Citation Nr: 1120316 Decision Date: 05/25/11 Archive Date: 06/06/11 DOCKET NO. 09-44 446 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 10 percent for shrapnel wound, left face, with residual scars, postoperative carotid ligation. 3. Entitlement to an initial compensable evaluation for vascular/venous disorder as secondary to the service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation. 4. Entitlement to service connection for a heart disorder, to include as secondary to the service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation 5. Whether new and material evidence has been received to reopen a claim for service connection for bilateral hearing loss. 6. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Rick D. Little, Agent ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to March 1966. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Los Angeles, California, Department of Veterans Affairs (VA) Regional Office (RO). In September 2008, the Board remanded the claims for additional development and adjudicative action. The case has been returned to the Board for further appellate review. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The competent and probative medical evidence of record demonstrates that the Veteran's PTSD is characterized by sleep impairment, anger, hypervigilance, isolative behavior, nightmares, irritability, flashbacks, intrusive thoughts, and difficulty in social and occupational functioning. 3. The competent and probative medical evidence of record demonstrates that the Veteran's service-connected shrapnel wound of the left face with residual scars, postoperative carotid ligation, is manifested by three characteristics of disfigurement and no evidence of complete paralysis of the fifth facial cranial nerve. 4. The competent and probative medical evidence of record demonstrates that the Veteran's service-connected vascular/venous disorder is characterized by no characteristics of disfigurement and no recurrent episodes occurring one to three times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. 5. Competent evidence of a heart disorder is not of record. 6. Service connection for bilateral hearing loss was denied in a December 2004 rating decision. The Veteran was notified of this decision and of his appeal rights. He did not appeal the decision. 7. Since the December 2004 rating decision which denied service connection for bilateral hearing loss, evidence that relates to an unestablished fact necessary to substantiate the claim has not been presented or secured. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a 30 percent disability rating, and no higher, for shrapnel wound, left face, with residual scars, postoperative carotid ligation, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.118, 4.124a, Diagnostic Codes 7800, 8205 (prior to October 23, 2008, 2010). 3. The criteria for an initial compensable rating for vascular/venous disorder as secondary to the service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.118, Diagnostic Codes 7800, 7826 (2010). 4. A heart disorder was not incurred in or aggravated by the Veteran's military service, nor is it secondary to the service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1133, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2010). 5. The December 2004 rating decision, which denied entitlement to service connection for bilateral hearing loss, is final, and evidence received since that decision is not new and material. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.156(a), 20.1103 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and 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) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that 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; and (3) that the claimant is expected to provide. In regard to the Veteran's claims for service connection, the Board finds that the VCAA notice requirements have been satisfied by the June 2006 letter. In the June 2006 letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. Turning to the Veteran's claims for increased ratings, the June 2006 letter informed the Veteran that the evidence necessary to substantiate the claims for increased evaluations would be evidence showing that his disabilities were worse than the current evaluations contemplate. The letter also informed the Veteran that he must provide medical or lay evidence demonstrating a worsening of his disability and the impact on his employment and daily life, which can also be substantiated by sending statements from other individuals who are able to describe in what manner the disabilities have become worse. The Court, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006),held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. In the present appeal, the June 2006 VCAA letter to the Veteran included the type of evidence necessary to establish disability ratings and effective dates for the disabilities on appeal. On March 31, 2006, the Court issued a decision in the appeal of Kent v. Nicholson, 20 Vet. App. 1 (2006), which establishes new requirements regarding the VCAA notice and reopening claims. The Court held that the VCAA notice must include the bases for the denial in the prior decision and VA must respond with a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. Id. The question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied. See Evans v. Brown, 9 Vet. App. 273, 283 (1996) (holding evidence is material if it is relevant to and probative of an issue that was a specified basis for the last final disallowance). The Veteran has been apprised of the information necessary to reopen his claim for service connection for bilateral hearing loss in the June 2006 VCAA letter. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA obtained the Veteran's service treatment records. The Veteran was also provided VA examinations in connection with his increased rating claims, which are found to be adequate for rating purposes. The examiners reviewed the Veteran's medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board finds that the VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA has not provided the Veteran with an examination in connection with his claim for service connection for bilateral hearing loss; however, the Board finds that VA was not under an obligation to have the Veteran examined for his claim. The Veteran has not brought forth new and material evidence to reopen the claim. 38 C.F.R. § 3.159(c)(4)(iii) states that paragraph (c)(4) applies to a claim to reopen a finally adjudicated claim only if new and material evidence is presented or secured. For these reasons, the Board finds that VA was not under an obligation to provide an examination in connection with his claim. VA has also not provided the Veteran with an examination in connection with his claim for service connection for a heart disorder. The Board notes that there is no duty on the part of VA to provide any additional assistance such as requesting a medical examination or opinion, because as in Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003), the Veteran has been advised of the need to submit competent medical evidence indicating that he has the disorder in question, and further substantiating evidence suggestive of a linkage between his active service or a service-connected disorder and the currently claimed disorder. The Veteran has not done so, and no evidence thus supportive has otherwise been obtained. Here, as in Wells, the record as a whole, after due notification, advisement, and assistance to the Veteran under the VCAA, does not contain competent evidence to suggest that the Veteran has a current heart disorder which is in any way related to his period of service, to include presumptively. Given these matters of record, there is no competent evidence that the aforementioned claimed disorder may be associated with the claimant's active military service. 38 U.S.C.A § 5103A(d); cf. Charles v. Principi, 16 Vet. App. 370 (2002). Under such circumstances, there is no duty to provide an examination or to obtain a medical opinion. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328. II. Decision A. Increased Rating Claims Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2010). Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). An appeal from the initial assignment of a disability rating, requires consideration of the entire period since service connection has been in effect, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2 (2010); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is noted that in Hart v. Mansfield, 21 Vet. App. 505 (2007), the United States Court of Appeals for Veterans Claims (Court) held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Posttraumatic Stress Disorder (PTSD) The Veteran contends that his service-connected PTSD warrants a higher disability rating. Throughout the rating period on appeal, the Veteran's PTSD has been rated as 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). That code section evaluates PTSD under the general rating formula for mental disorders. Such general rating formula provides a 50 percent rating where the evidence demonstrates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. In order to be entitled to the next-higher 70 percent evaluation, the evidence must show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. Id. The Global Assessment Functioning (GAF) scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2010). In October 2006, the Veteran was afforded a VA general psychiatry examination through QTC Medical Services (QTC). The Veteran informed the VA examiner that since the unexpected death of his wife in March 2006, his service-connected PTSD symptoms have exacerbated. He admitted to having intensified increased startle response, increased nightmares, and an increase in "survivor['s] guilt" since his wife's passing. He further added that he avoids political discussions about Vietnam with other people and endorses an aversion to Asian people. The Veteran admitted to using cocaine and marijuana in the past, as well as abusing alcohol, but has since been involved in a 12-step program for recovering addicts and continues to be an active member of Alcoholics Anonymous (AA). The Veteran stated that he lives alone, but has contact with his two children. On a typical day, he goes to cardiac rehabilitation after suffering from a heart attack several years ago, and attends AA meetings. He admitted to having contact with friends and family. The Veteran informed the examiner that for years he worked part-time as an actor and performed technical work for a motion picture studio. He admitted to not receiving any psychiatric treatment for his service-connected PTSD. Upon mental status examination testing, the examiner noted that the Veteran was casually dressed with normal personal hygiene, but appeared somewhat restless through the interview. He demonstrated an angry mood, shifted continuously in his chair, and reacted in a hostile manner. His rate and flow of speech was deemed rapid by the examiner and contained many irrelevant details and tangential answers. Due to his hostility, the examiner reported that there was intermittent impairment of communication. He was observed as being sarcastic and irritable, with no delusions or hallucinations. There was "[p]ossibl[e]" impaired impulse control, inappropriate behavior, and sleep impairment, with no signs of panic attacks. The Veteran was oriented to time, place, and situation, and his recent, medium, and remote memory was intact. The examiner