Source: https://va-claim.com/2018/01/19/peripheral-neuropathy-of-the-right-lower-extremity-peripheral-neuropathy-of-the-left-lower-extremity-and-compensable-rating-for-bilateral-tinea-pedis-denied-citation-nr-1754157/
Timestamp: 2019-04-20 18:55:02+00:00

Document:
1.  Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to bilateral tinea pedis.
2.  Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to bilateral tinea pedis.
3.  Entitlement to a compensable rating for bilateral tinea pedis.
The Veteran had active service from September 1973 to March 1974.
These matters are before the Board of Veterans' Appeals (Board) on appeal of a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas.
In August 2014, the Veteran testified at a hearing before the undersigned Veterans Law Judge.  A transcript of the hearing is associated with the record.
The Board remanded this case in October 2015.
This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017).  38 U.S.C. § 7107(a)(2) (2012).
1.  The evidence does not show that the Veteran's peripheral neuropathy of the right lower extremity had its onset during his active service, is otherwise etiologically related to his active service, or was proximately due to, caused by, or aggravated by his service-connected bilateral tinea pedis.
2.  The evidence does not show that the Veteran's peripheral neuropathy of the left lower extremity had its onset during his active service, is otherwise etiologically related to his active service, or was proximately due to, caused by, or aggravated by his service-connected bilateral tinea pedis.
3.  Throughout the entire rating period, the Veteran's bilateral tinea pedis has covered less than 5 percent of the entire body affected and less than 5 percent of exposed areas, and has not required the use of systemic therapy such as corticosteroids or other immunosuppressive drugs.
1.  The criteria for entitlement to service connection for peripheral neuropathy of the right lower extremity have not been met.  38 U.S.C. §§ 1110, 5103, 5107A (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017).
2.  The criteria for entitlement to service connection for peripheral neuropathy of the left lower extremity have not been met.  38 U.S.C. §§ 1110, 5103, 5107A (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017).
3.  The criteria for entitlement to a compensable rating for bilateral tinea pedis have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7813 (2017).
Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.159, 3.326 (2017); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).
VA's duty to notify was satisfied by a letter dated in December 2011.  See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).
VA has also satisfied its duty to assist the Veteran.  The Veteran's service treatment records and VA treatment records have been associated with the record, as have lay statements from the Veteran.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159.
The record indicates that the Veteran was granted Social Security Administration disability benefits at some point.  The RO contacted the Social Security Administration to obtain records associated with the Veteran's claim for those benefits.  However, in November 2015, the Social Security Administration informed VA that the medical records associated with the Veteran's claim for Social Security Administration disability benefits have been destroyed and are no longer available.  Later in November 2015, the RO informed the Veteran of the Social Security Administration's response, and informed him that he may submit any records he had in his possession.  Accordingly, VA has satisfied its duty to assist in obtaining the Veteran's Social Security Administration disability records.  See 38 C.F.R. § 3.159(c)(2).
The Board notes that, although the Veteran's full Social Security Administration records are not available, a Social Security Administration Administrative Law Judge's decision dated in January 1990 is of record and shows that the Veteran was found disabled for Social Security Administration purposes from August 26, 1988, based on nonservice-connected psychiatric and physical conditions.  Therefore, based on that decision, it appears that the Veteran's Social Security Administration records are likely not relevant to the issues on appeal.
The duty to assist also includes the provision of a VA examination when necessary to decide a claim.  38 C.F.R. § 3.159(c)(4).  In this case, the Veteran was provided VA examinations as to his claim for entitlement to service connection for peripheral neuropathy of the bilateral lower extremities in January 2012 and November 2015.  The examiners who conducted those examinations reviewed the record, considered the Veteran's reported symptomatology and medical history, and addressed the likely etiology of the Veteran's peripheral neuropathy of the bilateral lower extremities, providing supporting explanation and rationale for all conclusions.  The explanations and rationale give insight into the medical aspects of the Veteran's condition and its likely etiology.  The examinations were thorough, and the opinions provided serve as a sufficient basis for a decision on those issues.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444 (2000).  Therefore, the Board finds the examinations to be adequate for decision-making purposes.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).
The Veteran was also provided VA examinations as to his claim for a compensable rating for bilateral tinea pedis in January 2012 and November 2015.  The examiners considered the Veteran's reported symptomatology and provided the medical information necessary to address the rating criteria in this case.  See generally Nieves-Rodriguez, 22 Vet. App. 295.  Therefore, the Board finds the examinations to be adequate for decision-making purposes.  See Barr, 21 Vet. App. at 312.
