his exposed area. The examiner found "white flaky patches with surrounding erythema" that was located on the Veteran's elbows, shins, and right thigh. The psoriasis impacted his ability to work in that he "Always wears long shirts to help prevent itching and bleeding. Wakes up frequently throughout the night due to the itching."

A July 2021 VA medical record notes that the Veteran "states he is in 'extreme discomfort' with his psoriasis, the medication he is using is 'not doing anything.'"

The August 2021 VA examination report notes that the Veteran had a "progressive worsening rash with associated arthritis." Treatment with Calcipotriene and with betamethasone (categorized as a corticosteroids or other immunosuppressive medication) was noted. On physical examinations, the Veteran's psoriasis was estimated to cover at least 5 percent but less than 20 percent of his total body area and of his exposed area. There were "thickened, scaly patches on his back, extremities." It was noted that the Veteran's psoriasis did not impact his ability to work.

A November 2021 VA dermatology telephone encounter record notes that the Veteran "reports psoriasis has been worsening in the past year, affecting almost all of his body, mostly in ankle, back, back of head, elbow." It was separately noted that the Veteran "has also had joint pain for a while," which suggests that the symptoms that the Veteran has described as occurring almost all over his body are the dermatological symptoms. The Veteran reported "some psoriasis improvement in [the] arms and elbows." His Clobetasol ointment was refilled.

A May 2022 VA telephone record notes that the Veteran "reports he got Clobetasol cream but he thinks he needs stronger cream.... He reports psoriasis is still very bad and almost all his body is affected except private and axilla area." He was scheduled to be seen the next month.

A June 2022 VA dermatology record notes that the Veteran reported having "rashes/psoriasis still covering his chest, back, extremities (especially elbows and knees)." On examination "he presented with psoriatic patches on elbows, knees
the dermatological symptoms. The Veteran reported "some psoriasis improvement in [the] arms and elbows." His Clobetasol ointment was refilled.

A June 2022 VA dermatology record notes that the Veteran reported having "rashes/psoriasis still covering his chest, back, extremities (especially elbows and knees)." On examination "he presented with psoriatic patches on elbows, knees, over k[n]uckles bilaterally. Other than that, most of the rashes appear more of folliculitis instead of psoriasis." It was noted that "The finding is matching his previous SDVA documentation [that] I only found about 5-6% BSA [body surface area] affected by psoriasis." It was noted that all of these skin conditions had been treated as if they were psoriasis with limited help. His medications were changed in order to treat the folliculitis as well as the psoriasis. The following notation was made: "Cutaneous findings: Scaly patches found on elbows, knees and knuckles, about 5-6% BSA involved."

A September 2022 VA dermatology record notes that the Veteran's "Skin condition is also improved (less nodules noted on upper arms, less itchy; improved folliculitis)." On examination, it was noted that the Veteran had "improved scaly patches found on elbows, knees and knuckles; improved from 5-6% BSA to 3-4%."

The October 2022 VA skin diseases examination report notes current symptoms that include "Chronic fatigue, chronic joint pain, lesions and plaques over entire body, bleeding, open sores." Treatment consisted of "Progression of injection biologics - Otezla, Humira, Taltz x2, lots of topical steroids, lots of non-steroidal topicals, pain meds." The Board notes that this treatment is not limited to the skin disease symptoms.

The October 2022 VA examination report notes that the Veteran has been treated with betamethasone constantly or nearly constantly and with biologics for less than six weeks during the past 12 months. The examiner found that the Veteran's psoriasis affects at least 20 percent and up to 40 percent of his total body area and less than 5 percent of his exposed areas. The examiner noted that there were "Plaque likely erythematous areas on the right ear pinna, scattered over the upper and lower extremities, feet, and nail changes from psoriasis on hands and feet." The examiner determined that the Veteran's psoriasis did not impact his ability to work.

A January 26, 2023, VA medical record notes that the Veteran stated the following: "In 2018 the psoriasis has changed significantly and is all over my body and is not controlled; I'm using steroids on a daily basis way more than I should; I'm on my 4th medicine for psoriasis." He reported that he has "lesions all over body: back, legs, arms; big sore spot below my chin; lesions inside the ears which is really unpleasant."