diagnosed the Veteran with PTSD, bereavement, and alcohol and polydrug abuse in remission. He was assigned GAF scores of 58 for his PTSD, 50 for his bereavement, and 70 for his alcohol and drug abuse. In this case, the Veteran's PTSD does not more nearly approximate the criteria for a 70 percent disability rating. The evidence of record describes a fairly consistent pattern of symptoms and manifestations of sleeplessness, nightmares, intrusive thoughts, increased startle response, and depression. The Board acknowledges the examiner's assertion that an incident during the October 2006 examination could "[p]ossibly [demonstrate] impaired impulse control," but there are no other references or discussion made by the examiner, and this appears to be an isolated manifestation of symptomatology as the medical records are otherwise negative for any evidence of impaired impulse control. Furthermore, the Veteran has the ability to establish and maintain effective relationships, both in the context of obtaining treatment for his alcohol abuse and in maintaining family relationships, as is demonstrated by his marriage of 39 years to his previous wife, and admitted contact with his two children. Thus, while the Veteran may have difficulty in establishing and maintaining social contacts, there is no evidence of any inability to do so, as described in the criteria for a 70 percent rating. Other symptoms required for the 70 percent evaluation, are neither complained of nor observed by medical health care providers. Review of the record shows that the there is no evidence of suicidal or homicidal ideation or plans. Furthermore, the evidence does not show that the Veteran has any obsessive or ritualistic behavior. While his speech has been described as rapid with many irrelevant details and tangential answers, it was not been found to be illogical, obscure, or irrelevant. Additionally, the Veteran's orientation has been intact, and he is generally described as having normal grooming and hygiene. The Board notes that while the Veteran's mood was described by the October 2006 examiner as angry, there is no evidence that he has demonstrated near-continuous panic or depression affecting his ability to function independently, appropriately and effectively. In fact, at the October 2006 examination, the examiner noted that the Veteran's service-connected PTSD resulted in no significant diminished interest in significant activities, as well as no current impairment in social and occupational functioning. He further added that the Veteran was competent to manage his financial affairs independently. In addition, the examiner noted that the Veteran was functional in his continuing work with AA. The Board is also cognizant of the Veteran's assigned GAF score of 58 for his service-connected PTSD. See the October 2006 VA examination report. Such GAF score is indicative of moderate symptoms, but when considering the evidence as a whole, does not justify assignment of the next-higher 70 percent rating. The Board also points out that the examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is a factor for consideration. It is not determinative of the percentage VA disability rating to be assigned. The VA disability percentage rating is based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2010); VAOPGCPREC 10-95. In this case, as noted above, the Veteran's symptoms are not productive of, or consistent with, the criteria for a 70 percent rating. In this case, as noted above, the Veteran's symptoms are not productive of, or consistent with, the criteria for the next-higher 70 percent rating. The Board has duly considered staged ratings, pursuant to Hart, supra, but finds the 50 percent rating assigned appropriate for the entire rating period. The Board is aware that the symptoms listed under the 70 percent evaluation are essentially examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a 70 percent evaluation. Nevertheless, the Board finds that the record does not show the Veteran manifested symptoms that equal or more nearly approximate the criteria for a 70 percent evaluation at any time during the pendency of this appeal. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In summary, the Veteran is not entitled to an evaluation in excess of 50 percent, for his service-connected PTSD, and the benefit-of-the-doubt rule is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Shrapnel Wound, Left Face, with Residual Scars, Postoperative Carotid Ligation The Veteran contends that his service-connected shrapnel wound to the left face warrants a higher disability rating. Throughout the rating period on appeal, the Veteran has been assigned a 10 percent disability evaluation for his service-connected left face shrapnel wound pursuant to 38 C.F.R. §§ 4.104, 4.124a, Diagnostic Codes 7114-8207. Prior to evaluating the Veteran's service-connected disability under the applicable diagnostic codes, the Board notes that it is not clear why the RO evaluated the Veteran's left face shrapnel wound under Diagnostic Code 7114, which is for arteriosclerosis obliterans and Diagnostic Code 8207, which is for paralysis of the seventh (facial) cranial nerve. As the Veteran's service-connected disability involves a scar on the left temporal parietal and affects the fifth cranial nerve, the Board the finds that the Veteran's service-connected disability is more appropriately rated under Diagnostic Code 7800 and Diagnostic Code 8205. See the October 2006 examination report. The applicable rating criteria for skin disorders, to include scars, are found at 38 C.F.R. § 4.118. During the pendency of this appeal for an increased rating, the criteria for evaluation of scars were amended as of October 23, 2008. However, the revisions are applicable to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Here, VA