Citation Nr: 0207357 Decision Date: 07/08/02 Archive Date: 07/17/02 DOCKET NO. 97-20 026 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for acne, to include as due to herbicide exposure. 2. Entitlement to service connection for onychomycosis of the toenails, and for athlete's foot (claimed as fungus and red blotches on feet with stiffness of great toes). 3. Whether new and material evidence has been presented to reopen a claim for entitlement to service connection for a skin disorder of the hands and legs. 4. Entitlement to an increased (compensable) rating for bilateral hearing loss, for the period prior to October 12, 2000. 5. Entitlement to a rating in excess of 10 percent for bilateral hearing loss, for the period from October 12, 2000, to the present. 6. Entitlement to an increased rating for a lateral meniscus tear, left knee, post-operative, currently rated as 20 percent disabling. 7. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently rated as 70 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. H. Eskenazi, Counsel INTRODUCTION The veteran had active service from July 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from August 1996, March 1998, and January 1999 rating decisions of the St. Paul Regional Office and Insurance Center (RO), in St. Paul, Minnesota, of the Department of Veterans Affairs (VA), which denied the benefits sought on appeal. In regard to the PTSD issue, the Board notes that (as explained in greater detail in the decision below), the issue developed for appellate review is entitlement to an increased rating for PTSD, currently rated as 70 percent disabling. However, in a supplemental statement of the case (SSOC) dated in January 2001, as well as an SSOC dated in October 2001, the RO recharacterized the PTSD issue as: entitlement to an evaluation greater than 30 percent for PTSD earlier than May 18, 1995. That issue has not been developed by the RO, and is not presently on appeal. Nevertheless, the Board notes that the veteran's representative offered argument on that issue in a November 2001 statement, and an April 2002 Brief. To the extent that the veteran wishes to pursue an appeal in this regard, that matter is hereby referred back to the RO for appropriate action. The Board also notes that in a statement received in July 1998, the veteran requested "special medical devices for his home and vehicle." In another July 1998 statement the veteran requested a "prosthetic seat for driving and a comfort system bed for sleeping." Finally, in a December 1998 statement, the veteran inquired as to the status of his claims for a therapeutic seat for his truck and a bed. It does not appear that the RO adjudicated the foregoing claims. As such, the claims for automobile adaptive equipment and special adaptive housing are referred back to the RO for any appropriate action. FINDINGS OF FACT 1. The veteran was notified of the evidence needed to substantiate his claims, and all relevant evidence necessary for an equitable disposition of this appeal was obtained. 2. The veteran served in Vietnam during the Vietnam Era; his awards and decorations include the Purple Heart and the Combat Infantryman Badge. 3. Medical evidence indicates that the veteran has a current diagnosis of chloracne, which is causally related to Agent Orange exposure during active service. 4. The evidence does not show that any current onychomycosis of the toenails and/or athlete's foot is causally or etiologically related to an incident of active service. 5. In an unappealed October 1981 rating decision, the RO denied a claim for a skin rash on the hands and legs. 6. The evidence associated with the claims file subsequent to the October 1981 rating decision is so significant that it must be considered in order to fairly decide the merits of the veteran's claim for service connection for a skin disorder of the hands and legs. 7. The evidence does not show that any current skin disorder of the hands and legs is causally or etiologically related to an incident of the veteran's active service. 8. Prior to October 12, 2000, the veteran's hearing manifested no higher than Level II hearing impairment in the right ear, and no higher than Level II hearing impairment in the left ear. 9. Since October 12, 2000, the veteran's hearing is productive of Level IV hearing impairment in the right ear, and Level IV hearing impairment in the left ear. 10. The veteran's lateral meniscus tear, left knee, postoperative, is currently productive of some limited flexion and complaints of pain. 11. The veteran's PTSD is currently productive of severe symptomatology, manifested by frequent flashbacks, nightmares, and thoughts of Vietnam, as well as hypervigilance, startle response, depression, anger, irritability, suicidal thoughts, and impaired employability. CONCLUSIONS OF LAW 1. Acne (diagnosed as chloracne) was incurred during active military service. 38 U.S.C.A. §§ 1110, 1116, 1154(b), 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102 and 3.159); Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116); 38 C.F.R. §§ 3.303, 3.304(d), 3.307, 3.309 (2001). 2. Onychomycosis of the toenails, and athlete's foot (claimed as fungus and red blotches on feet with stiffness of great toes) was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1116, 1154(b), 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102 and 3.159); Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116); 38 C.F.R. §§ 3.303, 3.304(d), 3.307, 3.309 (2001). 3. The RO's October 1981 rating decision, which denied service connection for a skin rash on the hands and legs, is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. § 20.200 (2001). 4. New and material evidence has been presented to reopen a claim for entitlement to service connection for a skin disorder of the hands and legs. 38 U.S.C.A. §§ 5103, 5103A, 5108 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102 and 3.159); 38 C.F.R. § 3.156 (2001). 5. A skin disorder of the hands and legs was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1116, 1154(b), 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102 and 3.159); Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116); 38 C.F.R. §§ 3.303, 3.304(d), 3.307, 3.309 (2001). 6. The requirements for entitlement to an increased (compensable) rating for bilateral hearing loss, for the period prior to October 12, 2000, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.102, 3.159); 38 C.F.R. §§ 4.1-4.14, 4.85-4.87 (1998 & 2001). 7. The requirements for entitlement to a rating in excess of 10 percent for bilateral hearing loss, for the period from October 12, 2000 to the present, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.102, 3.159); 38 C.F.R. §§ 4.1-4.14, 4.85-4.87 (1998 & 2001). 8. The schedular criteria for a rating in excess of 20 percent for a lateral meniscus tear, left knee, postoperative, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102 and 3.159); 38 C.F.R. Part 4, including § 4.71a, Diagnostic Code 5257 (2001). 9. The criteria for a 100 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102, 3.159); 38 C.F.R. Part 4, including 38 C.F.R. § 4.130, Diagnostic Code 9411 (2001); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises out of various claims raised by the veteran. In summary, he requests service connection for several skin disorders, as well as increased ratings for his service-connected bilateral hearing loss, left knee disability, and PTSD. As a preliminary matter, the Board notes that on November 9, 2000, the Veterans Claims Assistance Act of 2000 was enacted. Pub. L. No. 106-475, 114 Stat. 2096 (2000); see 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2001). Among other things, the VCAA amended 38 U.S.C.A. § 5103 to clarify VA's duty to notify claimants and their representatives of any information that is necessary to substantiate the claim for benefits. The VCAA also created 38 U.S.C.A. § 5103A, which codifies VA's duty to assist, and essentially states that VA will make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim. Implementing regulations for the VCAA were subsequently enacted, which were also made effective November 9, 2000, for the most part. 66 Fed. Reg. 45,620, 45,630-32 (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.159). The intended effect of the implementing regulations was to establish clear guidelines consistent with the intent of Congress regarding the timing and scope of assistance VA will provide to claimants who file a claim for benefits. 