DERMATOPHYTOSIS OF THE NAILS, TINEA UNGUIUM (ONYCHOMYCOSIS)

Summary

The Veteran, an Air Force Veteran who served honorably from January 1997 to June 2001, appeals the denial of a compensable rating for his service-connected bilateral onychomycosis of the toenails, specifically from April 6, 2019, forward. The Veteran contended that a 10 percent rating was warranted due to pain, or alternatively, that a rating by analogy under DC 5284 (other foot injuries) or an extraschedular rating was appropriate. The Board reviewed the evidence, including VA examinations from April 2018 and April 2020, and the Veteran's treatment records. The April 2018 VA examination noted thickened, discolored toenails and painful motion but did not provide a percentage. A subsequent April 2020 opinion estimated the body surface area affected by the onychomycosis to be 1%, which is less than the 5% threshold for a compensable rating. The Board found that the Veteran's onychomycosis did not meet the criteria for a compensable rating under the General Rating Formula for the Skin (DC 7813-7806), as it did not involve the required percentage of body surface area or necessitate intermittent systemic therapy for the relevant period. The Board also determined that rating by analogy to foot injury codes was inappropriate because onychomycosis is specifically listed under skin diagnostic codes. Furthermore, the Board found that the Veteran's claim for an extraschedular rating failed the second prong of the Thun test, as the evidence did not demonstrate marked interference with employment or frequent hospitalizations due to the condition, particularly since the Veteran remained employed throughout the appeal period and chose to discontinue systemic treatment. Consequently, the Board denied entitlement to a compensable rating for the bilateral onychomycosis of the toenails.

Rationale

Did not meet criteria for compensable rating under DC 7813-7806.; Rating by analogy to foot codes inappropriate as onychomycosis is a skin condition.; Extraschedular consideration failed second Thun element (marked interference with employment/hospitalizations).

Full Decision Text

Citation Nr: A26040400
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 210427-155490
DATE: April 29, 2026

ORDER

Entitlement to a compensable evaluation from April 6, 2019 for service-connected bilateral onychomycosis of the toenails is denied.

FINDINGS OF FACT

1. The persuasive evidence of record is against a finding that the Veteran's service-connected bilateral onychomycosis of the toenails more closely approximates characteristic lesions involving at least five percent but less than 20 percent of the entire body affected, exposed areas, or requires 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.  

2. The persuasive evidence of record is against a finding that the Veteran's service-connected bilateral onychomycosis of the toenails warrants either an extraschedular rating or a rating by analogy.

CONCLUSION OF LAW

The criteria for entitlement to a compensable rating from April 6, 2019 for service-connected bilateral onychomycosis of the toenails have not been met.  38 U.S.C. §§ 503, 1155, 5107, 7104; 38 C.F.R. §§ 3.102, 3.104, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.20, 4.21, 4.40, 4.59, 4.71a, DC 7813-7806.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served honorably on active duty in the United States Air Force from January 1997 to June 2001.  His awards and decorations include the Humanitarian Service Medal and the Air Force Good Conduct Medal, among others.

Evidentiary Window

The rating decision on appeal was issued in April 2020; therefore, the modernized review system, known as the Appeals Modernization Act (AMA), applies.  In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket before a Veterans Law Judge.  A Board hearing was held in November 2024 with the undersigned Veterans Law Judge.  A transcript is of record.  Under the hearing docket, the Board is authorized to review the evidence considered by the Agency of Original Jurisdiction (AOJ) at the time of the April 2020 rating decision on appeal as well as evidence submitted at the Board hearing and within 90 days of the Board hearing which is until February 5, 2025.  38 C.F.R. § 20.302(a).

Evidence provided during the hearing evidence submission window must be relevant to the period on appeal identified above.  Evidence submitted either 1) during the period after the AOJ issued the April 2020 rating decision on appeal and prior to the date the Board received the VA Form 10182 or 2) more than 90 days following the Board hearing was not considered by the Board in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran wishes to have the Board consider evidence submitted outside of the review window, a supplemental claim should be submitted identifying such evidence.  Cook v. McDonough, 36 Vet. App. 175 (2023); 38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.