The April 2023 VA skin diseases examination report notes that the Veteran's current symptoms consist of "plaques on hands, arms, feet, legs, back[,] fingers and toes." It was noted that he treats his psoriasis with "Gaselkumab injections, clobetasol lotion, Calcipotriene lotion, fluocinonide ointment." He notes limitation of function in that he has to "limit exposure to water because irritates plaques." The examiner noted that the Veteran's treatment includes constant or near-constant use of corticosteroids or other immunosuppressive medications (Clobetasol and fluocinonide ointment); biologics for less than six weeks during the past 12 months (Gaselkumab); and constant or near-constant use of other medication (Calcipotriene). The examiner found that the Veteran's psoriasis affects greater than 40 percent of his total body area and less than 5 percent of his exposed areas. The examiner stated that the Veteran's psoriasis does not impact his ability to work.

Even though these five VA skin diseases examinations were conducted less than three years apart, they note different percentages of both total skin area and exposed skin area that are affected by the Veteran's psoriasis. The Board notes
osuppressive medications (Clobetasol and fluocinonide ointment); biologics for less than six weeks during the past 12 months (Gaselkumab); and constant or near-constant use of other medication (Calcipotriene). The examiner found that the Veteran's psoriasis affects greater than 40 percent of his total body area and less than 5 percent of his exposed areas. The examiner stated that the Veteran's psoriasis does not impact his ability to work.

Even though these five VA skin diseases examinations were conducted less than three years apart, they note different percentages of both total skin area and exposed skin area that are affected by the Veteran's psoriasis. The Board notes, however, that disabilities of the skin tend to wax and wane with active and inactive periods. See Ardison v. Brown, 6 Vet. App. 405 (1994). In this case, the Veteran has consistently reported that his psoriasis affects great portions of his body, and he has been consistently receiving treatment for this disability. The Board will therefore resolve reasonable doubt in the Veteran's favor and find that his psoriasis has affected greater than 40 percent of his total body area throughout the appeals period.

Thus, effective March 5, 2020, the criteria for entitlement to a 60 percent rating for psoriasis have been met. This constitutes an increase of the previously-assigned 10 percent rating for the period from March 5, 2020, through June 13, 2022, and the previously-assigned 30 percent rating from June 14, 2022, through April 18, 2023.

The Board finds that a rating in excess of 60 percent is not warranted for any portion of the appeals period, to include the period on and after April 19, 2023. The Board notes that the 60 percent rating is the maximum rating that is allowable under Diagnostic Code 7816. Although the Veteran is competent to describe the symptoms of this condition, the Board finds that there is no basis upon which to otherwise award an increased schedular evaluation.

In short, the criteria for entitlement to an initial rating of 60 percent (increased from 10 percent effective from March 5, 2020, through June 13, 2022, and from 30 percent disabling from June 14, 2022, through April 18, 2023) is warranted. Entitlement to an initial rating in excess of 60 percent is not warranted for any portion of the appeals period.

5. Entitlement to an initial rating in excess of 10 percent for psoriatic arthritis with back pain is denied.

The Veteran is currently in receipt of a 10 percent rating for psoriatic arthritis with back pain under 38 C.F.R. § 4.71a, Diagnostic Code 5237. He contends that a higher rating is warranted.

Diagnostic Code 5237 applies to lumbosacral strain and includes rating criteria that pertain to limitation of motion of the lumbar spine.

Diagnostic Codes 5235 through 5242 direct that the disability be rated under the General Rating Formula for Diseases and Injuries of the Spine.

The General Rating Formula assigns a 10 percent evaluation for forward flexion of the lumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.

A 20 percent evaluation is warranted for forward flexion greater than 30 degrees but not greater than 60 degrees; or, combined range of motion 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.

An evaluation of 40 percent is warranted when there is forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine.

Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent disability rating. Unfavorable ankylosis of the entire spine warrants a 100 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242.

Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999); Lewis v. Derwinski, 3 Vet. App. 259 (1992).

Note (2) (see also Plate V) explains that, for VA compensation purposes, normal flexion of the thoracolumbar spine is from zero to 90 degrees, extension from 0 to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The normal combined range of motion, then, is 240 degrees and refers to the sum of the range of forward flexion, backward extension, left and right lateral flexion, and left and right rotation.