The Veteran has not alleged, nor does the record show, that his bilateral tinea pedis has increased in severity since the November 2015 VA examination.  See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time is not a basis for requiring a new examination).  Rather, the Veteran contends only that a higher disability rating is warranted.  See, e.g., Appellant's Post-Remand Brief dated in October 2017.  As such, the Board finds that the examinations of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary.
There is no indication in the record that any additional evidence, relevant to the claim adjudicated in this decision, is available and not part of the record.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless.  See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009).
As noted in the Introduction, the Board remanded this case in October 2015.  The October 2015 Board remand directed the Agency of Original Jurisdiction (AOJ) to contact the Social Security Administration to obtain any records associated with the Veteran's claim for benefits; schedule the Veteran for a VA examination to determine the nature, extent, and severity of his service-connected bilateral tinea pedis; schedule the Veteran for a VA examination to determine the nature and likely etiology of his peripheral neuropathy of the lower extremities; and then readjudicate the claim and issue a supplemental statement of the case, if warranted.  Pursuant to the October 2015 Board remand, the AOJ made appropriate efforts to obtain any relevant Social Security Administration records, as explained above; provided the Veteran with VA examinations in November 2015 that were responsive to and consistent with the October 2015 remand directives; and readjudicated the appeal in a December 2015 supplemental statement of the case.  Accordingly, the Board finds that VA at least substantially complied with the October 2015 Board remand.  See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008).
Also as noted in the Introduction, the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) in August 2014.  At the hearing, the VLJ asked the Veteran specific questions concerning the symptoms of and treatment for his peripheral neuropathy of the bilateral lower extremities and bilateral tinea pedis.  In addition, the VLJ solicited information as to the existence of any outstanding evidence.  No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or his representative.  See Bryant v. Shinseki, 23 Vet. App. 488 (2010).  Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing.  See Scott, 789 F.3d 1375; Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016).
The Veteran contends that he has a peripheral nerve disability that is caused or aggravated by his service-connected bilateral tinea pedis.  Generally, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017).  To establish service connection for a disability, the Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred in or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).
A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  38 C.F.R. § 3.310(a).  Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service connected.  38 C.F.R. § 3.310(b).
Turning to the relevant evidence of record, the Veteran's VA treatment records include a May 2011 EMG consultation note.  The note indicates that NCS/EMG testing revealed electrodiagnostic evidence of peripheral neuropathy of the bilateral lower extremities with possible causes including diabetes, toxic exposures, nutritional deficiencies, and endocrine-associated polyneuropathy.  Accordingly, there is competent evidence of a current disability of peripheral neuropathy of the bilateral lower extremities.
A review of the service treatment records reveals that the Veteran was treated for various other conditions, to include pseudofolliculitis barbae, an upper respiratory infection, and a twisted foot.  However, they do not show treatment for or diagnosis of peripheral neuropathy or any other neurological disability of the lower extremities.  As such, there is no competent evidence of record showing that the Veteran was diagnosed with peripheral neuropathy or any other neurological disability during his active service, and there is no basis in the record for concluding that the Veteran's current peripheral neuropathy of the bilateral lower extremities had its onset during his active service or is otherwise directly related to his active service.
As to the Veteran's contentions that his peripheral neuropathy of the bilateral lower extremities is caused or aggravated by his service-connected bilateral tinea pedis, he is considered competent to describe his symptoms, such as itching and burning at the site of his tinea pedis and pain and numbness from his peripheral neuropathy.  See Layno v. Brown, 6 Vet. App. 465, 469 (1994).  However, he is not considered competent to render opinions on complex medical issues such as the etiology of his peripheral neuropathy, as doing so requires specialized medical knowledge and expertise he has not been shown to possess.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  Therefore, his statements are not probative in showing that his current peripheral neuropathy of the bilateral lower extremities is caused by or aggravated his service-connected bilateral tinea pedis.  To determine whether such a relationship exists, the Board instead turns to the competent opinion medical evidence of record, which in this cases consists of the January 2012 and November 2015 VA examiners' opinions.
The January 2012 VA examiner reviewed the record and diagnosed the Veteran with peripheral neuropathy of the bilateral lower extremities.  She opined that it is not at least as likely as not that the Veteran's peripheral neuropathy of the lower extremities is proximately due to or the result of his service-connected tinea pedis.  As a rationale for that opinion, she explained that tinea pedis is a skin disorder that is not known to cause peripheral neuropathy.  Tinea pedis is a localized skin infection involving only the feet.  The Veteran has peripheral neuropathy of unknown etiology.  He does have dry skin that can cause itching.
The November 2015 VA examiner reviewed the record and noted the Veteran's reports of itching and burning from his service-connected tinea pedis since his active service.  She also noted the Veteran's reports of decreased sensation beginning in 1975, which started in his toes and now affects the feet and legs.  The examiner opined that it is not at least as likely as not that the Veteran's peripheral neuropathy of the lower extremities was caused or aggravated by his service-connected skin condition.  As a rationale for that opinion, the examiner explained that the Veteran's bilateral tinea pedis is a superficial fungal infection of the skin of the feet.  According to UpToDate, "Tinea infections are common causes of localized pruritus".  Frequently, patients describe itching and burning sensation concurrently when describing athlete's foot.  In addition, peripheral neuropathy is a "peripheral problem occurring somewhere along the length of the nerve between the nerve root and the most distal fibers".  The Veteran's May 2011 EMG indicates that the Veteran has a symmetric, distal-predominant, sensorimotor peripheral polyneuropathy of the lower leg and foot muscles.  The May 2011 treatment note lists as possible causes of the peripheral neuropathy as diabetes mellitus, toxic exposures, nutritional deficiencies, and endocrine-associated polyneuropathy.  It does not list as a potential cause the Veteran's tinea pedis or any other skin infection.
The Board affords probative weight to the VA examiners' opinions.  The examiners based their opinions on an accurate understanding of the Veteran's medical history and their own medical knowledge and expertise with citation to relevant medical authorities.  The Board interprets the opinions as indicating that the Veteran's tinea pedis is a skin-level infection of the feet, whereas his peripheral neuropathy affects the nerve itself.  As such, the Veteran's tinea pedis does not cause or aggravate his peripheral neuropathy of the bilateral lower extremities.  Furthermore, the May 2011 treatment note in which the Veteran's peripheral neuropathy was diagnosed lists nonservice-connected conditions as the possible causes of the peripheral neuropathy, and does not list the Veteran's tinea pedis as a possible cause.  The Board therefore accepts the VA examiners' opinions as probative evidence that it is not at least as likely as not that the Veteran's peripheral neuropathy of the right lower extremity was proximately due to, caused by, or aggravated by his service-connected bilateral tinea pedis.
In summary, the probative evidence of record does not show that it is at least as likely as not that the Veteran's peripheral neuropathy of the bilateral lower extremities had its onset during his active service, is otherwise etiologically related to his active service, or was proximately due to, caused by, or aggravated by his service-connected bilateral tinea pedis.  In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for peripheral neuropathy of the right lower extremity and the left lower extremity.  Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied.  38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
The Veteran seeks entitlement to a compensable rating for bilateral tinea pedis.  He has contended that he is entitled to a 30 percent rating.  See Correspondence received in December 2012.  He testified at the August 2014 Board hearing that the condition is manifested by burning, itching, and dry skin.  He treats the condition using topical creams and Epsom salt.
Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases.  38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002).
When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant.  38 C.F.R. § 4.3.  Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.
The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings.  Hart v. Mansfield, 21 Vet. App. 505, 519 (2007).
The Veteran's increased rating claim was received on July 5, 2011.  Therefore, the relevant rating period is from July 5, 2010, one year prior to receipt of the claim, through the present.  See 38 C.F.R. § 3.400(o)(2).  The Veteran's bilateral tinea pedis is currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7813.
Diagnostic Code 7813 instructs the rater to rate the disability as disfigurement of the head, face, or neck (Diagnostic Code 7800); scars (Diagnostic Codes  7801, 7802, 7803, 7804, or 7805); or dermatitis (Diagnostic Code 7806), depending on the predominant disability.  The medical evidence of record does not show that the Veteran's tinea pedis has resulted in scars or disfigurement of the head, face, neck, or elsewhere on the body.  Therefore, the Board finds that the disability is most appropriately rated under Diagnostic Code 7806, relating to dermatitis or eczema.
Under Diagnostic Code 7806, a noncompensable rating is assigned for involvement of less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period.  A 10 percent rating is assigned for involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period.  A 30 percent rating is assigned for involvement of 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas; or, when systemic therapy such as with corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period.  A maximum 60 percent rating is assigned for involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, when constant or near-constant systemic therapy such as with corticosteroids or other immunosuppressive drugs was required during the past 12-month period.
Diagnostic Code 7806 draws a clear distinction between systemic therapy and topical therapy as its operative terms.  "Systemic therapy" means treatment pertaining to or affecting the body as a whole, whereas "topical therapy" means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.  Although a topical corticosteroid treatment may meet the definition of systemic therapy if it is administered on a large enough scale such that it affects the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy.  See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017).
Turning to the relevant evidence of record, the VA treatment records show that, during the relevant rating period, the Veteran was prescribed magnesium sulfate crystals for foot soaks and clotrimazole cream, triamcinolone acetonide cream, and Betamethasone steroid cream for his tinea pedis, and that the creams were to be applied directly to the affected areas.  A note dated in April 2011 indicates that the Veteran's pes planus and a plantar wart, and not this tinea pedis, were the cause of reported foot pain.  The tinea pedis was associated with scaling, drying, and itching.  The condition covered none of the exposed area and 5 percent of the total body area.  It did not cause disfigurement or scarring.  A July 2011 podiatry note indicates that the option of Lamisil pills was also discussed with the Veteran, but that the Veteran declined and indicated that he wished only to use topical creams.
The January 2012 VA examiner indicated that the Veteran's bilateral tinea pedis requires constant or near constant use of topical antifungal medications.  In addition, the Veteran did not have any debilitating episodes in the prior 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis.  On examination, the Veteran's condition affected none of the exposed areas and less than 5 percent of the total body area.  The examiner noted that the Veteran had dry skin on the lower legs and that the dry skin can cause itching.  She opined that the Veteran's service-connected skin condition does not impact his ability to work.
At the November 2015 VA examination, the Veteran reported that he has constant itching and burning due to the tinea pedis, mainly on the tops of his feet.  The condition is worse in the summer.  During the summer, he gets blisters that cause a burning sensation and are itchy.  When he scratches the blisters, they break and he has to use a cream.  He further reported that he treats the tinea pedis with over-the-counter cortisone 10, which he applies daily after his shower.   The November 2015 VA examiner indicated that the Veteran's bilateral tinea pedis requires constant or near-constant use of topical corticosteroids.  In addition, the Veteran did not have any debilitating or non-debilitating episodes in the prior 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis.  The Veteran's condition affected none of the exposed areas and less than 5 percent of the total body area.  The Veteran had dry scaling skin on the bilateral feet and heels in a moccasin distribution.  He had dry discolored maceration between all toes on the right and between toes 2 and 3, 3 and 4, and 4 and 5 on the left.  She opined that the Veteran's service-connected skin condition does not impact his ability to work.
Accordingly, the treatment records and VA examinations reflect that, throughout the relevant rating period, the Veteran's bilateral tinea pedis has covered less than 5 percent of the entire body affected and less than 5 percent of exposed areas, and has not required the use of systemic therapy such as corticosteroids or other immunosuppressive drugs.  The evidence indicates that the Veteran's topical antifungal and corticosteroid medications were to be applied directly to the affected areas on his feet.  As such, there is no indication that those topical medications were administered on a large enough scale such that they affected the body as a whole and could be considered systemic in nature.  See Johnson, 862 F.3d 1351.  Therefore, the treatment records and VA examinations do not show that the criteria for a compensable rating were met under Diagnostic Code 7806 at any time during the relevant rating period.
The Board acknowledges the Veteran's assertions that a rating of 30 percent is warranted for his bilateral tinea pedis.  In support of that argument, the Veteran has submitted a Board decision that is dated in 2000 and relates to a different Veteran, as well as copies of regulations.  Each decision by the Board is necessarily based on review of the evidence of record in a particular record and has no precedential value toward adjudication of appeals by other claimants, even those who may appear to be similarly situated.  See 38 C.F.R. § 20.1303.  Therefore, the prior Board decision submitted by the Veteran has no precedential value in this case.  Moreover, the Board decision and the copies of the regulations submitted by the Veteran both refer to rating criteria that were in effect prior to October 30, 2002.  Because the Veteran's claim was received in July 2011, the prior version of the rating criteria in effect prior to October 20, 2002, is not for application in this case.  Under the current criteria for rating the Veteran's bilateral tinea pedis, a 30 percent rating is assigned when there is involvement of 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas; or, when systemic therapy such as with corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period.  As discussed above, the medical evidence of record simply does not show that the criteria for a 30 percent rating were met at any time during the relevant rating period.
Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected bilateral tinea pedis, nor have any other such issues been reasonably raised by the record.  See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017).
The Board therefore finds that the criteria for a compensable rating for the Veteran's bilateral tinea pedis have not been met at any time during the rating period.  Accordingly, there is no basis for staged rating of the Veteran's bilateral tinea pedis pursuant to Hart, 21 Vet. App. at 519.  As the preponderance of the evidence is against the assignment of a compensable rating, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49.
Entitlement to service connection for peripheral neuropathy of the right lower extremity is denied.
Entitlement to service connection for peripheral neuropathy of the left lower extremity is denied.
Entitlement for a compensable rating for bilateral tinea pedis is denied.

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