As a final initial matter, the Board notes that during the November 2024 Board hearing, the Veteran and his attorney specifically indicated that they were not appealing the assigned 30 percent rating from April 6, 2018 to April 5, 2019.  However, both indicated that a compensable rating from April 6, 2019 was on appeal.  See Hearing Tr. at 13.  Based on this explicit indication from both the Veteran and his attorney, the Board will limit its review of the appeal window to a compensable rating for service-connected bilateral onychomycosis of the toenails from April 6, 2019.

Entitlement to a compensable evaluation from April 6, 
.

As a final initial matter, the Board notes that during the November 2024 Board hearing, the Veteran and his attorney specifically indicated that they were not appealing the assigned 30 percent rating from April 6, 2018 to April 5, 2019.  However, both indicated that a compensable rating from April 6, 2019 was on appeal.  See Hearing Tr. at 13.  Based on this explicit indication from both the Veteran and his attorney, the Board will limit its review of the appeal window to a compensable rating for service-connected bilateral onychomycosis of the toenails from April 6, 2019.

Entitlement to a compensable evaluation from April 6, 2019 for service-connected bilateral onychomycosis of the toenails is denied.

The Veteran and his attorney contend that the Veteran is entitled to a compensable rating for his bilateral onychomycosis of the toenails.  Specifically, they contend that a 10 percent rating is warranted due to the Veteran's pain.  In the alternative, they contend that a compensable rating under DC 5284 (other foot injuries), rating by analogy, is warranted.  See Hearing Tr. at 13.

Legal Principles

Increased Evaluations

Disability evaluations are determined by comparing a Veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran.  38 C.F.R. § 4.3.

In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability.  38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991).

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 for that rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances.  38 C.F.R. § 4.21.

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern.  Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation under 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings.  Francisco v. Brown, 7 Vet. App. 55 (1994).  In deciding this appeal, the Board will consider whether separate ratings for different periods of time based on the facts found within the record is warranted.  This is a practice of assigning ratings referred to as "staged" ratings.  Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008).

In making all determinations, the Board must fully consider the lay assertions of record.  A layperson is competent to report on the onset and continuity of his current symptomatology.  Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007
 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1376-77.

Analogous Ratings

When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings.  Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin.  38 C.F.R. § 4.20.

The United States Court of Appeals for Veterans Claims has held that it is not appropriate to rate by analogy a disability that is listed in the rating schedule.  Disabilities specifically listed in the rating schedule may be rated only under the diagnostic codes that specifically pertain to them.  Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015).

Foot disabilities are generally evaluated pursuant to Diagnostic Codes 5276 (acquired flatfoot), 5277 (bilateral weak foot), 5278 (acquired claw foot or pes cavus), 5279 (anterior metatarsalgia or Morton's disease), 5280 (unilateral hallux valgus), 5281 (unilateral hallux rigidus), 5282 (hammer toe), 5283 (malunion or nonunion of tarsal or metatarsal bones), and 5284 (other foot injuries).  38 C.F.R. § 4.71a, Diagnostic Codes 5276-5284.  If a Veteran has been granted service connection for a disability other than those listed in Diagnostic Code 5276-5283, he or she may be rated by analogy to an appropriate diagnostic code.  Yancey v. McDonald, 27 Vet. App. 484 (2016).  An unlisted disability may also be rated by analogy to Diagnostic Code 5284 (other foot injuries) even if the unlisted disability is a degenerative condition that does not meet the plain language definition of an "injury."  Scott v. Wilkie, 920 F.3d 1375 (2019).

Pyramiding, or the evaluation of one manifestation under different diagnoses, is to be avoided.  38 C.F.R. § 4.14.  The rating schedule may not be used to compensate a claimant twice or more for the same symptomology.  Esteban v. Brown, 6 Vet. App. 259, 261 (1994), citing Brady v. Brown, 4 Vet. App. 203 (1993).

Extraschedular Consideration

Consideration of an extraschedular rating requires a three-step inquiry.  Thun v. Peake, 22 Vet. App. 111 (2008).  The threshold factor for extraschedular consideration is a finding on the part of the AOJ or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1). 

Initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability.  If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no extraschedular consideration is required. VAOGCPREC 6-96 (Aug. 16, 1996); Thun, supra
 schedular ratings for the service-connected disability at issue are inadequate. Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1). 

Initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability.  If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no extraschedular consideration is required. VAOGCPREC 6-96 (Aug. 16, 1996); Thun, supra.

If the rating schedule does not contemplate the claimant's level of disability and

symptomatology, and is found inadequate, the RO or Board must determine

whether the claimant's exceptional disability picture exhibits other related factors

such as those provided by the regulation as "governing norms" (including marked

interference with employment and frequent periods of hospitalization). See 38

C.F.R. § 3.321(b)(1).  

The first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms.  Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses.  Yancy v. McDonald, 27 Vet. App. 484, 495 (2016).  If the Veteran's disability picture meets the second inquiry, then the third step traditionally requires referring the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted.  Thun, 22 Vet. App. 111.  However, the Board may now award a benefit on an extraschedular basis in the first instance without first receiving a decision from the Director of Compensation Service.  Witkowski v. Collins, 38 Vet. App. 459 (2025).

Notably, the application of the first Thun step is not a mere "mechanical test," and as such it is not automatically satisfied because a certain symptom or functional effect is not expressly listed under a diagnostic code; "[it] is satisfied only when a veteran presents symptoms that are truly unusual or exceptional."  Long v. Wilkie, 33 Vet. App. 167, 173 (2020).  Further, Thun's first step is a broad analysis focusing on whether the Veteran's disability picture as a whole (i.e., the full symptomatology) presents an impairment so exceptional that the rating schedule is not capable of assessing it in the first instance.  Id.

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3.  When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  The benefit of the doubt rule does not apply when the evidence persuasively favors one side or the other.  Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021).

Rating criteria

The Veteran's bilateral onychomycosis of the toenails is rated under Diagnostic Codes (DC) 7813-7806.  38 C.F.R. § 4.118; see April 2020 Codesheet.  Both DC 7813 and 7806 fall under the General Rating Formula for the Skin which applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824.  38 C.F.R. § 4.118.  

The General Rating Formula for the Skin provides that a non-compensable 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 ultr
ensable 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 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.  38 C.F.R. § 4.118, General Rating Formula for the Skin.

As it pertains to DC 7806, 38 C.F.R. § 4.118(a), explicitly states that "systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin."

The Board notes that the General Rating Formula for the Skin is conjunctive meaning that requirements of the lower rating must be met before a greater rating can be assigned.  However, each individual rating is disjunctive meaning that only one of the criteria for each individual rating must be met in order for that specific rating to be assigned.  Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned); Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met).

Increased Rating

Initially, the Board notes that the Veteran was granted service connection in a January 2005 rating decision and assigned a non-compensable rating effective December 16, 2003.  In March 2018, the Veteran filed an increased rating claim for his bilateral onychomycosis.

In the April 2020 rating decision on appeal, the AOJ increased the Veteran's rating from non-compensable to 30 percent due to systemic therapy having been prescribed for 12 weeks.  The Board will treat this as a favorable finding that will not be disturbed.  38 C.F.R. § 3.104.

Following the March 2018 increased rating claim, the Veteran was provided with a VA skin examination in April 2018.  The examiner noted a continuing diagnosis of onychomycosis of the bilateral toenails.  The examiner did not indicate what percentage of the Veteran's body was affected by the onychomycosis.  However, the examiner did indicate that the Veteran's current diagnosis indicates a progression of the previous diagnosis resulting in painful toenails and that he is unable to cut his toenails as they have become elongated.