received the Veteran's claim in April 2006. Therefore, only the pre-October 2008 version of the schedular criteria is applicable in this case. Under Diagnostic Code 7800, a 10 percent evaluation is warranted for scars of the head, face, and neck when there is one characteristic of disfigurement. A 30 percent evaluation requires visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent evaluation requires visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) or; with four or five characteristics of disfigurement. An 80 percent evaluation requires visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (prior to October 23, 2008). Under note (1), the eight characteristics of disfigurement for purposes of evaluation under Diagnostic Code 7800, are: a scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39-sq.cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39-sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39-sq. cm.); skin indurated and inflexible in an area exceeding six square inches (39-sq. cm.). Under note (3) the adjudicator is required to take into consideration unretouched color photographs when evaluating scars under these criteria. 38 C.F.R. § 4.118, Diagnostic Code 7800 (prior to October 23, 2008). Under Diagnostic Code 8205, a 10 percent disability rating is warranted for paralysis of the left fifth cranial nerve when the paralysis is incomplete and moderate. A 30 percent disability rating is warranted when the paralysis is incomplete and severe. A maximum disability rating of 50 percent is warranted when there is complete paralysis of the involved nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8205 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2010). In October 2006, the Veteran underwent a VA examination provided by QTC for his service-connected status post shrapnel wound of the left face. At the examination, the Veteran reported that the service-connected disability is located on the left side of his face and neck. He admitted to not having any pain, loss of strength, weakness, fatigue, or impairment of coordination associated with his service-connected status post shrapnel wound of the left face. Upon physical examination of the Veteran, the VA examiner noted a depressed scar at the left temporal parietal measuring approximately 12 centimeters by 0.7 centimeters with tenderness, disfigurement, adherence, tissue loss of less than six square inches, and hypopigmentation of less than six square inches. There was no ulceration, instability, inflammation, edema, keloid formation, hyperpigmentation, or abnormal texture. The VA examiner indicated that there was no muscle group involvement or muscle wound present associated with the Veteran's service-connected disability, but rather muscle injury involving damage to the left temporal bone and nerve damage to the fifth cranial nerve. Palpation of the muscle revealed no loss of deep fascia or muscle substance, as well as no impairment of muscle tone. There were no signs of lowered endurance, impaired coordination, or muscle herniation. Examination of the peripheral pulses bilaterally reflected femoral pulse 2+, popliteal pulse 2+, dorsalis pedis pulse 2+, and anterior tibial pulse 2+. Neurological testing of the upper and lower extremities revealed motor function within normal limits as well as sensory function being within normal limits. Examination of the cranial nerves showed abnormal findings of reduced sensation on the left side of the face and middle portion around the left ear, attributable to neuritis. X-rays of the facial bones showed no evidence of fracture or other structural abnormalities; radiodense clips/sutures, anterior to the sella on the left side; mucoperiosteal thickening in the left maxillary sinus, which could be secondary to previous trauma; with evidence of a craniotomy seen in the frontal region. The VA examiner diagnosed the Veteran with status post shrapnel wound, left face, with residual scars, postoperative carotid ligation, and noted no change in the diagnosis. Based upon the evidence of record, the Board finds that a 30 percent rating, but no higher under Diagnostic Code 7800, is warranted for the Veteran's service-connected shrapnel wound of the left face. In order to warrant the next-higher 30 percent disability evaluation, the Veteran's scar must display visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement. In this case, the Veteran's scar associated with his service-connected shrapnel wound has three characteristics of disfigurement. As previously mentioned, at the October 2006 examination, the VA examiner described the Veteran's first scar as depressed, 0.7 centimeters in width, and adherent to underlying tissue. This satisfies three of the eight characteristics of disfigurement under Diagnostic Code 7800. As such, a 30 percent disability evaluation is warranted. However, a rating in excess of 30 percent is not warranted for the Veteran's service-connected shrapnel wound of the left face under Diagnostic Code 7800 or Diagnostic Code 8205. In order to warrant the next-higher 50 percent disability evaluation under Diagnostic Code 7800, the Veteran's scar must display visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with four or five characteristics of disfigurement. Such as not been demonstrated in this case. While the October 2006 examiner stated that there was tissue loss associated with the scar, it is less than six square inches, and there is no gross distortion or asymmetry of any of the Veteran's facial features. Additionally, as mentioned above, the Veteran's scar demonstrates three characteristics of disfigurement - scar at least one-quarter inch wide at the widest part, elevated or depressed on palpation, and adherent to underlying tissue. But, the scar has not displayed any of the other