Note (5) in Diagnostic Codes 5235-5242 provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: 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; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Alternatively, intervertebral disc syndrome (IVDS) should be evaluated either under the General Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25 (VA's combined ratings table).

Under the Formula for Rating IVDS Based on Incapacitating Episodes, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months.

Note (1) in Diagnostic Code 5243 for IVDS defines an incapacitating episode as a period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician.

The Veteran has undergone VA back conditions examinations in June 2021 and April 2023.

He reported at the June 2021 examination that he currently experiences "progressive low back pain, aching and stiff in the morning." He treats his disability with ibuprofen, and he had back fusion surgery in 2008 and 2019. He reported that flare-ups occur two to three times per month and last three to four days. It is moderate in severity and is precipitated by driving and prolonged sitting and alleviated by Ibuprofen and rest. He reported functional loss or impairment due to
period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician.

The Veteran has undergone VA back conditions examinations in June 2021 and April 2023.

He reported at the June 2021 examination that he currently experiences "progressive low back pain, aching and stiff in the morning." He treats his disability with ibuprofen, and he had back fusion surgery in 2008 and 2019. He reported that flare-ups occur two to three times per month and last three to four days. It is moderate in severity and is precipitated by driving and prolonged sitting and alleviated by Ibuprofen and rest. He reported functional loss or impairment due to back pain in the form of limited sitting and decreased walking.

Initial range of motion was flexion to 80 degrees and extension, left and right lateral flexion, and left and right lateral rotation were each to 30 degrees, with pain in all planes of motion. There was objective evidence of pain on weight-bearing, during active motion, and on rest/non movement, and the pain results in "limited standing and sitting, limited lifting and bending." No additional range of motion was lost after three repetitions. The procured evidence did not suggest that pain, fatigability, weakness, lack of endurance, or incoordination significantly limit functional ability with repeated use over time or on flare-up. There was evidence of localized tenderness that did not result in abnormal gait or abnormal spinal contour. There was no evidence of muscle spasm or guarding. It was noted that the Veteran does not have IVDS. The Veteran did not use any assistive devices as a normal mode of locomotion. There was functional impact on the Veteran's ability to work that resulted in "limited sit[t]ing, standing, driving, bending, and lifting."

The Veteran reported at the April 2023 VA back conditions examination that he experiences low back pain daily. His treatment consists of his psoriasis treatment. He reported that his back disability impacts his functioning in that he "has to avoid lifting and carrying 20 pounds, difficulty with walking for the first 3 hours of the day." He did not report flare-ups.

Initial range of motion was flexion to 70 degrees, extension to 25 degrees, and left and right lateral flexion and left and right lateral rotation were each to 30 degrees, with pain on forward flexion, right lateral flexion, and right lateral rotation. There was objective evidence of pain on weight-bearing, during active motion, and on rest/non movement, and the pain results in "less rom [range of motion] and pain with movement." No additional range of motion was lost after three repetitions. The procured evidence did not suggest that pain, fatigability, weakness, lack of endurance, or incoordination significantly limit functional ability with repeated use over time. There was no evidence of localized tenderness, guarding, or muscle spasm. It was noted that the Veteran does not have IVDS. The Veteran did not use any assistive devices as a normal mode of locomotion. There was functional impact on the Veteran's ability to work in that he "may have difficulty with lifting, carrying and bending over with a job."

Based on the above, the Board finds that the criteria for entitlement to a rating in excess of 10 percent is not warranted for the Veteran's back disability. Even when considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, pain on movement, flare-up, or repetitive use over time, the Veteran's range of motion does not satisfy the criteria for a rating in excess of 10 percent. The greatest limitation of forward flexion was found to be 70 degrees, while flexion must be greater than 30 degrees but not greater than 60 degrees to warrant a 20 percent rating. Alternatively, combined range of motion can be no greater than 120 degrees to warrant a 20 percent rating. The greatest limitation of combined range of motion in this case is to 215 degrees. Thus, the Veteran's back disability does not satisfy the criteria for entitlement to a rating in excess of 10 percent based on forward flexion or based on combined range of motion.

In the absence of evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, entitlement to a 20 percent rating is not warranted.