Following this April 2018 VA skin examination, the AOJ denied the Veteran's increased rating claim and the Veteran appealed (under the legacy appeals system).  As part of the appeal, the record does not indicate that the AOJ requested a clarification examination; however, a clarification opinion was received on April 8, 2020, prior to the issuance of the Statement of the Case (SOC).  See April 8, 2020 Medical Opinion.  This medical opinion was not provided by the same examiner as the April 2018 VA examination.  The examiner indicated that the "average person's top of the foot/toes makes up
 toenails and that he is unable to cut his toenails as they have become elongated.

Following this April 2018 VA skin examination, the AOJ denied the Veteran's increased rating claim and the Veteran appealed (under the legacy appeals system).  As part of the appeal, the record does not indicate that the AOJ requested a clarification examination; however, a clarification opinion was received on April 8, 2020, prior to the issuance of the Statement of the Case (SOC).  See April 8, 2020 Medical Opinion.  This medical opinion was not provided by the same examiner as the April 2018 VA examination.  The examiner indicated that the "average person's top of the foot/toes makes up 1.75% of the total surface area of the body.  Therefore, for the onychomycosis of all toenails - I would estimate this involves aprox 0.5% of body surface area of each foot for a total body surface area of 1%. Therefore, this is Less than 5% of the entire body."

The SOC and rating decision were both on April 9, 2020.  This rating decision awarded a staged rating resulting in a 30 percent rating, on a facts found basis, from April 6, 2018 to April 5, 2019, based on the Veteran receiving systemic therapy and applied that evaluation for a full year.  The AOJ then assigned a non-compensable rating from April 6, 2019, as the record indicated that the Veteran was no longer prescribed systemic therapy for the onychomycosis.  This finding has a basis in the record.

The Board notes that it has reviewed the Veteran's VA and private treatment records during the appeal period.  The Board notes that the Veteran was afforded a podiatry referral for thick toenails in March 2018.  See March 2018 CAPRI record.  An April 6, 2018 medical note indicates that the Veteran's toes presented as thickened, with yellow discoloration, disfigured, and dull with subungual debris.  Based on this finding, the Veteran started terbinafine tablet and urea cream treatment.  However, a May 8, 2018 medical note indicates that the Veteran stated, "I decided I'm not going to take the antibiotic medication for my toenails.  The fact that I need labs done and the possible side effects of this medication are not what I want in my body.  Please discontinue the antibiotics and will need to [cancel] all labs."  The record indicates that the Veteran's providers cancelled the treatment and all labs.  See March 2020 CAPRI record.  There is no further indication within the treatment records that the Veteran either requested or was prescribed an alternative medication.

The record implies that the AOJ found the Veteran's April 6, 2018 medical note as indicative of systemic therapy sufficient to warrant a 30 percent rating and extended that rating for one year.  However, as the record does not indicate that the Veteran continued with his treatment or was provided a different treatment for his onychomycosis, the AOJ found that the Veteran was no longer receiving systemic treatment such that the 30 percent rating for systemic therapy was warranted.  As such, a non-compensable rating was assigned.

There are no other private or VA examinations of record during the appeal period.

Based on the above, the Board finds that a compensable rating under DC 7813-7806 is not warranted.  The April 2018 VA examination, April 2020 medical opinion, and the facts found within the Veteran's treatment record indicate that the Veteran's onychomycosis did not involve characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body or exposed areas or resulting in 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 from April 6, 2019.

Rating by Analogy

The requirements for rating by analogy are discussed above.  Scott v. Wilkie,  920 F.3d 1375 (2019) is distinguishable from the present case.  In Scott, the Veteran was diagnosed with a foot disability of bilateral pes planus which was rated under DC 5276.  The diagnosis later changed to plantar fibromas with hallux valgus deformity.  The Board determined that the Veteran was not eligible for rating by analogy under DC 5284 because pes planus and hallux valgus were specifically listed in the rating schedule and, as such, the plantar fib
 the past 12-month period from April 6, 2019.

Rating by Analogy

The requirements for rating by analogy are discussed above.  Scott v. Wilkie,  920 F.3d 1375 (2019) is distinguishable from the present case.  In Scott, the Veteran was diagnosed with a foot disability of bilateral pes planus which was rated under DC 5276.  The diagnosis later changed to plantar fibromas with hallux valgus deformity.  The Board determined that the Veteran was not eligible for rating by analogy under DC 5284 because pes planus and hallux valgus were specifically listed in the rating schedule and, as such, the plantar fibromas diagnosis would constitute impermissible pyramiding if provided a rating under DC 5284.  On appeal, the Federal Circuit held that under Copeland and Yancy, the Board is obligated to consider analogous DCs, including DC 5284, when rating unlisted conditions, despite the presence of listed symptoms.

Here, the Board must note that the Veteran was not rated under the Diagnostic Codes applicable to the foot.  The Veteran was rated under the Diagnostic Codes applicable to the skin.  Further, the Veteran's disability of onychomycosis is specifically listed under DC 7813 as dermatophytosis of the nails, tinea unguium (onychomycosis).  As such, the Board cannot rate the Veteran's bilateral onychomycosis of the toenails by analogy under a separate diagnostic code for the foot, to include DC 5284.  Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015); Yancey v. McDonald, 27 Vet. App. 484 (2016).

Extraschedular Consideration

As noted above, the Veteran contends his bilateral onychomycosis toenail condition warrants a compensable rating based on his pain.  Since the Veteran's symptoms do not meet the compensable rating criteria for his condition and an analogous rating is not appropriate for the facts here, the Board liberally interprets this contention as a request for extraschedular consideration (although not TDIU given his employment throughout the appeal period).

Thun Analysis - First Element

The criteria for an extraschedular consideration are discussed above.  The first question in an extraschedular determination is whether the schedular rating criteria adequately contemplate the Veteran's disability picture.  Here, the Board notes that there is no discussion within the rating schedule that painful onychomycosis of the toes may warrant a compensable rating simply based on pain.  38 C.F.R. § 4.118(a)-(b).

"Functional impairment" is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment.  38 C.F.R. § 4.10.  However, "functional loss" is primarily the inability, due to damage or infection in parts of the bodily system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance.  It is essential that the examination on which ratings are based adequately portrays the Veteran's anatomical damage, and the functional loss, with respect to all these elements.  The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion.  38 C.F.R. § 4.40.  

Additionally, "painful motion" under 38 C.F.R. § 4.59 is based on painful motion, pressure, or manipulation of affected joints.  "It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.  Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased.  Flexion elicits such manifestations.  The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint."  Id.

The Board finds that functional impairment, functional loss, and painful motion  apply specifically to bones, joints, muscles, structures, deformities, adhesions, or defective innervations.  There is no indication within the record that bilateral onychomycosis toenail pain falls under one of these categories of functional loss
pitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased.  Flexion elicits such manifestations.  The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint."  Id.

The Board finds that functional impairment, functional loss, and painful motion  apply specifically to bones, joints, muscles, structures, deformities, adhesions, or defective innervations.  There is no indication within the record that bilateral onychomycosis toenail pain falls under one of these categories of functional loss, functional impairment, or painful motion of a joint.  While the Board understands that the Veteran's bilateral onychomycosis toenail causes pain in daily activities, the Board cannot find that such pain is the result of pain within the joints of the toes.  As such, the Board finds that the General Rating Schedule for the skin does not adequately contemplate the Veteran's bilateral onychomycosis toenail pain.

Thun Analysis - Second Element

As the first prong under Thun has been met, the Board then turns to the second prong regarding whether there is an exceptional disability picture that includes other related factors, such as marked interference with employment and frequent periods of hospitalization.

The Board notes that the word "marked" is not defined in the VA rating schedule.  Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018).  Accordingly, the VA must evaluate and consider all evidence of record and not apply a mechanical formula.  Although the use of similar terminology by medical professionals must be considered, it is not dispositive.  Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating.  38 C.F.R. §§ 4.2, 4.6.  The Board has considered the Merriam-Webster definition of terms and notes that "marked" means distinctive or emphasized character.  See https://www.merriam-webster.com/dictionary/marked, April 2026).

As noted above, the Board has reviewed the Veteran's VA and private treatment records.  The Veteran does not have a history of recurrent hospitalizations for his bilateral onychomycosis toenail pain and neither the Veteran nor his attorney have alleged a history of such.  Rather, the Veteran testified his career as a nurse requires 16-hour shifts, four days per week, and being constantly on his feet.  While the Veteran's testimony indicates that this results in pain daily, he has not indicated that his bilateral onychomycosis toenail pain has prevented or resulted in marked interference with his ability to work.  See Hearing Tr. at 5, 7-11.  The marked interference with employment is also undercut by the fact that the Veteran was employed during the entire appeal period.  This evidence is probative that the Veteran's bilateral onychomycosis toenail pain has not caused marked interference with employment.

Marked interference with employment is also not supported by the Veteran's medical record and his purposeful choice, while understandable, to decline the systemic treatment available for his condition (the prescribed antibiotic medication).  Despite desiring to not take such medication due to the possible impact to his kidneys, there is no indication anywhere in the record that the Veteran's decision results in the significant interference with his duties as a nurse due to the bilateral onychomycosis toenail pain, or that if he took the medication, he would have marked interference with his ability to function as a nurse.  

Based on the above, the persuasive weight of the evidence is against a finding that the second element of Thun is met, as the Veteran does not have the requisite exceptional disability picture, exhibiting other related factors such as marked interference with employment and frequent periods of hospitalization.

Therefore, while the first Thun element was met in this case, the second Thun element was not met as explained above.  The Court has stated regarding the Thun elements for extraschedular consideration that "[i]f either element is not met, then referral for extraschedular consideration is not appropriate."  Yancy v. McDonald, 27 Vet. App. 484 (2016).  As the second Thun element was not met in this case, extraschedular consideration is not warranted and there is no reasonable doubt to be resolved in the Veteran's favor.  38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.321.

Conclusion

The Board is sympathetic to the Veteran's assertions and grateful for his service, but the Board is bound and constrained by law, and its decision is dictated by
 regarding the Thun elements for extraschedular consideration that "[i]f either element is not met, then referral for extraschedular consideration is not appropriate."  Yancy v. McDonald, 27 Vet. App. 484 (2016).  As the second Thun element was not met in this case, extraschedular consideration is not warranted and there is no reasonable doubt to be resolved in the Veteran's favor.  38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.321.

Conclusion

The Board is sympathetic to the Veteran's assertions and grateful for his service, but the Board is bound and constrained by law, and its decision is dictated by the relevant statutes and regulations.  Moreover, the Board is without authority to grant benefits simply because it might perceive such a grant to be equitable.  38 U.S.C. §§ 503, 7104; Harvey v. Brown, 6 Vet. App. 416, 425 (1994).  "[N]o equities, no matter how compelling, can create a right to payment out of the United States Treasury that has not been provided for by Congress."  Smith v. Derwinski, 2 Vet. App. 429, 432-33 (1992).

Therefore, the Board concludes that the competent and probative evidence of record persuasively weighs against a finding that the Veteran's bilateral onychomycosis toenail symptomology warrants a compensable rating under DC 7813-7806.  Further, the Board concludes that the Veteran's bilateral onychomycosis-related toenail pain warrants neither rating by analogy under DC 5284, nor extraschedular consideration.  Accordingly, the appeal is denied.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

Colleen M. Glaser-Allen

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Daniel Stephens, Associate 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.