characteristics of disfigurement. The scar is not 5 or more inches in length, and the skin texture is not abnormal, indurated, or inflexible in an area exceeding six square inches. While the Veteran's scar has been described by the examiner as being hypopigmented, it does not exceed six square inches. Similarly, the scar has tissue loss, but it does not exceed six square inches. A higher rating is also not warranted under Diagnostic Code 8205. As mentioned above, in order to warrant the next-higher 50 percent disability rating under Diagnostic Code 8205, the Veteran must demonstrate complete paralysis of the fifth facial cranial nerve. At the October 2006 examination, the VA examiner reported nerve damage to the cranial nerve along with reduced sensation on the left side of the face and middle portion around the left ear, with no mention of any type of paralysis. Therefore, a higher rating is not warranted under Diagnostic Codes 7800 or 8207. The Board recognizes that there are situations in which the application of 38 C.F.R. §§ 4.40 or 4.45 is warranted in order to evaluate the existence of any functional loss due to pain, or any weakened movement, excess fatigability, incoordination, or pain on movement of the Veteran's joints. See DeLuca, supra. However, in this case, where the diagnostic code under which the Veteran is rated, in this case, Diagnostic Codes 7800 and 8205, is not predicated on loss of range of motion, §§ 4.40 and 4.45 do not apply. See Johnson v. Brown, 9 Vet. App. 7(1996). "Staged ratings" are not appropriate in this case, as there are no distinct time periods where the Veteran's symptoms warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In summary, and for the reasons and bases set forth above, the Board finds that the evidence supports a finding that the Veteran's service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation warrants a 30 percent rating, and no higher, and all reasonable doubt has been resolved in the Veteran's favor. See Gilbert, supra, 1 Vet. App. at 55. Vascular/Venous Disorder The Veteran contends that he warrants a compensable rating for his service-connected vascular/venous disorder. The Veteran's service-connected vascular/venous disorder is rated as 0 percent disabling under the 38 C.F.R. § 4.104, Diagnostic Codes 7199-7123. The Board notes that the Veteran's specific disability is not listed on the Rating Schedule, and the RO assigned Diagnostic Code 7199 pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99." See 38 C.F.R. § 4.20 (2010). The RO determined that the most closely analogous Diagnostic Code is 38 C.F.R. § 4.104, Diagnostic Code 7123, soft tissue sarcoma (of vascular origin). The Board finds that Diagnostic Code 7123 is not the most analogous diagnostic code for the Veteran's service-connected disability, but rather, 38 C.F.R. § 4.118, Diagnostic Code 7826, vasculitis, primary cutaneous, is more appropriate in this case. The Board notes that the RO analyzed the Veteran's service-connected disability under Diagnostic Code 7826 in the September 2009 Statement of the Case (SOC). Diagnostic Code 7826, which pertains to primary cutaneous vasculitis. Under this code, a 10 percent rating is warranted where there are recurrent debilitating episodes occurring one to three times during the past twelve months, and requiring intermittent systemic immunosuppressive therapy for control. A 30 percent rating is warranted where there are recurrent debilitating episodes occurring at least four times during the past twelve months, and requiring intermittent systemic immunosuppressive therapy for control. A 60 percent rating is warranted where there are recurrent debilitating episodes occurring at least four times during the past twelve months despite continuous immunosuppressive therapy. In addition, Diagnostic Code 7826 directs VA to rate vasculitis as disfigurement of the head, face or neck, pursuant to Diagnostic Code 7800, or scars, under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805, depending upon the predominant disability. See 38 C.F.R. § 4.118, Diagnostic Code 7826. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2010). The Veteran was afforded a VA examination provided by QTC in October 2006 for his service-connected vascular/venous disability. He admitted to not receiving any treatment for this disability and indicated that it does not prevent him from exertion or from performing any exercise. Physical examination of the Veteran revealed a scar associated with his vascular/venous disability located on the left anterior neck. The scar measured approximately 3 centimeters by 0.2 centimeters with hypopigmentation of less than six square inches. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hyperpigmentation, abnormal texture, inflammation, or edema associated with it. The examiner concluded that other than the scar located on the left anterior neck, there is no diagnosis for the Veteran's claimed vascular/venous disability because it has resolved. The Board finds that based upon the evidence of record, a compensable rating is not warranted for the Veteran's service-connected vascular/venous disorder under Diagnostic Codes 7826 or 7800. There is no evidence of recurrent episodes occurring one to three times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. In fact, at the October 2006 examination, the Veteran admitted to not receiving any treatment for the disability and more importantly, the VA examiner opined that the disability has resolved since service. Furthermore, there is no evidence that the Veteran's scar is reflective of a characteristic of disfigurement. The evidence of record indicates that the Veteran does not have a scar five or more inches (13 or more centimeters) in length, a scar at least one-quarter inch (0.6 centimeters) wide at the