The Board has also considered whether entitlement to an increased rating is warranted based on incapacitating episodes. The VA examiners did not note any incapacitating episodes due to back symptomatology, and the Veteran's medical treatment records do not reflect that he had any incapacitating episodes as defined
to 215 degrees. Thus, the Veteran's back disability does not satisfy the criteria for entitlement to a rating in excess of 10 percent based on forward flexion or based on combined range of motion.

Caselaw requires the Board to take due consideration that the beneficial effects of medication are discounted unless such effects are otherwise contemplated in a particular diagnostic code. See Ingram v. Collins, 38 Vet. App. 130 (2025). In this case, the VA examiner, in rendering range of motion findings, noted and considered the Veteran's lay statements describing functional limitations when his pain and functional impairment are at its worst (e.g., during flare ups, on repetitive motion, due to lack of endurance, lack of coordination, etc.). The examination reports as a whole do not indicate whether the Veteran was on any pain medications at the time of the examinations themselves, but in any case, it is clear the examiners already provided opinions estimating range of motion findings discounting any potential ameliorating effects of medication. As such, the Board finds the examination reports and the remainder of the evidentiary record form an adequate basis for a decision, resolving all reasonable doubt in the Veteran's favor.

In short, the Board finds that the criteria for entitlement to an initial rating in excess of 10 percent for psoriatic arthritis with back pain have not been met.

6. Entitlement to an initial rating in excess of 10 percent for right heel psoriatic arthritis is denied.

The Veteran's right heel psoriatic arthritis is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5284. This diagnostic code applies to "Foot injuries, other." Under Diagnostic Code 5284, the criterion for a 10 percent rating is a moderate foot injury. The criterion for a 20 percent rating is a moderately severe foot injury. The criterion for a 30 percent rating, the maximum schedular rating under Diagnostic Code 5284, is a severe foot injury. Actual loss of use of the foot is rated at 40 percent.

The Veteran underwent a VA foot conditions examination in June 2021. The examiner noted that the Veteran's current symptoms were heel pain, achiness, and stiffness and that he uses Ibuprofen. He denied experiencing flare-ups. He reported functional loss in that "walking around []is harder and painful." He reported having "daily morning achiness and stiffness" and there was "Some tenderness to the heel." The examiner noted that the Veteran's symptoms were of mild severity. The examiner found that there was functional loss due to pain. There was no functional loss due to other factors, such as less movement than normal, more movement than normal, weakened movement, swelling, deformity, atrophy of disuse, instability of station, disturbance of locomotion, interference with sitting, interference with standing, fatigue, weakness, lack of endurance, or incoordination. The examiner noted that there was no additional functional loss during flare-ups or after repeated use over time. There was achiness and stiffness on weight-bearing and on rest/non-movement. The Veteran's right heel disability impacted his ability to perform occupational tasks in that "morning stiffness, achiness makes standing, walking hard."

Based on the above, the Board finds that the criteria for entitlement to a rating in excess of 10 percent are not met. The VA examiner determined that the Veteran has mild pain and achiness and stiffness in the morning that make walking and standing more difficult. There are no other factors that contribute to functional impairment. The Board finds that the type and degree of impairment is adequately contemplated under the 10 percent rating, which applies to moderate disability of the foot.

Caselaw requires the Board to take due consideration that the beneficial effects of medication are discounted unless such effects are otherwise contemplated in a particular diagnostic code. See Ingram v. Collins, 38 Vet. App. 130 (2025). In this case, the VA examiner noted and considered the Veteran's lay statements describing functional limitations when his pain and functional impairment are at its worst (e.g., during flare ups, on repetitive motion, due to lack of endurance, lack of coordination, etc.). The examination report as a whole does not indicate whether the Veteran was on any pain medications at the time of the examination itself, but in any case, it is clear the examiner already provided an opinion discounting any potential ameliorating effects of medication. As such, the Board finds the examination report and the remainder of the evidentiary record form an adequate basis for a decision, resolving all reasonable doubt in the Veteran's favor.

In short, the Board finds that the criteria for entitlement to an initial rating in excess of 10 percent for right heel psoriatic arthritis have not been met.

7. Effective September 2, 2016, entitlement to a TDIU due to service-connected PTSD with OCD is granted.

A total disability rating based upon individual unemployability due to service-connected disabilities is assigned when service-connected disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A TDIU may also be assigned based on a single disability.

A claim for a total compensation rating based upon individual unemployability, "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994).

In evaluating a veteran's employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19.

In the case at hand, the Veteran has been in receipt of a 70 percent rating for his PTSD with OCD since September 2, 2016.

The claims file contains individual unemployability statements from VA examiners. The June 2022 opinion, obtained in connection with a thyroid examination, found that the Veteran had no restrictions in job activities from his hypothyroidism. The July 2022 opinion, obtained in connection with a hearing loss and tinnitus examination, found that the Veteran had no restrictions in job activities from his bilateral hearing loss and tinnitus. No such opinion has been provided by a VA examiner in connection with the Veteran's PTSD with OCD.

Also of record is an October 2022 vocational assessment report from a private vocational rehabilitation consultant. Based on review of the record, the consultant provided the following opinions with respect to the Veteran's PTSD with OCD specifically:

In my vocational opinion, the symptoms and limitations associated with the Veteran's service-connected PTSD with OCD have at least as likely as not precluded him from meeting the vocational requirements of substantially gainful employment at any skill or physical demand level, as noted above, since September 2016 and continuing to the present.

He also stated the following:

[I]t is my vocational opinion that the symptoms outlined above from [the Veteran's] service-connected PTSD with OCD cause limitations in his ability to interact appropriately and effectively with others in the workplace which have at least as likely as not further contributed to his inability to secure and follow even unskilled sedentary employment since at least September 2016.

The
to the Veteran's PTSD with OCD specifically:

He also stated the following:

The Board finds this opinion to be highly probative, as it was authored by a vocational rehabilitation consultant who possesses the necessary education, training, or experience to provide competent evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and provides a highly detailed opinion that discusses the Veteran's pertinent symptoms and describes how these symptoms render the Veteran unemployable.

In short, the Board finds that, from September 2, 2016, the criteria for entitlement to a TDIU due solely to the Veteran's service-connected PTSD with OCD have been met. The benefit sought on appeal is granted.

8. Entitlement to an effective date of September 2, 2016, for DEA benefits under 38 U.S.C. Chapter 35 based on permanent and total disability status is granted.

The June 2023 rating decision had granted entitlement to DEA benefits effective April 19, 2023. This benefit had been awarded effective from the date that the Veteran was found to have a permanent total service-connected disability. 38 U.S.C. §§ 3501, 3510; 38 C.F.R. §§ 3.807(a), 21.3021. He contends that an earlier effective date is warranted.

As noted above, the Board has granted entitlement to a TDIU based on the service-connected PTSD with OCD effective September 2, 2016. Thus, effective September 2, 2016, the Veteran is eligible for DEA benefits based on the presence of a permanent and total service-connected disability.

Based on the above, entitlement to an effective date of September 2, 2016, but no earlier is warranted for the Veteran's DEA benefits. The benefit sought on appeal is granted.

9. Effective March 5, 2020, entitlement to SMC at the housebound rate is granted.

VA has a well-established duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008).

Additional compensation will be warranted on the basis of being housebound where the veteran (1) has, in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently rated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems (known as statutory housebound), or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i).

One is permanently housebound when substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.351(d).

A TDIU may meet the requirement of a disability rated at 100 percent disabling for purposes of 38 U.S.C. § 1114(s), for entitlement to SMC at the housebound rate, if the TDIU is based on a single condition. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008).

In the case at hand, the Board has, above, granted entitlement to a TDIU based on a single disability (PTSD with OCD) effective September 2, 2016. This satisfies the requirement that the Veteran have a single disability rated at 100 percent disabling.

Effective March 5, 2020
3.351(d).

Effective March 5, 2020, the Veteran has disabilities independently rated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involve different anatomical segments or bodily systems. Specifically, in the above decision, the Board has granted an increased, 60 percent rating for the Veteran's psoriasis effective March 5, 2020. Therefore, effective March 5, 2020, the criteria for entitlement to SMC at the housebound rate are met.

Prior to that date, effective September 2, 2016, the Veteran had been assigned a 10 percent rating for tinnitus, a 10 percent rating for hypothyroidism, and a 0 percent rating for bilateral hearing loss. These ratings do not combine to produce a 60 percent rating. Therefore, entitlement to SMC at the housebound rate is not warranted prior to March 5, 2020.

TANYA SMITH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Elizabeth Jalley, 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.

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