66 Fed. Reg. 45,620 (Aug. 29, 2001). Both the VCAA statutes and the implementing regulations will be collectively referred to as "the VCAA." A review of the claims file reveals that the RO explicitly applied the VCAA, at least in some degree. Specifically, in a January 2001 letter, the RO notified the veteran of the new law, as pertains to his claims for service connection for acne/chloracne and onychomycosis of the toenails and athlete's foot. Although the veteran was not specifically notified of the VCAA in the context of his other claims on appeal, the Board finds that the requirements under VCAA have been satisfied, as explained below. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (when the Board addresses a matter not addressed by the RO, the Board must provide an adequate statement of reasons and bases as to why there is not prejudice to the appellant). In that regard, the veteran was notified of the reasons his claims were denied by various rating decisions, statements of the case (SOC) and supplemental statements of the case (SSOC). Additionally, the veteran was provided notice of the basic requirements for establishing his claims, as evidenced by letters from the RO in the claims file. Pertinent laws and regulations are set forth in the SOCs, including laws and regulations pertaining to service connection claims, new and material evidence claims, and increased rating claims. The veteran was offered opportunities to present testimony in his appeal at a hearing, but he declined that opportunity. The record contains the veteran's service medical records, as well as post-service private treatment records and VA treatment records. The veteran has been afforded numerous VA examinations pertaining to all disabilities on appeal, and the Board does not find that any additional VA examinations or medical opinions are necessary in this case. The record also contains statements from the veteran, his wife, and acquaintances. The Board is not aware of any outstanding relevant evidence that should be obtained prior to proceeding with this appeal. In short, the Board finds that the duties to notify and assist the veteran were satisfied, and the case is ready for appellate review. See 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2001). I. Service Connection. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from an injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, in active military, naval, or air service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Generally, to qualify for service connection, the veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1360-61 (Fed. Cir. 2001). The mere fact of an in-service injury is not enough; there must be chronic disability resulting from that injury. If there is no evidence of a chronic condition during service, or an applicable presumption period, then a showing of continuity of symptomatology after service is required to support the claim. 38 C.F.R. § 3.303(b). Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-498 (1997). If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Id. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue in a service connection claim involves a medical diagnosis, competent medical evidence is required. This burden cannot be met by lay testimony because lay persons are not competent to offer medical opinions. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). In the case of any veteran who engaged in combat with the enemy in active service during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and to that end, shall resolve every reasonable doubt in favor of the veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In regard to claims for service connection as a result of Agent Orange exposure, the Board observes that there has been a recent change in the law pertaining to service connection for diseases associated with herbicide exposure in Vietnam. See Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116). The amendments made to 38 U.S.C.A. § 1116 are effective December 27, 2001, and are applicable to the present claim. Although the RO has not had an opportunity to consider the applicability of the amendments in this case, the Board finds that there is no prejudice in applying this law in the first instance. See Bernard, supra. In that regard, the amendments to the law are generally more favorable to claimants. The law provides that for claims involving exposure to an herbicide, such as Agent Orange, veterans who served on active military, naval, or air service in the Republic of Vietnam during the period beginning January 9, 1962, and ending on May 7, 1975 (known as the Vietnam era), shall be presumed to have been exposed to an herbicide agent during such service, unless there is affirmative evidence to the contrary. Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116(f)). Certain diseases specified by statute warrant a presumption of service connection by reason of having positive association with herbicide exposure, if the disease becomes manifest within a period prescribed by regulation. 38 U.S.C.A. § 1116(a)(1). The diseases subject to presumptive service connection are as follows: non-Hodgkin's lymphoma, soft tissue sarcoma, chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, porphyria cutanea tarda, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and multiple myeloma. 38 U.S.C.A. § 1116(a)(2) (West 1991 & Supp. 2001); Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116(a)(2)). For presumptive service connection, the foregoing diseases shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year from the date of service separation. 38 C.F.R. § 3.307(a)(6)(ii). Notwithstanding the foregoing discussion regarding presumptive service connection, which originated out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Public Law No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), and the Agent Orange Act of 1991, Public Law No. 102-4, § 2, 105 Stat. 11 (1991), the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). In other words, presumption is not the sole method for showing causation in establishing a claim for service connection as due to herbicide exposure. According to the veteran's DD Form 214, he served on active duty from July 1967 to July 1969, during the Vietnam Era. His specialty in service was light weapons infantry, and his awards and decorations include the Purple Heart and the Combat Infantryman Badge. A. Acne. The veteran claims that he has acne, or chloracne, as a result of his exposure to Agent Orange during active service in Vietnam. The veteran's service medical records consist of his service entrance examination report, and his service separation report. Those records are negative for any evidence of a skin disorder, such as acne or chloracne. In June 1981, the veteran submitted a statement in which he stated that when he was separated from service he had a rash between his legs, and on his hands. He stated that he neglected to take care of it because it went away, but had been on and off for the past 10 years. The veteran stated that during the past 6 months, he had been having problems with the fungus and rash. VA outpatient treatment records dated in February 1995 indicate that the veteran was seen with bumps on his face and a rash on his face, which he felt may be chloracne and fungus nail infections. The diagnosis was acne and fungus nail infection. A private medical record from Dr. Sandell, reveals that in May 1995 the veteran was diagnosed with urticaria. In June 1995, a Dr. Hoenig diagnosed him with stasis dermatitis. A statement from the veteran dated in April 1999 indicates that he was submitting photographs of his skin to demonstrate that he currently had acne, and that he had it during service. In September 1999, the veteran submitted photographs dated shortly prior to entry into service, during service, and following service. He indicated that he submitted the pictures to show the continuity of his skin disorder from 1969 to the present. Photographs dated in September 2000 show areas of the veteran's skin, including his back, arms, and legs. In a statement from the veteran dated in January 2001, he indicates that the photographs show pimples on his face and neck, as well as pimples and rash on his arms, legs, back, and other areas. In a September 2000 VA examination for skin, the veteran reported that he first noticed a rash in his groin and feet in 1968. He described the rash as pruritic, and stated that to this date the rash continues to intermittently itch. He stated that his skin rash was not formally evaluated while he was in the military. The diagnosis included tinea pedis, history of onychomycosis, urticaria, and probably chloracne involving lateral temples, lateral cheeks, and postauricular areas. In a September 2000 addendum to that examination, the examiner indicated that with respect to chloracne, the veteran reported a history of Agent Orange exposure, which may have caused the skin changes noted in the examination, which were described as consistent with chloracne. An undated private medical statement from Gerald K. Kvistberg, M.D., received at the RO in July 2001, indicates that physical examination revealed some erythematous papules, with some scarring, on the forehead, cheeks, chin, and back. The doctor commented that "I would think that the [veteran] has acne vulgaris because he was exposed to Agent Orange multiple times when he was in Viet Nam." The examiner noted that since the veteran's Vietnam service, he had developed various skin diseases and other conditions. The examiner also commented that based on the physical examination, he felt that the papules on the veteran's skin represented chloracne from exposure to Agent Orange. The Board has reviewed all the evidence of record, and concludes that resolving any remaining doubt in favor of the veteran, the evidence supports a claim for service connection for chloracne. Initially, the Board notes that the veteran's service medical records are negative for any evidence of a skin disorder. Nevertheless, the Board acknowledges that the veteran served in combat in Vietnam during the Vietnam era, and presumably was exposed to herbicide agents, such as Agent Orange. The veteran reported on several occasions that he developed a rash around the time of service separation. He stated that he did not seek treatment for the rash in service, and in fact did not seek treatment for the rash for many years following service separation. However, he stated that the rash was present since service, and he submitted photographs in support of his claims. The Board accepts the veteran's statements regarding the onset of his skin rash, and the continuity of symptoms. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Significantly, the record contains two medical opinions linking the veteran's skin disorder to Agent Orange exposure. As discussed above, Dr. Kvistberg indicated that the papules on the veteran's skin represented chloracne from exposure to Agent Orange. Additionally, in the September 2000 addendum to the September 2000 VA examination, the examiner indicated that the veteran's exposure to Agent Orange may have caused the skin changes noted in the examination, which were described as consistent with chloracne. In light of the foregoing opinions, as well as the veteran's statements, the Board finds that the evidence is in relative equipoise. Resolving the benefit of the doubt in the veteran's favor, service connection for chloracne is granted. 38 U.S.C.A. § 5107(b)(West 1991 & Supp. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). B. Onychomycosis and athlete's foot. In March 1998, the veteran initiated a claim for service connection for a bilateral foot condition, to include a fungus of the big toes. Essentially, the veteran maintains that these conditions were brought about as a result of being continuously wet during the monsoon season. The veteran's service medical records are negative for any evidence of a skin disorder of the feet, to include onychomycosis and/or athlete's foot. VA outpatient treatment records dated in February 1995 indicate that the veteran was seen with bumps on his face and a rash on his face, which he felt may be chloracne and fungus nail infections. The diagnosis was acne and fungus nail infection. A VA treatment record dated in January 1999 indicates that the veteran was seen for evaluation of a chronic nail problem. An April 1999 mycology smear revealed that no fungal elements were seen. In a September 2000 VA examination, the veteran reported a history of a rash involving his feet dating back to 1968. He indicated that his rash was not formally evaluated while he was in the service, but he maintained that he has had problems with his feet since that time. Examination revealed some evidence of maceration and scale in the lateral toe webs. There was slight residual erythema noted over the left lateral fifth and fourth toes, but no residual scale noted at the time of the examination. Right great toenail showed slight distal discoloration, but remaining toenails appeared normal. The diagnosis included tinea pedis and history of onychomycosis involving the right great toenail. In a September 2000 addendum to that examination report, the examiner stated that the etiology of tinea pedis and onychomycosis was fungus infection. The examiner stated that "some people are genetically predisposed to be more likely to have problems with fungal infections of the skin." The examiner also stated that fungus infection is more likely to develop and be a problem in conditions of chronic moisture retention, and high humidity. The Board has reviewed the evidence of record, and finds that the preponderance of the evidence is against a claim for service connection for onychomycosis of the toenails, and for athlete's foot (claimed as fungus and red blotches on feet with stiffness of great toes). Initially, the Board notes that onychomycosis of the toenails and athlete's foot are not among the types of disorders for which a causal relationship to Agent Orange exposure may be presumed by statute. See Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116); 38 U.S.C.A. § 1116 (West 1991 & Supp. 2001). Additionally, although there is recent medical evidence of onychomycosis and tinea pedis (athlete's foot), there is no medical opinion suggesting that the etiology of any current onychomycosis or athlete's foot is causally related to an incident of the veteran's active service. In fact, in a September 2000 VA examination, the examiner indicated that onychomycosis was usually caused by a fungus infection, and that some people are more likely than others to have fungal infections. The Board acknowledges that the veteran served in combat in Vietnam, and was probably exposed to situations of high humidity. Nevertheless, the record is negative for any evidence of a foot fungus or a similar condition until many years after the veteran's separation from service. Moreover, the medical evidence, as discussed above, does not support the veteran's claim. Despite the veteran's contentions that his current foot disorder is related to his active service, his contentions alone are not enough to establish service connection. See Espiritu, 2 Vet. App. at 494-95 (laypersons may be competent to provide an "eye-witness account of a veteran's visible symptoms," but they are not capable of offering evidence that requires medical knowledge). Rather, current medical evidence that the veteran suffers from the claimed disorder, as well as a medical opinion linking any current disorder to service, is needed to support the claims of service connection. In this case, the medical evidence simply does not show that any currently diagnosed foot disorder, to include onychomycosis of the toenails and athlete's foot, are causally related to service. In conclusion, for the reasons discussed above, the Board finds that the preponderance of the evidence is against a claim for service connection for onychomycosis of the toenails and athlete's foot, and the appeal is denied. As there is not an approximate balance of positive and negative evidence regarding the merits of the veteran's claims that would give rise to a reasonable doubt in favor of the veteran, the provisions of 38 U.S.C.A. § 5107(b) (West 1991 & Supp. 2001) are not applicable, and the appeal is denied. II. New and Material Evidence. A review of the claims file reveals that in an October 1981 rating decision, the RO denied service connection for a skin rash on the hands and legs, as a result of exposure to Agent Orange, on the basis that although there was current evidence of scaly macules on the veteran's arms, there was no evidence that the claimed skin rash was due to the veteran's active service, including Agent Orange exposure. The veteran was notified of that decision and his appellate rights by VA letter dated in October 1981, but he did not initiate an appeal, and the decision became final. 38 U.S.C.A. § 7104(a)(c); 38 C.F.R. § 20.200. In March 1996, the veteran filed a request to reopen his claim for service connection for a skin rash. The RO denied the veteran's request to reopen in an August 1996 rating decision. The veteran disagreed with that decision, and initiated a timely appeal. As there is a prior final decision on this issue, the Board must determine whether new and material evidence has been presented before reopening and adjudicating the claim for service connection on the merits. See Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996) (regardless of a determination made by the regional office, the Board must ensure that it has jurisdiction over a case before adjudicating the case on the merits). According to the law, if new and material evidence is presented or secured with respect to a claim that has been finally disallowed, the claim shall be reopened and reviewed. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a veteran seeks to reopen a final decision, the first inquiry is whether the evidence presented or secured since the last final disallowance of the claim is "new and material." Under 38 C.F.R. § 3.156(a), new and material evidence is defined as evidence not previously submitted which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with the evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. See 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The Board notes that there has been a regulatory change pertaining to the definition of new and material evidence, with respect to claims made on or after August 29, 2001. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.156(a)). As the veteran filed his claim prior to this date, the earlier version of the law remains applicable in this case. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for his claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C.A. § 5103A (West Supp. 2001) (eliminates the concept of a well-grounded claim). Initially, the Board notes that this issue is distinguished from the other two issues on appeal that involve skin disorders. While the other two issues pertain to acne (chloracne) and a skin disorder of the feet, the present issue involves a rash on the hands and legs. As noted above, the basis for the RO's denial of the veteran's claim in the October 1981 rating decision was that there was no evidence that any current rash on the hands and legs was causally related to the veteran's active service, to include Agent Orange exposure. The evidence present at the time of that earlier decision included the veteran's service medical records and post-service VA examination reports dated in September 1969 and February 1980. The veteran's service medical records and the September 1969 VA examination report are negative for any evidence of a skin disorder. The February 1980 VA examination was an Agent Orange examination. The report indicated that the veteran complained of a rash on his arms and legs since 1969. Physical examination revealed a few scaly macules on the veteran's arms. In summary, the evidence present at the time of the October 1981 rating decision revealed that the veteran had a current skin disorder on his arms, although there was no medical opinion regarding the etiology of any current skin disorder. The Board has thoroughly reviewed the evidence of record, and finds that new and material evidence has been presented to reopen a claim for service connection for a skin disorder of the hands and legs, but the preponderance of the evidence is against an award of service connection. In that regard, the evidence missing at the time of the October 1981 rating decision was evidence of a nexus, or link, between any current skin disorder of the hands and legs and the veteran's active service, to include Agent Orange. Since that time, the evidence associated with the claims file includes a September 2000 VA examination report and addendum, which contains a medical opinion as to the etiology of the veteran's skin disorder on his legs and arms. As this evidence was not present at the time of the October 1981 rating decision, this evidence is new, and is so significant that it must be considered in order to fairly decide the merits of the claim. As such, the Board finds that new and material evidence has been presented to reopen the claim for service connection for a skin disorder of the hands and legs. Although the Board finds that new and material evidence has been presented to reopen the claim, the Board finds that the preponderance of the evidence is against a claim for service connection for a skin disorder of the hands and legs. The September 2000 VA examination contains a diagnosis of urticaria with evidence of dermatographism involving the trunk, and the upper and lower extremities. However, when asked to comment on the etiology of the skin disorder, in a September 2000 addendum the VA examiner opined that there was no specific cause for the veteran's urticaria or dermatographism. Rather, the examiner stated that "it appears that [the veteran's] urticaria is idiopathic in nature, and no specific cause for [the veteran's] urticaria or dermatographism has been identified to date." The record contains adequate evidence that the veteran currently has a skin disorder of the hands and legs, diagnosed most recently as urticaria. Nevertheless, urticaria is not a type of disorder for which a causal relationship to Agent Orange exposure is presumed by statute. See Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001) (to be codified at 38 U.S.C. 1116); 38 U.S.C.A. § 1116 (West 1991 & Supp. 2001). Additionally, considering the veteran's claim under principles of direct service connection, there is no medical evidence or opinion of a causal link between any currently diagnosed skin disorder of the hands and legs and an incident of his active service. The Board acknowledges the veteran's statements that he has had a skin disorder on his hands and legs for many years. In the September 2000 VA examination report, the veteran reported that this condition was intermittent, going on for at least 20 to 25 years. The Board does not dispute the veteran's statements regarding the history of his skin disorder, and the Board acknowledges that the veteran served in combat, and was exposed to harsh environmental conditions. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Despite the veteran's contentions, the veteran's claim still must fail as there is no persuasive medical evidence indicating that any current skin disorder of the hands and legs had its onset during the veteran's active service. While the veteran sincerely believes that his skin disorder of the hands and legs is related to service, his statements alone are not sufficient to establish an award of service connection. In that regard, while laypersons are competent to testify as to observations, they are not competent to provide evidence requiring medical expertise, such as the etiology of a disorder or whether symptoms are related to a current disorder. See Espiritu, 2 Vet. App. at 494-95 (laypersons may be competent to provide an "eye-witness account of a veteran's visible symptoms," but they are not capable of offering evidence that requires medical knowledge). Rather, medical evidence linking a current skin disorder to service is needed to support the claim of service connection. In this case, the medical evidence, especially the VA examination in September 2000, is against a finding that the veteran has a current skin disorder of the hands and legs that is related to service, including Agent Orange exposure. In conclusion, for the reasons discussed above, the Board finds that the preponderance of the evidence is against a claim for service connection for a skin disorder of the hands and legs, and the appeal is denied. As there is not an approximate balance of positive and negative evidence regarding the merits of the veteran's claim that would give rise to a reasonable doubt in favor of the veteran, the provisions of 38 U.S.C.A. § 5107(b) (West Supp. 2001) are not applicable, and the appeal as to this issue is denied. III. Increased Ratings Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making a disability evaluation. 38 C.F.R. § 4.1. However, the current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A. Hearing Loss. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by pure tone audiometric tests in the frequencies 1,000, 2,000, 3,000 and 4,000 cycles per second. The rating schedule establishes eleven auditory acuity levels designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. VA audiological examinations are conducted using a controlled speech discrimination test together with the results of a pure tone audiometry test. The vertical lines in Table VI (in 38 C.F.R. § 4.85) represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the pure tone decibel loss. The percentage evaluation is found from Table VII (in 38 C.F.R. § 4.85) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. For example, if the better ear has a numeric designation Level of "V" and the poorer ear has a numeric designation Level of "VII," the percentage evaluation is 30 percent. See 38 C.F.R. §§ 4.85(b), 4.87. Effective June 10, 1999, regulatory changes were made to the schedule for rating disabilities pertaining to diseases of the ear, including the criteria for evaluating hearing loss. However, the method described above using Tables VI and VII was not changed, and therefore, does not affect the veteran's claim. However, pertinent changes were made to 38 C.F.R. § 4.86, which are discussed below. The regulations now provide that in cases of exceptional hearing loss, i.e. when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. See 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) provide that when the pure tone threshold is 30 decibels or less at 1,000 hertz, and 70 decibels or more at 2,000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results is the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. In the present case, the veteran was awarded service connection for high frequency hearing loss in an August 1970 rating decision, rated as noncompensable from July 1969. In March 1996, the veteran submitted a request for an increased rating for his bilateral hearing loss. In a January 2001 rating decision, the RO awarded the veteran a 10 percent rating for his bilateral hearing loss, effective from October 12, 2000, the date of a VA examination. As the veteran was awarded an increased rating for a portion of the appeal period, there are essentially two time periods to consider in this appeal. The Board will examine whether an increased (compensable) rating is warranted prior to October 12, 2000, and whether a rating in excess of 10 percent is warranted from October 12, 2000. The Board notes that as the provisions for exceptional patterns of hearing impairment were not effective until June 1999, those provisions are not applicable to evidence dated prior to that time. See 38 C.F.R. § 4.86. At the time of an August 1994 VA examination, the veteran's right ear manifested an average puretone threshold of 41 decibels, and 96 percent of speech discrimination, which results in a Level I designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of 49 decibels, and 96 percent of speech discrimination, resulting in a Level I designation. Combining two Level I designations results in a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. At the time of a July 1996 VA examination, the veteran's right ear manifested an average puretone threshold of 45 decibels, and 92 percent of speech discrimination, which results in a Level I designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of 55 decibels, and 94 percent of speech discrimination, resulting in a Level I designation. The combined rating warrants a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. At the time of a May 1997 VA examination, the veteran's right ear manifested an average puretone threshold of approximately 50 decibels, and 88 percent of speech discrimination, which results in a Level II designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of approximately 51 decibels, and 96 percent of speech discrimination, resulting in a Level I designation. The combined rating warrants a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. At the time of an August 1998 VA examination, the veteran's right ear manifested an average puretone threshold of approximately 44 decibels, and 88 percent of speech discrimination, which results in a Level II designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of approximately 53 decibels, and 96 percent of speech discrimination, resulting in a Level I designation. The combined rating warrants a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. At the time of a May 1999 VA examination, the examiner commented that the veteran's hearing loss was stable since his last examination in 1997. The veteran's right ear manifested an average puretone threshold of 45 decibels, and 96 percent of speech discrimination, which results in a Level I designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of 50 decibels, and 96 percent of speech discrimination, resulting in a Level I designation. The combined rating warrants a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. At the time of an October 2000 VA examination, the veteran's right ear manifested an average puretone threshold of 48 decibels, and 70 percent of speech discrimination, which results in a Level IV designation. 38 C.F.R. § 4.85, Table VI. The veteran's left ear manifested an average puretone threshold of 69 decibels, and 80 percent of speech discrimination, resulting in a Level IV designation. The combined rating warrants a 10 percent rating. See 38 C.F.R. § 4.85, Table VII. The Board has considered whether the provisions for evaluating exceptional patterns of hearing loss are appropriate. However, the veteran's hearing does not meet the requirements under 38 C.F.R. § 4.86 regarding exceptional patterns of hearing impairment. Based on the foregoing evidence, the Board finds that the preponderance of the evidence is against a compensable rating for bilateral hearing loss prior to October 12, 2000 (the date of the VA examination). Prior to that time, as noted above, the evidence of record consistently supported no more than a noncompensable rating for the veteran's bilateral hearing loss. However, at the time of the October 2000 VA examination, the veteran's bilateral hearing loss met the requirements for a 10 percent rating. The Board finds this rating appropriate, and finds no basis for a rating in excess of 10 percent for bilateral hearing loss from October 12, 2000. In reaching the foregoing determination, the Board has considered the history of the veteran's bilateral hearing loss, as well as the current clinical manifestations and the effect this disability may have on the veteran's earning capacity. See 38 C.F.R. §§ 4.1, 4.2. The Board has also considered the veteran's statements and contentions concerning his problems with hearing, as well as other lay statements of record, and assigned ratings based on the objective clinical findings obtained from audiometric testing. As noted earlier, disability ratings for hearing loss are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann, supra. In the present case, applying the rating criteria to the clinical evidence of record results in no more than a noncompensable rating for bilateral hearing loss prior to October 2000, and a 10 percent rating since that date. Further, the regular schedular standards appear sufficient for evaluation to the extent that the veteran's bilateral hearing loss has not caused marked interference with employment (i.e., beyond that already contemplated in the assigned ratings), or necessitated frequent periods of hospitalization, such that application of the regular schedular standards is impracticable. Thus, consideration of an extra-schedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1); See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). B. Left Knee. In an October 1995 rating decision, the veteran was awarded service connection for a tear of the lateral meniscus, postoperative, left knee. A 10 percent rating was assigned from September 1994. In March 1996, the veteran requested an increased evaluation of his left knee disability, particularly based on a private medical statement from a Dr. Page J. Potter. During the pendency of this appeal, in a March 1999 rating decision, the RO assigned a 20 percent rating for the veteran's left knee disability, effective from March 1996, the date of the veteran's claim for increase. As the veteran has not been assigned the maximum benefit available, his pending appeal is not abrogated. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a claimant disagrees with an RO decision assigning a particular rating, a subsequent RO decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In evaluating disabilities of the musculoskeletal system it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Reviewing the more recent medical evidence of record reveals the following. An August 1995 VA examination reported left knee flexion to 115 degrees, and extension to zero (0) degrees. An x-ray report contains an impression of mild degenerative disease noted in the medial and lateral compartment of the left knee. A March 1996 private medical record from Page J. Potter, D.C., indicates that the veteran's left knee range of motion was flexion of 120 degrees and 30 degrees of extension, with severe extension lag noted. McMurray's test was positive. Pain and tenderness were elicited upon palpation on the joint line, which Dr. Page indicated is indicative of a possible torn meniscus. Another test revealed possible ligament damage. In a May 1996 VA general medical examination, the veteran reported that his left knee felt like it might hyperextend while walking. The diagnosis was status post surgical meniscectomy, left knee. In a May 1996 VA joints examination, the veteran's lower extremities were described as symmetrical, with normal muscle bulk, tone, and strength. There was no patellar crepitus or tenderness. Medial and lateral collateral ligaments and anterior cruciate ligaments were intact. There was full range of motion bilaterally, with negative tibial grind maneuver. Goniometry range of motion measured -3 to 119. X-ray findings for the right knee were reported, but there were no x-ray findings reported for the left knee. The diagnosis was status post-surgical meniscectomy, left knee. In a July 1996 general medical VA examination, the veteran's left knee range of motion was flexion to 120 degrees, and extension to zero (0) degrees. Knees showed no excess patellar mobility or lateral instability, and there was no swelling, redness, deformity, or extremity atrophy. There was crepitus on motion of both knees. The diagnosis was as follows: loose body in the left knee joint space; status post left knee lateral meniscectomy in November 1975 for bucket-handle tear of the lateral meniscus; and status post resection of the left knee surgical scar and granuloma in December 1977. A VA outpatient treatment record dated in August 1996 revealed left knee flexion to 125 degrees, at which point the veteran reported pain in his left hip. Extension of the left knee was to zero (0) degrees. The diagnosis pertaining to the left knee was status post knee surgery in 1975 and 1977. In a September 2000 VA joints examination, the veteran complained that his knee hurt him on a daily basis, and was aggravated by walking, standing, or changes in the weather. He also reported pain in his knee while sleeping. Examination of the left knee revealed a well healed surgical scar. There was no redness, warmth, or swelling. There was tenderness to palpation along the lateral joint line, and some on the medial joint line, but to a lesser extent. Range of motion was zero (0) to 120 degrees, and the veteran reported pain with full extension. There was no evidence of ligamentous instability, but the veteran reported discomfort when the knee was manipulated. The diagnosis was lateral meniscal tear, left knee, status post partial meniscectomy. The examiner indicated that the veteran declined additional x-rays of his left knee, maintaining that he already had a lot of radiologic studies, and he did not feel that his left knee has changed in such a significant manner over the past four years. The examiner opined that this was a reasonable decision. At the time of the original award of service connection, the veteran's left knee was assigned a 10 percent rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5259, which assigns a 10 percent rating for symptomatic removal of semilunar cartilage. A 10 percent rating is the only rating available under that diagnostic code provision. In the March 1999 rating decision, the RO assigned a 20 percent rating for the veteran's lateral meniscus tear, left knee, post operative, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257, which prescribes a 20 percent rating for moderate knee impairment, manifested by recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe knee impairment, manifested by recurrent subluxation or lateral instability. The Board finds that the medical evidence summarized above is consistently negative for findings of instability or subluxation. At most, the medical evidence indicates that the veteran's left knee disability is currently manifested by some limited flexion, and complaints of pain on motion. As such, the Board finds no basis for a higher rating under Diagnostic Code 5257. As the Board finds no basis to assign a higher rating under Diagnostic Code 5257, the Board will consider whether a higher rating is warranted based on limitation of motion of the knee. In a March 1996 private medical record, the veteran reportedly had 30 degrees of extension, and 120 degrees of flexion. Since that time, the evidence consistently reflects that the veteran's left knee range of motion manifested around zero degrees extension and flexion to 125 degrees. Recent findings in September 2000 showed extension to zero degrees and flexion to 120 degrees. See 38 C.F.R. § 4.71, Plate II (normal knee motion is from zero to 140 degrees). There are no findings in the record that the veteran's left knee manifests flexion limited to 15 degrees or more, so as to warrant a rating in excess of 20 percent under Diagnostic Code 5260. Moreover, other than the March 1996 private medical record, there is no evidence that the veteran's left knee manifested limited extension to 15 degrees or more, so as to warrant a rating in excess of 20 percent under Diagnostic Code 5261. Rather, the veteran's left leg extension was more consistently reported as zero degrees. Therefore, there is no basis for a higher rating due to limitation of motion. As to the veteran's complaints of pain and swelling, including pain on motion, the Board finds that the 20 percent rating adequately contemplates such pain. There is no evidence in the record that the veteran's motion, albeit painful, is specifically limited by pain. Thus, the Board does not find that the veteran warrants a higher rating for pain, including functional loss due to pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202, 206-7. The Board finds no other potentially applicable rating criteria that would allow for a higher rating. The record is devoid of any evidence of ankylosis (Diagnostic Code 5256), or impairment of the tibia and fibula (Diagnostic Code 5262). In short, the Board finds that the currently assigned 20 percent rating for a lateral meniscus tear, left knee, postoperative is appropriate, and the preponderance of the evidence is against a higher rating at this time. Although an August 1995 VA examination report contains x-ray findings of mild degenerative disease in the medial and lateral compartment of the left knee, there are no recent findings of arthritis in the left knee. The veteran declined further x-rays in September 2000. As such, the Board finds no basis for assigning a separate rating for arthritis due to x-ray findings and limitation of motion, or painful motion. VAOPGCPREC 9-98; see also 38 C.F.R. § 4.59, VAOPGCPREC 23-97, Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). In reaching the foregoing determination, the Board has considered the history of the veteran's left knee disability, as well as the current clinical manifestations and the veteran's complaints of pain, and the effect this disability may have on the veteran's earning capacity. See 38 C.F.R. §§ 4.1, 4.2. The Board has also applied all pertinent aspects of 38 C.F.R. Parts 3 and 4. In conclusion, the current medical evidence is consistent with no more than a 20 percent rating for a lateral meniscus tear, left knee, postoperative. Should the veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. At present, however, there is no basis for a rating in excess of 20 percent. As the evidence is not in relative equipoise, the benefit of the doubt doctrine does not offer a favorable outcome in this appeal. See 38 U.S.C.A. § 5107(b)(West 1991 & Supp. 2001); Gilbert, 1 Vet. App. at 55-56. Finally, to the extent that the veteran's left knee disability may adversely affect his employability, the Board notes that the VA Schedule for Rating Disabilities assigns percentage ratings that are intended to represent, as far as can practicably be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Therefore, in the present case, the effects of the veteran's left knee disability on his employability are reflected in the currently assigned rating. Moreover, there is no evidence in the record (such as frequent periods of hospitalization or marked interference with employment) that the schedular criteria are inadequate to evaluate the veteran's left knee. As such, the Board finds no basis to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) for assignment of an extra-schedular evaluation. See Bagwell, supra; Floyd, supra; Shipwash, supra. C. PTSD. The veteran requests an increased rating for his service- connected PTSD, presently rated as 70 percent disabling. For purposes of clarity, the Board will set forth the procedural history of this appeal. In a March 1994 rating decision, the veteran was awarded service connection for PTSD, evaluated as 30 percent disabling from March 1994. Although the veteran initiated an appeal as to that decision, he did not file a timely substantive appeal as to that decision, and it became final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.302. In March 1996, the RO received the veteran's claim for an increased rating for his PTSD, then rated as 30 percent disabling. By rating decision dated in April 1996, the RO assigned a temporary 100 percent rating for PTSD, effective from March 12, 1996, based on a period of hospitalization in excess of 21 days for PTSD. In August 1996, the RO assigned a 50 percent rating for PTSD, effective from June 1, 1996, which was the date that the veteran was released from the hospital. In a September 1996 statement, the veteran continued to express disagreement with his PTSD rating. In an October 1996 substantive appeal, the veteran indicated that his rating should be higher than 50 percent, and he also claimed that the effective date should be prior to June 1, 1996. In an April 1997 rating decision, the RO granted the veteran's claim for an earlier effective date, and assigned an effective date of May 18, 1995 for the 50 percent rating, finding that an informal claim had been filed on that date. The veteran did not disagree with that effective date, but continued his increased rating claim. Specifically, in a June 1997 statement, the veteran claimed that his PTSD should be rated 70 percent disabling. In a March 1998 rating decision, the RO awarded a 70 percent rating for PTSD, effective from May 18, 1995, the date of the informal claim for increase, which initiated this appeal. In short, aside from a temporary total rating from March 12, 1996 to June 1, 1996, the veteran's PTSD has been rated 70 percent disabling from the date that he initiated an informal claim for an increased rating. A January 1999 rating decision confirmed and continued the 70 percent rating. The increased rating claim is still pending. See AB, 6 Vet. App. at 38 (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The Board notes that following the January 1999 rating decision, the PTSD increased rating issue was listed in two SSOCs, dated in January 2001 and October 2001. However, neither of those decisions provided any analysis of the issue, and merely noted that no new evidence pertinent to those claims had been submitted. A close look at those SSOCs reveals that the RO recharacterized the issue as: entitlement to an evaluation greater than 30 percent for PTSD earlier than May 18, 1995. As noted in the Introduction to this decision, that issue has not been developed by the RO, and is not presently on appeal. The sole issue for consideration at this time is entitlement to an increased rating for PTSD, currently rated as 70 percent disabling. After the veteran's initial claim for an increased rating for PTSD was received, the regulations pertaining to evaluation of mental disorders were amended, effective November 7, 1996. See 61 Fed. Reg. 52695-52702 (1996) (presently codified at 38 C.F.R. §§ 4.125- 4.130 (2001) (hereinafter referred to "current" regulations). The United States Court of Appeals for Veterans Claims (Court) has held that "where the law or regulation changes after a claim has been filed or reopened but before the ... judicial appeal process has been concluded, the version most favorable to appellant should and ... will apply unless Congress provided otherwise or permitted the Secretary of Veterans Affairs (Secretary) to do otherwise and the Secretary did so." Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991); but see 38 U.S.C.A. § 5110(g) (where an increase is awarded pursuant to a change in the law, the effective date shall not be earlier than the effective date of the new law). The RO assigned the veteran a 70 percent evaluation for PTSD pursuant to 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996), which requires evidence of severe impairment in the ability to establish and maintain effective or favorable relationships, and psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent rating is assigned if the evidence demonstrates that the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). According to the current rating criteria for mental disorders, a mental disorder shall be evaluated "based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination." 38 C.F.R. § 4.126(a). PTSD is evaluated by applying the General Rating Formula for Mental Disorders. Under those criteria, a 70 percent evaluation is assigned if 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 worklike setting); and an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is assigned 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 or hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Reviewing the pertinent medical evidence of record reveals the following. In a May 1994 VA examination for PTSD, the veteran reported getting only a few hours of sleep per night. He recalled choking his wife one night during a nightmare. He reported frequent nightmares about Vietnam, as well as daily intrusive thoughts and flashbacks. He was hypervigilant, and was startled by unexpected noises. He avoided fireworks, but described an Adrenalin rush when blowing things up. He was diagnosed with chronic PTSD, delayed, and assigned a Global Assessment of Functioning (GAF) score of 45. A January 1996 VA PTSD evaluation indicates that the veteran was extremely hypervigilant, and was taking medication for depression and anxiety. He reported suicidal thoughts, but no intent. The examiner's assessment was "an extremely severe and chronic [PTSD] secondary to extensive combat experiences and the Vietnam War." A VA outpatient treatment record dated in February 1996 indicates that the veteran reported flashbacks and nightmares, as well as suicidal thoughts. A March 1996 VA record indicates that the veteran was unemployed, due to an on-the-job injury. In a March 1996 statement, the veteran described his experiences in Vietnam. The veteran reported that he did not currently attend social functions, including his childrens' school activities, as he could not stand crowds. He stated that he thought about Vietnam everyday. The veteran's wife submitted two statements in March 1996, describing her observations of the veteran's behavior. She described his extreme rage, which he would sometimes take out on her both physically and verbally. She indicated that she noticed a drastic change of attitude in the veteran, and described him as a loner. She also described an occasion when she found the veteran sitting on their bed with a handgun pointed to his head. From March 1996 to May 1996, the veteran was hospitalized at a VA medical center for his PTSD. He was diagnosed with chronic PTSD, manifested by combat dreams, hyperirritability to loud noises, and flashback phenomena. At the time of a July 1996 VA examination, the veteran was diagnosed with severe chronic PTSD. The examiner noted that the veteran had difficulty sleeping, and had total flashbacks two to three times per week. He had a violent temper, and had a great deal of trouble with this temper, particularly with his family. He had startle response, and was hypervigilant. The veteran appeared pleasant and neat, but his affect was characterized by tension. The veteran had suicidal thinking at times. An October 1996 VA letter from one of the veteran's treating physicians contains a diagnosis of chronic, severe PTSD. In a March 1997 private medical statement from James E. Lewis, a licensed clinical psychologist, he opined that the veteran was incapable of work due to PTSD and physical health. The veteran was described as having a lack of friends, and social isolation. He manifested a sense of hopelessness, and described flashbacks of seeing faces of men killed in Vietnam, including the first man he killed. He had complete flashbacks of Vietnam, and severe sleep problems. In a May 1997 VA examination, the veteran was diagnosed with chronic, severe PTSD. He reported suicidal ideation, but no intent. He was oriented, and denied manic or psychotic symptoms. A great deal of the symptoms described in earlier examinations were present in this examination. The veteran stated that his PTSD symptoms have worsened since he was unable to work. In a September 1998 VA examination, the veteran was again diagnosed with chronic, severe PTSD. His symptoms were consistent with those already reported above, although the examiner noted that the veteran's PTSD had stabilized at a severe level, and was unlikely to improve. The veteran's GAF score was 37. The most recent VA PTSD examination report of record is dated in September 2000. The veteran was diagnosed with PTSD, and assigned a GAF of 59. The veteran denied hallucinations or delusions, but admitted to flashbacks, agoraphobia, and intrusive thoughts. The veteran's mood was depressed, and he admitted to significant fear and anxiety. The examiner commented that the veteran had a past work history of working with cement, but had been "unable to work since 1994 because of significant pain and also worsening of his PTSD symptoms." The Board has reviewed all the evidence of record pertaining to the veteran's PTSD claim and evaluated the evidence in light of both the former and current versions of the rating criteria for rating PTSD. The Board finds that resolving all doubt in the veteran's favor, the criteria for a 100 percent rating for PTSD have been met, and the appeal is allowed. The medical evidence summarized above has consistently described the veteran's PTSD as chronic and severe. In January 1996, the veteran's PTSD was described as "extremely severe and chronic," secondary to extensive combat experiences and the Vietnam War. The veteran's significant symptoms over the years have included nightmares, flashbacks, hypervigilance, irritability, depression, and suicidal thoughts. The veteran's wife described the veteran's behavior, which includes intense anger, depression, and isolation. The veteran has difficulty sleeping, and reports that he thinks of his experiences in Vietnam every day. The veteran has described many of these experiences rather vividly. Two medical professionals have indicated that the veteran's PTSD has contributed to his inability to work. A March 1997 private physician stated that the veteran is unable to work due to his PTSD and his physical health. In the most recent VA examination (September 2000), the examiner stated that the veteran has been unable to work since 1994 due to pain and worsening of his PTSD symptoms. In short, the Board finds that resolving any remaining doubt in the veteran's favor, the evidence supports a 100 percent rating under both the prior and current versions of the rating criteria for evaluation of PTSD. In reaching this decision, the Board has considered the history of the veteran's PTSD, as well as the current clinical manifestations of this disability and its effect on the veteran's earning capacity. See 38 C.F.R. §§ 4.1, 4.2, 4.41. For reasons discussed above, the Board finds that the evidence supports a 100 percent rating for PTSD. See 38 U.S.C.A. § 5107(b). As the veteran is awarded the highest rating available for PTSD, consideration of an extra- schedular evaluation is not appropriate. 38 C.F.R. § 3.321(b)(1). ORDER Service connection for chloracne is granted, subject to the rules and regulations governing awards of monetary benefits. Service connection for onychomycosis of the toenails and for athlete's foot (claimed as fungus and red blotches on feet with stiffness of great toes), is denied. New and material evidence has been presented to reopen a claim for entitlement to service connection for a skin disorder of the hands and legs, and to that extent the appeal is allowed. Service connection for a skin disorder of the hands and legs is denied. Prior to October 12, 2000, the schedular criteria for a compensable rating for bilateral hearing loss have not been met, and the appeal is denied. Since October 12, 2000, the schedular criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met, and the appeal is denied. The schedular criteria for a rating in excess of 20 percent for a lateral meniscus tear, left knee, postoperative, have not been met, and the appeal is denied. Subject to the rules and regulations governing awards of monetary benefits, a 100 percent rating for PTSD is granted. WARREN W. RICE, JR. Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.