widest part, surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue, hypo-or hyper-pigmented skin in an area exceeding six square inches (39 square centimeters); abnormal skin texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters), underlying soft tissue missing in an area exceeding six square inches (39 square centimeters) or indurated and inflexible skin in an area exceeding six square inches (39 square centimeters). Thus, the Veteran does not have at the minimum one characteristic of disfigurement. There is no contrary evidence of record suggesting that the Veteran's symptomatology associated with his service-connected vascular meet the criteria for a higher rating. Thus, the Board finds that the criteria for a compensable evaluation have not been met. The objective medical evidence of record does not show that the Veteran warrants a compensable evaluation; therefore, the Board finds no basis upon which to predicate assignment of "staged" ratings pursuant to Fenderson and Hart, supra. The Veteran is competent to report his symptoms. The Board does not doubt the sincerity in the Veteran's belief that his disability is worse than the 0 percent evaluation; however, the objective medical evidence does not support the contention for a compensable evaluation. The Board finds that the preponderance of the evidence is against the claim for compensable rating for the Veteran's service-connected vascular/venous disorder, and the benefit-of-the-doubt rule is not for application. See Gilbert, 1 Vet. App. at 55. Extraschedular Consideration Consideration has also been given regarding whether the schedular evaluations are inadequate for the Veteran's service-connected disabilities, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations in this case are not inadequate. Evaluations in excess of that assigned are provided for certain manifestations of the service-connected disabilities at issue, but the medical evidence reflect that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected disabilities. For this reason, the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). B. Service Connection Claims Applicable Laws and Regulations New and Material Pursuant to 38 U.S.C.A. § 7105(c), a decision by the RO may not thereafter be reopened and allowed and a claim based upon the same factual basis may not be considered. The exception to this rule is described under 38 U.S.C.A. § 5108, which provides that "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim." Therefore, once a rating decision has been issued, absent the submission of new and material evidence, the claim cannot be reopened or adjudicated by VA. 38 U.S.C.A. §§ 5108, 7105(c); See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) (reopening after a prior Board denial). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Additionally, when determining whether the claimant has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). In Evans, the United States Court of Appeals for Veterans Claims (Court) indicated that the newly presented evidence need not be probative of all the elements required to award the claim, but need only tend to prove each element that was a specified basis for the last disallowance. Id. at 284. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection for certain "chronic diseases" (including arthritis) may be granted if manifest to a compensable degree within one year of separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1133, 1137 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309(a) (2010). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). In addition, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2010). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service-connected disability. See 71 Fed. Reg. 52744 (2010). The amendment sets forth language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the clam or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Heart Disorder The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the grant of service connection for a heart disorder, to include as secondary to the Veteran's service-connected shrapnel wound to the left face with residual scars, postoperative carotid ligation. Service treatment records do not reflect findings of a heart disorder. At an annual examination in May 1965, clinical evaluation of the Veteran's heart was normal. However, and more importantly, based upon the evidence in the claims file, no current diagnosis of the claimed heart disorder has been found. In April 2006, the Veteran's representative asserted that service connection is warranted for residuals of a heart attack secondary to poor blood flow. The Veteran was informed in June 2006 that he must have evidence of a current disability for his claimed heart disorder. He has not presented any such evidence nor has he provided any information as to where VA could obtain such evidence. Since there is no competent medical evidence of any current "disability," service connection cannot be granted. The United States Court of Appeals for Veterans Claims (Court) has held that a condition or injury occurred in-service alone is not enough; there must be a current disability resulting from that condition or injury. See Chelte v. Brown, 10 Vet. App. 268 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim"); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992); see Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (symptoms alone, without a finding of an underlying disorder, cannot be service-connected.) The resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, a heart disorder requires specialized training for a determination as to diagnosis and causation, and is therefore not susceptible of lay opinions on etiology. For the reasons stated above, the Board finds that a preponderance of the evidence is against the claims for service connection for a heart disorder, to include as secondary to the Veteran's service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation, and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Bilateral Hearing Loss At the time of the December 2004 rating decision, which denied service connection for bilateral hearing loss, the evidence of record consisted of the Veteran's service treatment records, the Veteran's February 2004 informal application for compensation benefits, a July 2004 formal application for compensation benefits, his DD Form 214, and results from an October 2004 VA examination provided by QTC Medical Services. In the December 2004 rating decision, the RO conceded that the Veteran was exposed to acoustic trauma in service, due to being a recipient of the Purple Heart Medal; however, results from the October 2004 audiological evaluation revealed that the Veteran's hearing was within normal limits. The RO concluded that because the Veteran has not been diagnosed with bilateral hearing loss, service connection must be denied. The Veteran was notified of the denial in a January 2005 letter, including his appeal rights, and he did not appeal the decision. Thus, it is final. See 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. Based upon the evidence of record, the Board finds that the Veteran has not presented evidence since the December 2004 rating decision, which raises a reasonable possibility of substantiating the claim for service connection for bilateral hearing loss. Since the December 2004 rating decision, the pertinent evidence received into the record includes the Veteran's informal claim for service connection for bilateral hearing loss dated April 2006, his April 2006 notice of disagreement (NOD) and his substantive appeal, received by the RO in November 2009. As of this date, the Veteran has not submitted any medical evidence showing a current bilateral hearing loss disability. In fact, the Veteran has not expressed any specific contentions regarding his claim for service connection for bilateral hearing loss since the December 2004 rating decision. As such, because the Veteran has not submitted new and material evidence to substantiate his claim, his claim for service connection for bilateral hearing loss is not reopened. For the reasons and bases set forth above, the Board finds that the evidence received in conjunction with the claim to reopen is not new and material, and does not serve to reopen the claim for service connection for bilateral hearing loss. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156(a). Having found that the evidence is not new and material, no further adjudication of this claim is warranted. See Kehoskie v. Derwinski, 2 Vet. App. 31 (1991). ORDER Entitlement to an increased evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a 30 percent evaluation for shrapnel wound, left face, with residual scars, postoperative carotid ligation, is granted subject to the laws and regulations pertaining to the payment of monetary benefits. Entitlement to a compensable evaluation for vascular/venous disorder as secondary to the service-connected shrapnel wound, left face, with residual scars, postoperative carotid ligation is denied. Entitlement to service connection for a heart disorder is denied. New and material evidence not having been presented, the application to reopen a claim for service connection for bilateral hearing loss is denied. REMAND Although further delay is regrettable, the Board finds that the record as it stands is currently inadequate for the purpose of rendering a fully informed decision as to the claim of entitlement to a TDIU. Where the record before the Board is inadequate to render a fully informed decision, a remand is required in order to fulfill VA's statutory duty to assist the Veteran to develop the facts pertinent to the claim. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). The law provides that a TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2010). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2010). At the October 2006 examination for the Veteran's service-connected status post shrapnel wound, left face, with residual scars, postoperative carotid ligation and his service-connected vascular/venous disability secondary to carotid ligation, the Veteran informed the examiner that he cannot keep up with his normal work requirements because of his visual impairment due to his service-connected left eye enucleation. The Board notes that while the Veteran has been afforded VA examinations, an opinion as to his unemployability and the effect of his service-connected disabilities on his employability was not rendered. The Board finds that the Veteran should be afforded an appropriate VA examination to determine whether he is unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. Therefore, in order to give the Veteran every consideration with respect to the present appeal and to ensure due process, this matter is REMANDED for the following action: 1. Schedule a VA medical examination for an opinion regarding whether it is at least as likely as not ( 50 percent or greater likelihood) that the Veteran's service-connected disabilities, in and of themselves, prevent him from securing or maintaining substantially gainful employment. The examination report must indicate whether pertinent records in the claims file were reviewed in conjunction with the examination. A rationale for any opinion reached must be provided. If the VA examiner concludes that an opinion cannot be offered without engaging in speculation then she/he should indicate this and discuss why an opinion cannot be rendered. 2. Thereafter, readjudicate the issue of entitlement to a TDIU. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs