Citation Nr: 0813237 Decision Date: 04/22/08 Archive Date: 05/01/08 DOCKET NO. 95-31 412 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to a disability evaluation in excess of 20 percent for post-operative residuals, medical meniscectomy with chondromalacia and limitation of motion, post-ligament transplant for instability of the right knee. 2. Entitlement to an effective date earlier than August 30, 2000 for special monthly compensation (SMC) for loss of use of a creative organ. 3. Entitlement to an effective date earlier than November 5, 2003 for the grant of service connection for acid reflux. 4. Entitlement to an effective date earlier than November 5, 2003 for the grant of service connection for hypertension. 5. Entitlement to an effective date earlier than April 14, 2003 for the grant of Chapter 35 benefits, Dependents' Educational Assistance (DEA). 6. Entitlement to disability compensation for post-traumatic stress disorder (PTSD) due to sexual trauma, pursuant to the provisions of 38 U.S.C.A. § 1151. 7. Entitlement to disability compensation for brain syndrome due to lack of oxygen from arthroscopic surgery, pursuant to the provisions of 38 U.S.C.A. § 1151. 8. Entitlement to service connection for a dental disability due to bulimia. 9. Entitlement to an effective date earlier than May 1, 1994 for the grant of service connection for right knee arthritis. 10. Entitlement to an effective date earlier than May 8, 2000 for the grant of service connection for bulimia. 11. Entitlement to service connection for glaucoma suspect and asteroid hyalosis, right eye, claimed as increased pressure in the right eye. 12. Entitlement to service connection for residuals of right shoulder injury. 13. Entitlement to service connection for left acromioclavicular joint separation. 14. Entitlement to service connection for arthritis of the left hand. 15. Entitlement to service connection for arthritis of the right hand. 16. Entitlement to service connection for a thyroid disability. 17. Entitlement to an initial increased compensable evaluation for bulimia. 18. Entitlement to an initial increased rating for PTSD, currently rated at 100 percent. ATTORNEY FOR THE BOARD S. B. Mays, Counsel INTRODUCTION The veteran had active service from February 1964 to July 1966. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a December 1994 rating decision of the Phoenix, Arizona Regional Office (RO) of the Department of Veterans Affairs (VA), which in pertinent part, denied an evaluation in excess of 20 percent for right knee disability. The remaining issues were subsequently merged into the instant appeal, and the claims folder was transferred to the RO in Wichita, Kansas. According to the veteran's substantive appeal received in September 2006, he indicated that he wished to appear at a personal hearing before a Veterans Law Judge. Such a hearing was scheduled in August 2007, however, the veteran failed to appear. Thus, the Board considers the veteran's request for a hearing to be withdrawn. In a January 2008 letter, the veteran indicated that he had terminated his relationship with his private representative. He did not indicate that he wished to appoint another representative. Given such letter, the Board finds that the veteran wishes to represent himself. Also according to the January 2008 letter, the veteran stated that he had had open heart surgery in November 2006, and it appears that he wishes to file a service connection claim for his cardiovascular disability, other than hypertension. That matter is referred to the RO for the appropriate development. FINDINGS OF FACT 1. By a January 2008 letter, prior to the promulgation of a decision, the Board received a statement from the veteran indicating that he wished to withdraw his appeal seeking entitlement to: a disability evaluation in excess of 20 percent for right knee disability; an effective date earlier than August 30, 2000 for SMC for loss of use of a creative organ; an effective date earlier than November 5, 2003 for the grant of service connection for hypertension; an effective date earlier than April 14, 2003 for the grant of Chapter 35 DEA benefits; service connection for a dental disability due to bulimia; an effective date earlier than May 1, 1994 for the grant of service connection for right knee arthritis; service connection for glaucoma suspect and asteroid hyalosis, right eye; service connection for residuals of right shoulder injury; service connection for left acromioclavicular joint separation; service connection for arthritis of the left hand; service connection for arthritis of the right hand; service connection for thyroid disability; and an increased rating for PTSD. 2. A formal claim of entitlement to service connection for acid reflux was received at the RO on November 5, 2003, and there is nothing in the record received prior to November 5, 2003 that could be construed as an informal claim for service connection for acid reflux. 3. The veteran is in receipt of a 100 percent disability evaluation for PTSD based on Vietnam stressors, effective May 8, 2000. 4. There is no competent evidence of record demonstrating that the veteran has a separate or additional disability exhibited by PTSD resulting from a sexual assault occurring at a VA facility. 5. There is no competent evidence of record demonstrating that the veteran is diagnosed with organic brain syndrome. 6. There is nothing in the record received prior to May 8, 2000 that could be construed as an informal claim for service connection for bulimia, secondary to service-connected PTSD. 7. Bulimia is manifested by binge eating with self-induced vomiting, but no showing of incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to a disability evaluation in excess of 20 percent for right knee disability are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 2. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to an effective date earlier than August 30, 2000 for SMC for loss of use of a creative organ are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 3. The criteria for an effective date earlier than November 5, 2003 for the grant of service connection for acid reflux are not met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2007); 38 C.F.R. § 3.400 (2007). 4. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to an effective date earlier than November 5, 2003 for the grant of service connection for hypertension are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 5. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to an effective date earlier than April 14, 2003 for the grant of Chapter 35 DEA benefits, are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 6. The criteria for entitlement to disability compensation for PTSD due to sexual trauma, pursuant to the provisions of 38 U.S.C.A. § 1151, are not met. 38 U.S.C.A. §§ 1151, 7104 (West 2002 & Supp. 2007); 38 C.F.R. § 3.361 (2007). 7. The criteria for entitlement to disability compensation for organic brain syndrome due to lack of oxygen from arthroscopic surgery, pursuant to the provisions of 38 U.S.C.A. § 1151, are not met. 38 U.S.C.A. §§ 1151, 7104 (West 2002 & Supp. 2007); 38 C.F.R. § 3.361 (2007). 8. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for a dental disability due to bulimia are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 9. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to an effective date earlier than May 1, 1994 for the grant of service connection for right knee arthritis are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 10. The criteria for an effective date earlier than May 8, 2000 for the grant of service connection for bulimia are not met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2007); 38 C.F.R. § 3.400 (2007). 11. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for glaucoma suspect and asteroid hyalosis, right eye, are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 12. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for residuals of right shoulder injury are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 13. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for left acromioclavicular joint separation are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 14. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for arthritis of the left hand are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 15. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for arthritis of the right hand are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 16. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to service connection for a thyroid disability are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 17. The criteria for withdrawal by the veteran of a substantive appeal pertinent to the issue of entitlement to an increased rating for PTSD are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.202, 20.204 (2007). 18. The criteria for an initial increased compensable evaluation for bulimia are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R §§ 3.321, 4.130, Diagnostic Code 9521 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Dismissals The veteran perfected an appeal of rating decisions which denied: a disability evaluation in excess of 20 percent for right knee disability; an effective date earlier than August 30, 2000 for SMC for loss of use of a creative organ; an effective date earlier than November 5, 2003 for the grant of service connection for hypertension; an effective date earlier than April 14, 2003 for the grant of Chapter 35 benefits, DEA; service connection for a dental disability due to bulimia; an effective date earlier than May 1, 1994 for the grant of service connection for right knee arthritis; service connection for glaucoma suspect and asteroid hyalosis, right eye; service connection for residuals of right shoulder injury; service connection for left acromioclavicular joint separation; service connection for arthritis of the left hand; service connection for arthritis of the right hand; service connection for thyroid disability; and an increased rating for PTSD. According to a January 2008 letter, the veteran specifically indicated which claims he wishes to still pursue, and requested that the Board ignore the remainder of the issues on appeal. Given such letter, the Board finds that the veteran has expressed his intent to withdraw the issues noted directly above. An appeal may be withdrawn in writing at any time before a decision is rendered by the Board. 38 C.F.R. § 20.204(b) (2007). Once the veteran withdrew these issues, there remained no allegations of error of fact or law for appellate consideration. The Board does not have jurisdiction to review this issue on appeal and it is dismissed. 38 U.S.C.A. § 7105(d)(5) (West 2002 & Supp. 2007). II. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the veteran is challenging the effective dates assigned following the grant of service connection for acid reflux and bulimia and an increased rating for bulimia. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. With regard to the § 1151 claims, the VCAA duty to notify was satisfied by way of letters sent to the veteran on June 2001 and February 2003 that fully addressed all four notice elements. Collectively, those letters informed the appellant of what evidence was required to substantiate the claim(s) and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims folder contains service medical records, service personnel records, the veteran's contentions, internet and medical treatise articles, VA medical evidence, and private medical evidence. Significantly, the veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). III. Earlier Effective Date Claims The effective date of an award is generally the date of receipt of a claim (or informal claim where appropriate), or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.400 (2007). More specifically, the effective date of an award of disability compensation for direct service connection is the day following separation from active service or the date entitlement arose, if the claim was received within one year after separation from service; otherwise, it is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(b)(1) (West 2002 & Supp. 2007); 38 C.F.R. § 3.400(b)(2)(i) (2007). If a veteran files an application for service connection with VA and the claim is disallowed, he has the right to appeal that disallowance to the Board. See 38 U.S.C.A. §§ 7104, 7105 (West 2002 & Supp. 2007). If he does not initiate an appeal within one year, or if he initiates a timely appeal and the appeal is denied, the disallowance becomes final. See 38 C.F.R. §§ 20.302, 20.1100, 20.1103 (2007). With exceptions not here applicable, any award based on a subsequently filed application for benefits can be made effective no earlier than the date of the new application. See 38 C.F.R. § 3.400(q), (r) (2007). Specifically, the effective date of an award of disability compensation based upon the submission of new and material evidence other than service department records received after final disallowance will be the date of receipt of the new claim or the date that entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(1)(ii) (2007). Generally, a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. See 38 C.F.R. § 3.151(a) (2007). However, any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155 (2007). An informal claim must identify the benefit sought. See Brannon v. West, 12 Vet. App. 32, 34 (1998) (noting that VA "is not required to anticipate a claim for a particular benefit where no intention to raise it was expressed and citing Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995) for the proposition that VA is not required to do a "prognostication" but to review issues reasonably raised by the substantive appeal). a. Acid Reflux The veteran is seeking an effective date earlier than November 5, 2003 for the grant of service connection for acid reflux. In a September 2004 rating decision, the RO granted service connection for acid reflux, secondary to service- connected PTSD, and assigned a 10 percent evaluation, effective November 5, 2003, the date of receipt of the claim via facsimile (claim for gastrointestinal disability). In determining whether the veteran is entitled to an earlier effective date, the Board must consider whether the veteran filed an informal claim for service connection for acid reflux prior to the assigned effective date of November 5, 2003. Review of the claims folder fails to reveal any prior communication from the veteran or his representative at the time that may be construed as indicating intent to seek or apply for entitlement to service connection for acid reflux. Accordingly, there is no legal basis for an effective date prior to November 5, 2003 for the grant of service connection for acid reflux and the claim must be denied. The reasonable doubt doctrine is not for application as the preponderance of the evidence is against the veteran's claim. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2007). b. Bulimia The veteran is seeking an effective date earlier than May 8, 2000 for the grant of service connection for bulimia. In a February 2006 rating decision, the RO granted service connection for bulimia, secondary to service-connected PTSD, and assigned a noncompensable evaluation, effective May 8, 2000. On review, the Board finds that an effective date earlier than May 8, 2000 for the grant of service connection for bulimia is not warranted. The effective date currently assigned, May 8, 2000, is the effective date for the grant of service connection for PTSD. The veteran did not file a formal or informal claim of service connection for bulimia at any time prior to this date. Thus, the effective date for the grant of service connection for bulimia can be no earlier than that date. Accordingly, there is no legal basis for an effective date prior to May 8, 2000 for the grant of service connection for bulimia and the claim must be denied. The reasonable doubt doctrine is not for application as the preponderance of the evidence is against the veteran's claim. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2007). The Board acknowledges that the veteran's assertion to the effect that he is entitled to earlier effective dates for his acid reflux and bulimia, however, as a lay person, he does not possess the requisite knowledge, skill, experience, training, or education to qualify as a medical expert for his statements to be considered competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). IV. § 1151 Claims A veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA, and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2007). To determine whether additional disability exists within the meaning of § 1151, the veteran's condition immediately prior to the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based is compared to his or her condition after such care, treatment, examination, services, or program has been completed. Each body part or system involved is considered separately. 38 C.F.R. § 3.361(b) (2007). To establish causation, evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination, and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c) (1) (2007). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2) (2007). Additional disability or death caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(3) (2007). The proximate cause of disability or death is the action or event that directly caused the disability or death, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d) (2007). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death (see 38 C.F.R. § 3.361(c)) and (i) that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or (ii) that VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's, informed consent. 38 C.F.R. § 3.361(d)(1) (2007). a. PTSD as a result of Sexual Trauma In 2002, the veteran filed an § 1151 claim for PTSD due to sexual trauma. Specifically, he contends that while a patient at a VA facility, he was sexually traumatized by a female VA employee, and as a result developed PTSD. On review of all evidence of record, the Board finds that entitlement to disability compensation for PTSD due to sexual trauma, pursuant the provisions of 38 U.S.C.A. § 1151, is not warranted. While a March 2002 investigation report shows that the accused VA employee was determined to be in violation with VA policy by manipulating both physically and emotionally the veteran while a patient at VA, there is no evidence of additional disability. Significantly, the veteran is already service-connected for PTSD and is in receipt of a 100 percent evaluation for such disability. The award of service connection for PTSD is based on the veteran's Vietnam stressors. There is no competent evidence that the veteran has separate or additional disability of PTSD due to VA medical care. Thus, entitlement to disability compensation under the provisions of 38 U.S.C.A. § 1151 for PTSD due to sexual trauma is not established. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 3.102 (2007). The veteran's § 1151 claim for PTSD could be construed as an increased rating claim for PTSD, however, because he is in receipt of the maximum rating for PTSD, any issue as to an increased rating is moot. See AB v. Brown, 6 Vet. App. 35, 38 (1993). b. Organic Brain Syndrome The veteran also asserts that he is entitled to § 1151 disability compensation for organic brain syndrome. He asserts that he was deprived of oxygen during an arthroscopy performed in March 1994 at a VA facility. On review of all evidence of record, the Board finds that entitlement to disability compensation for brain syndrome, pursuant the provisions of 38 U.S.C.A. § 1151, is not warranted. In this regard, there is no objective evidence demonstrating that the veteran has been diagnosed with organic brain syndrome. In February 2003, the veteran underwent a VA psychiatric examination. After examining the veteran and conducting psychological testing, the examiner concluded that the veteran did not exhibit any symptoms or manifestations of brain dysfunction, or cognitive disorder. As there is no evidence of organic brain syndrome, the Board finds that the veteran is not entitled to disability compensation pursuant to § 1151 for organic brain syndrome. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 3.102 (2007). V. Increased Rating for Bulimia Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007). Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2 (2006); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When 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 (2006). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2006). Bulimia is assigned a noncompensable rating when manifested by binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder but without incapacitating episodes. A 10 percent evaluation requires binge eating followed by self- induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder and incapacitating episodes of up to two weeks total duration per year. A 30 percent evaluation requires self- induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of more than two but less than six weeks total duration per year. The note to Code 9521 explains that an incapacitating episode is a period during which bed rest and treatment by a physician are required. 38 C.F.R § 4.130, Diagnostic Code 9521 (2007). While the veteran has exhibited periods of binge and purge and it has been noted that he lost up to 10 pounds at one point, he has not had incapacitating episodes as defined by the regulation. The Board finds that the record, as a whole, does not support the claim. Finally, although consideration has been given to an extra- schedular evaluation, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether it is warranted. An extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1) may be assigned when there is evidence of exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, to suggest that the veteran is not adequately compensated by the regular rating schedule. See VAOPGCPREC 6-96. In this case, there is no evidence of any hospitalization associated with the disability in question. In addition, there is no suggestion in the evidence that bulimia has any significant impact on employability. In conclusion, the Board finds that the preponderance of the evidence is against an initial compensable evaluation for bulimia. 38 C.F.R. § 4.3. ORDER Entitlement to a disability evaluation in excess of 20 percent for post-operative residuals, medical meniscectomy with chondromalacia and limitation of motion, post-ligament transplant for instability of the right knee, is dismissed. Entitlement to an effective date earlier than August 30, 2000 for SMC for loss of use of a creative organ is dismissed. Entitlement to an effective date earlier than November 5, 2003 for the grant of service connection for acid reflux is denied. Entitlement to an effective date earlier than November 5, 2003 for the grant of service connection for hypertension is dismissed. Entitlement to an effective date earlier than April 14, 2003 for the grant of Chapter 35 benefits, DEA, is dismissed. Entitlement to disability compensation for PTSD due to sexual trauma, pursuant to the provisions of 38 U.S.C.A. § 1151, is denied. Entitlement to disability compensation for brain syndrome due to lack of oxygen from arthroscopic surgery, pursuant to the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement to service connection for a dental disability due to bulimia is dismissed. Entitlement to an effective date earlier than May 1, 1994 for the grant of service connection for right knee arthritis is dismissed. Entitlement to an effective date earlier than May 8, 2000 for the grant of service connection for bulimia is denied. Entitlement to service connection for glaucoma suspect and asteroid hyalosis, right eye is dismissed. Entitlement to service connection for residuals of right shoulder injury is dismissed. Entitlement to service connection for left acromioclavicular joint separation is dismissed. Entitlement to service connection for arthritis of the left hand is dismissed. Entitlement to service connection for arthritis of the right hand is dismissed. Entitlement to service connection for a thyroid disability is dismissed. Entitlement to an increased rating for PTSD is dismissed. Entitlement to an initial increased compensable evaluation for bulimia is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs