Citation Nr: 1306153 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 09-21 212 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for a left knee disorder. 2. Entitlement to a higher (compensable) initial rating for service-connected bilateral hearing loss. 3. Entitlement to an increased (compensable) rating for service-connected residuals of shrapnel wound of the left leg. 4. Entitlement to an initial rating in excess of 10 percent for dermatitis and tinea pedis of both feet. 5. Entitlement to an increased rating for posttraumatic stress disorder (PTSD) in excess of 50 percent from April 7, 2003 and in excess of 70 percent from April 4, 2007. REPRESENTATION Appellant represented by: Robert Chisholm, Attorney ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran (Appellant or Claimant) had active duty service from August 1969 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2007, November 2007, and December 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In January 2010, the Veteran, through his attorney, requested a videoconference hearing. A hearing was scheduled for November 2012. In correspondence received in November 2012, the Veteran's attorney indicated that the Veteran wished to cancel the hearing and did not want to reschedule. FINDINGS OF FACT 1. In a July 1986 rating decision, the RO denied service connection for a left knee condition, finding that the Veteran was not diagnosed with a chronic left knee condition in service and that a left knee disability was not shown upon VA examination. 2. The evidence received since the July 1986 rating decision denying service connection for a left knee condition that was not previously considered is cumulative, does not relate to an unestablished fact of the existence of a current disability necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. 3. Throughout the appeal period, the Veteran's hearing loss has been manifested by no worse than Level I hearing acuity in both ears. 4. Throughout the appeal period, the service-connected residuals of shrapnel wound of the left leg have been manifested by a scar that is not tender, not painful, is less than 144 square inches, and does not cause any limitation of motion or function. 5. Throughout the appeal period, dermatitis and tinea pedis of both feet has affected less than 40 percent of the entire body and less than 40 percent of exposed areas, and has not required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during a 12-month period. 6. Prior to April 4, 2007, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, without deficiencies in most areas. 7. From April 4, 2007, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas due to symptoms such as near continuous panic affecting the ability to function independently, appropriately, and effectively, and difficulty in adapting to stressful circumstances (including work or a worklike setting), and without total occupational and social impairment. CONCLUSIONS OF LAW 1. The July 1986 rating decision denying service connection for a left knee disability became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). 2. New and material evidence has not been received to reopen service connection for a left knee disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for a compensable rating for bilateral hearing loss have not been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.85, 4.86, Diagnostic Code 6100 (2012). 4. The criteria for a compensable rating for service-connected residuals of shrapnel wound of the left leg have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.118, Diagnostic Codes 7801-7805 (2007). 5. The criteria for a rating in excess of 10 percent for dermatitis and tinea pedis of both feet have not been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.118, Diagnostic Code 7806 (2012). 6. Prior to April 4, 2007, the criteria for a rating in excess of 50 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411 (2012). 7. From April 4, 2007, the criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102 , 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court has held that the VCAA requires additional notice when a claimant seeks to reopen a previously denied claim. In Kent v. Nicholson, 20 Vet. App. 1, 9-10 (2006), the Court held that VA must examine the basis for a denial of a previously disallowed claim and provide the appellant with notice of the evidence of service connection found lacking in the previous denial. A May 2007 letter explained the basis of the prior denial of service connection (left knee injury not found in service treatment records and no evidence of a left knee injury on VA examination in 1986) and provided the Veteran with notice of the evidence required to substantiate the claims for service connection for hearing loss and a skin condition. This letter notified the Veteran of what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. This letter included provisions for disability ratings and effective dates. In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The information required by Vazquez was provided in the May 2007 letter. The Veteran's appeals for higher initial ratings for hearing loss and dermatitis and tinea pedis stem from the disagreement with the initial ratings assigned in the July 2007 and November 2007 rating decisions which granted service connection for those disabilities. Because the appeal of those issues stems from the Veteran's disagreement with the initial ratings following the grant of service connection for bilateral hearing loss and dermatitis and tinea pedis of both feet, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i)(2012) (no duty to provide VCAA notice arises upon receipt of a Notice of Disagreement). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's statements. The Veteran has been afforded VA examinations. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was afforded VA examinations for hearing loss disability in May 2007, May 2010, and March 2011. He was afforded a VA examination of his left leg shrapnel wound in March 2007. The Veteran was afforded a VA examination for dermatitis and tinea pedis in March 2007, and VA examinations for PTSD in May 2007 and March 2011. The examinations considered all the pertinent evidence of record, including the Veteran's statements and the claims file. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Claim to Reopen Service Connection for a Left Knee Disorder The Veteran seeks to reopen a previously denied claim for service connection for a left knee condition. The Veteran filed a claim to reopen for service connection for a left knee condition in March 2007. The Veteran contends that he injured his left knee during a training run in service and was diagnosed with torn cartilage in his left leg. The claim for service connection for a left knee disorder was previously denied in a July 1986 rating decision. The RO denied the claim based upon a finding that there was no evidence that the Veteran was diagnosed with a chronic left knee condition incurred in or related to military service. The rating decision found that a left knee disability was not shown during service and that there was no current diagnosis of a left knee disability. The Veteran did not submit a timely notice of disagreement to the July 1986 decision, and it became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means 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). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence must be both new and material; if the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If the Board determines that the evidence submitted is new and material, it must reopen the case and evaluate the appellant's claim in light of all the evidence. Justus, 3 Vet. App. at 512. The evidence of record at the time of the July 1986 rating decision included service treatment records and a report of a VA examination dated in June 1986. Service treatment records show that the Veteran was seen in sick call in October 1970 with complaint of knee pain. The Veteran reported that he had pain in his knees with hopping, and his knees felt like they were going to give out. He did not report a left knee injury. Physical examination showed that the knees were symmetrical with no edema, effusion, instability, and no bony abnormalities palpable. No left knee disability was diagnosed. The Veteran was seen in June 1971 with a complaint of pain on the inner aspect of his left knee. He reported that his left knee had been aggravated by continued running and marches. Examination of the knee showed full range of motion, no deformity, no crepitus, no swelling, and no pain on motion. The June 1986 VA examination noted a complaint of left knee pain and a diagnosis of left knee strain. The evidence received since the prior final denial of service connection for a left knee condition in July 1986 includes VA medical records, medical records from two private physicians, Dr. Tweedy and Dr. McGrath, dated in 2007, records from University Sleep Center dated in 2007, records from Temple Hospital dated in 2007 and statements from the Veteran. The records from Dr. Tweedy, Dr. McGrath, University Sleep Center and Temple Hospital do not relate to a left knee disorder and, therefore, are not material to the issue of service connection for a left knee disorder. A report of a VA primary care initial evaluation dated in April 2009 reflects that the Veteran reported a history of a left knee injury in the military over 40 years ago. A VA physician noted a history of left knee injury and advised the Veteran to continue to take Mobic as needed for pain. The VA physician did not diagnose a left knee disability. The VA treatment record shows that the Veteran reported a history of a left knee injury in service. The VA physician did not diagnose a left knee disability, but only recorded the history of injury in service. Mere transcription of the lay history provided by the Veteran does not become competent medical evidence. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Elkins v. Brown, 5 Vet. App. 474, 478 (1993). Although the Veteran has reported knee pain, a complaint of pain does not establish a current diagnosis of a left knee disability. Symptoms such as pain, by itself and without an underlying medical condition, do not constitute a disability for VA disability compensation purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). In a written statement dated in October 2006, the Veteran indicated that his left leg gave way during a training run, and he hit the ground. He indicated that his leg was swollen and stiff following the in-service injury. The Veteran indicated that he visited sick bay and was diagnosed with torn cartilage in his left leg. The Veteran is competent to report that he sustained a left knee injury in service, experienced symptoms of swelling and stiffness, was diagnosed with torn cartilage, and was treated. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran is not competent to diagnose a current left knee disability. He is competent to report that he had swelling and stiffness, but symptoms of swelling and stiffness do not establish a diagnosis of a left knee disability. Sanchez-Benitez, supra. The Board finds that the evidence received since the prior final denial of service connection for a left knee disability is new, as it was not previously of record. However, the evidence is not material. The claim was previously denied because the evidence did not show a current disability of the left knee. The evidence received since the prior final denial does not relate to an unestablished fact of current disability that is necessary to substantiate the claim, as it does not provide evidence of a current disability. For these reasons, the Board finds that newly received evidence does not raise a reasonable possibility of substantiating the claim for service connection for a left knee disorder. Accordingly, the evidence received since the most recent final denial of the claim in July 1986 does not tend to show a current diagnosis, so it is not new and material, and reopening of service connection for a left knee disorder is not warranted. Because the new evidence, in the context of all the evidence of record, has not fulfilled the threshold burden of being new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Disability Ratings - Law and Regulations Disability evaluations (ratings) are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 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. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Initial Rating for Bilateral Hearing Loss A July 2007 rating decision granted service connection for bilateral hearing loss and assigned a non-compensable rating from March 2007. The Veteran contends that his hearing has worsened. He stated that he had to use hearing aids. The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The "puretone threshold average" as used in Table VI is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85(d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b). In this case, the exceptional pattern of hearing criteria of § 4.86 are not met, so the rating criteria for exceptional hearing impairment do not apply in this case. In this case, a report of a VA examination in May 2007 shows that the puretone thresholds at frequencies of 1000, 2000, 3000, and 4000 Hertz in the right ear were 20, 15, 25 and 35, with an average puretone threshold of 24 decibels. The puretone thresholds at frequencies of 1000, 2000, 3000, and 4000 Hertz in the left ear were 15, 15, 30, and 25, with an average puretone threshold of 21 decibels. Speech recognition scores were 84 percent in the right ear and 88 percent in the left ear. Using Table VI, the hearing impairment is Level I in both ears. This results in a noncompensable (0 percent) disability evaluation under Table VII. See 38 C.F.R. § 4.85. Private treatment records from Dr. McGrath, dated in April 2007, reflect a diagnosis of progressive hearing loss. These records did not provide audiometric thresholds or speech recognition scores. A report of a VA examination dated in May 2010 reflects that puretone thresholds at frequencies of 1000, 2000, 3000, and 4000 Hertz in the right ear were 20, 15, 25, and 30, with an average puretone threshold of 22. The puretone thresholds in the left ear at frequencies of 1000, 2000, 3000 and 4000 Hertz were 15, 20, 30 and 25, with a puretone threshold average of 22. Speech recognition scores were 94 percent in the right ear and 96 percent in the left ear. Using Table VI, the hearing impairment is Level I in both ears. This results in a noncompensable (0 percent) disability evaluation under Table VII. 38 C.F.R. § 4.85. Upon VA examination in March 2011, the puretone thresholds in the right ear at frequencies of 1000, 2000, 3000 and 4000 Hertz were 20, 20, 30 and 30, with a puretone threshold average of 25. The puretone thresholds in the left ear at frequencies of 1000, 2000, 3000 and 4000 Hertz were 20, 15, 30 and 30, with a puretone threshold average of 25. Speech recognition scores were 94 percent in each ear. Using Table VI, the hearing impairment is Level I in both ears. This results in a noncompensable (0 percent) disability evaluation under Table VII. 38 C.F.R. § 4.85. The Board has reviewed the lay and medical evidence and finds that the evidence does not support an initial compensable evaluation for hearing loss for any period. The VA and private audiology examination reports of record show that for the entire rating period the Veteran has had Level I hearing acuity in both ears. The level of hearing loss disability, as reflected by audiometric test scores and speech recognition test scores, does not establish entitlement to a higher (compensable) rating for bilateral hearing loss for any period. The rating of hearing loss disability involves the mechanical application of the rating schedule to numeric designations assigned to official audiometric results. See Lendenmann, 3 Vet. App. at 345. For these reasons, the Board finds that there is a preponderance of the evidence against the appeal for a higher (compensable) initial rating for bilateral hearing loss for any period. As there is a preponderance of the evidence against the appeal, reasonable doubt may not be resolved in the Veteran's favor. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Shrapnel Wound of the Left Leg The Veteran seeks an increased rating in excess of 0 percent for shrapnel wound, left leg. Service connection for shrapnel wound of the left leg, has been in effect since November 1988. A non-compensable rating is assigned. A claim for an increased rating was received in March 2007. The Veteran contends that his left leg shrapnel wound disability has worsened. The Board notes that as of October 23, 2008 revised provisions for evaluating scars were enacted; however, this new regulation indicates that the revised provisions are applicable only to claims received on or after October 23, 2008. Accordingly, these revisions do not apply to the present case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Rather, the Veteran's claim for a higher rating for scars will be considered solely under the criteria effective as of the date of the 2007 claim for an increased rating. Service treatment records reflect treatment for a shrapnel wound of the left leg. An October 1970 entry in the service treatment records reflects that the Veteran received minor shrapnel wounds of the left arm and leg when he was searching a base camp area, and a surprise firing device was detonated. The Veteran was medevaced from the field. Diagnostic Code (DC) 7800 rates scars of the head, face, or neck based upon disfigurement, and does not apply in this case as the service-connected shrapnel wound is located on the Veteran's left leg. Under DC 7801, scars, other than of the head, face or neck, that are deep or that cause limited motion warrant a 10 percent rating when the scars cover an area or areas exceeding 6 square inches (39 sq. cm.). Scars that are superficial, do not cause limited motion, and cover area of 144 inches or more are given a compensable rating under DC 7802. Unstable superficial scars are rated under DC 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Superficial scars that are painful on examination are rated under DC 7804. DC 7804 stipulates that a 10 percent disability evaluation will be warranted with evidence that a superficial service-connected scar is painful on examination. DC 7805 provides that other scars are rated on limitation of function of the affected part. A deep scar is one associated with underlying soft tissue damage, and a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801-7805. The Veteran had a VA examination in May 2007. The Veteran reported that he had a shell fragment wound in the left lower leg from a blast injury. On examination, the Veteran had a superficial scar in the left medial thigh in the mid region. The scar was 1 centimeter by 1 centimeter. The scar was not tender or painful. It was not adherent to underlying tissue. The texture was smooth. There was no ulceration or skin breakdown and no elevation of depression of the scar. There was no loss of underlying tissue and no inflammation, edema, or keloid formation. The VA examiner stated that the scar was barely visible as compared to the normal skin. There was no disfigurement from the scar. The Veteran had a VA examination in May 2010. The Veteran reported that he sustained an injury to the inner aspect of the left thigh when a blast went off and a piece of metal entered his thigh. The Veteran reported that he did not have any treatment since that time and did not experience any complaints or symptoms. He reported that he did not have any pain, and his activities of daily living were not affected by the injury to the left thigh. Upon physical examination in May 2010, there were no muscle deformities and no bony deformities related to the entry of shrapnel into the left thigh. There was no residual scar noted and no evidence of hard masses in the area of the shrapnel wound. The Board has reviewed all the lay and medical evidence and finds that the evidence does not support a compensable rating for shrapnel wound of the left leg for any period. The Veteran's left leg scar is not deep and does not exceed 6 inches. Accordingly, a higher rating is not warranted under DC 7801. A compensable rating under DC 7802 is not warranted, as the Veteran's scar does not cover an area of 144 inches or more. A compensable rating under DC 7803 is not warranted, as the scar is not unstable. A compensable rating is not warranted under DC 7804, as the scar is not painful on examination. The scar does not cause limitation of motion of the left leg; accordingly, a higher (compensable) rating is not warranted on that basis. The Board has considered whether a rating is assignable under the criteria set forth in 38 C.F.R. §§ 4.56 and 4.73 (2012), pertaining to evaluation of muscle disabilities. Under 38 C.F.R. § 4.56, slight disability of muscles is shown when there is a simple wound of muscle without debridement or infection and a history and service department records show a history and complaint of a superficial wound with brief treatment and return to duty and healing with good functional results. Objective findings for a slight disability of muscles include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus. The service treatment history and objective findings in this case more nearly approximate slight disability under § 4.56, for which a 0 percent evaluation is warranted under § 4.73, DC 5315. DC 5315 provides that a 20 percent rating is assignable for moderately severe injury of the muscle group. The service treatment records noted a minor shrapnel wound of the left leg. The scar is minimal, and there is no evidence of fascial defect, atrophy, or impaired tonus. The evidence does not show that there is impairment of muscle function associated with the shell fragment wound or metallic fragments retained in muscle tissue. The May 2010 VA examination indicated there were no muscle deformities related to the shrapnel wound. Accordingly, an increased (compensable) rating is not warranted under the criteria for muscle injuries found in 38 C.F.R. §§ 4.56 and 4.73. For these reasons, the Board finds that there is a preponderance of the evidence against the claim for an increased (compensable) rating for a shrapnel wound of the left leg for any period. As there is a preponderance of the evidence against the Veteran's claim for an increased rating, there is no reasonable doubt to be resolved in the Veteran's favor, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Dermatitis and Tinea Pedis A November 2007 rating decision granted service connection for dermatitis and tinea pedis, bilateral feet and assigned a non-compensable rating from March 2007. The Veteran entered a notice of disagreement with the initial rating assigned and seeks a higher initial rating. The Veteran contends that his feet break out with blisters, and he sometimes cannot wear shoes. Dermatitis is rated under Diagnostic Code 7806. Diagnostic Code 7813 provides that dermatophytosis, including tinea pedis, is to be rated as disfigurement of the head, face and neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804 or 7805), or dermatitis (DC 7806), depending on the predominant disability. Diagnostic Code 7806 provides that a 0 percent rating is assignable for dermatitis or eczema when less than 5 percent of the entire body or less than 5 percent of exposed areas are affected and no more than topical therapy required in the past 12-month period. A 10 percent rating is assignable when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected; or when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a duration of less than six weeks during the past 12-month period. A 30 percent rating is assignable when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assignable where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118. Service treatment records reflect that the Veteran reported sores on his feet in December 1970 and March 1971. In December 1970, foot powder was prescribed. Private medical records dated in 1992 noted chronic dermatitis involving both feet. The Veteran had a VA examination in May 2007. The Veteran reported a rash on his feet that had persisted since 1971. He reported that he used a topical cream that was prescribed by his primary physician on both feet daily for his chronic skin disability. The Veteran reported that he had been applying the prescribed topical cream once daily for the past 12 months with minimal improvement in his skin condition. The VA examiner noted that dermatitis affected less than 5 percent of exposed areas and less than 5 percent of the entire body. On examination in May 2007, the Veteran had a prominent area of dry scaly skin with faint minor fissures that measured 8 centimeters by 5 centimeters in the medial mid-portion of his right foot. Similar dry skin with faint fissures was noted in the medial aspect of the left foot. The chronic dermatitis was more prominent in the right foot compared to the left foot. The Veteran had a fungal rash between the webs of his toes of both of his feet from tinea pedis. There were no interdigital macerations or deep fissures present. The chronic dermatitis was superficial, not tender, and not painful. Upon VA examination in May 2010, the Veteran reported itchy, fluid-filled bumps on his feet. He reported that they could bleed and drain pus. He described the symptoms as constant. He reported that he used over-the-counter powder. The May 2010 VA examiner noted that the skin examination showed extensive scaling and some hyperpigmentation in a moccasin pattern bilaterally with interdigital maceration. The examiner noted that many of the toenails were onychomycotic. Zero percent of exposed areas were affected. Five percent of the entire body was affected. There was no scarring or disfigurement. The Board has reviewed the lay and medical evidence of record and finds that the evidence is against an evaluation in excess of 10 percent for dermatitis and tinea pedis of the feet for any period. The evidence during the entire rating period shows dermatitis and tinea pedis affects less than 20 percent of the entire body or exposed areas and has not required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. Accordingly, a rating higher than 10 percent is not assignable under DC 7806 for any period. For these reasons, the Board finds that a preponderance of the evidence is against the appeal for an initial rating higher than 10 percent for dermatitis and tinea pedis bilateral feet. As there is a preponderance of the evidence against the Veteran's claim for a higher initial rating, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Increased Rating for PTSD Service connection for PTSD was granted in a November 1988 rating decision, and a 30 percent rating was assigned. A claim for an increased rating was received in March 2007. A July 2007 rating decision granted a 50 percent rating from March 2007. A notice of disagreement was received in April 2008. In a December 2009 Statement of the Case, the RO determined that an informal claim for an increased rating for PTSD was received in April 2003. The RO assigned a 50 percent rating from April 2003. A 70 percent rating was assigned from April 2007. The Veteran contends that his PTSD has caused time lost from work, irritability and conflict with supervisors. He has indicated that that he has nightmares, is suspicious of people, and feels depressed. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this general rating formula, a 30 percent evaluation is warranted where the evidence shows occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if it is productive of 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 of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating, may be assigned for 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); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular evaluation contemplates 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, DC 9411. As noted below, treatment providers have rendered Global Assessment of Functioning (GAF) scores pursuant to the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). As indicated in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995), the GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. A score in the range of 51 to 60 indicates moderate symptoms (e.g., a flattened affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., avoiding friends, neglecting family, and unable to work). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See also 38 C.F.R. § 4.126(a) (2012) (an evaluation shall be based on all the evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of examination). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). Rating PTSD From April 7, 2003 to April 4, 2007 All of the evidence shows that, during this period, PTSD was characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as difficulty sleeping, feeling down, sad affect, poor appetite, and being startled easily. This impairment and symptomatology more nearly approximates the 50 percent criteria for rating PTSD under Diagnostic Code 9411. 38 C.F.R. § 4.130. In a January 2007 written statement, the Veteran indicated that his PTSD symptoms included not being able to sleep, nightmares, and stress. At an initial PTSD evaluation on April 7, 2003, the Veteran reported depressive symptoms such as little interest or pleasure, feeling down, trouble sleeping and being tired with lower energy. He reported poor appetite, feelings of failure and guilt and trouble concentrating. The Veteran reported no psychotic or hypomanic symptoms. The Veteran denied suicidal ideation. A VA psychiatrist stated that the Veteran met the criteria for generalized anxiety disorder. No GAF score was assigned. A VA mental health intake evaluation dated in May 2003 reflects that the Veteran reported feeling down a lot. He reported decreased energy, interest in activities and appetite and feeling hopeless. He reported that he was easily startled by loud noises and had difficulty sleeping and nightmares of combat experiences. The Veteran reported occasional thoughts of suicide. He denied any immediate plans to attempt suicide. On mental status examination, the Veteran was appropriately dressed. He showed no psychomotor agitation or retardation. There was a paucity of speech, but it was of normal rate, volume and tone. The Veteran's thought was linear and goal directed. The Veteran had occasional suicidal ideations with vague plans, but no current intent. He denied homicidal ideations. There were no delusions or fixations. His affect was tired and sad. He reported feeling down. He had limited insight into the severity of his depression. The Axis I diagnosis was PTSD, substance induced mood disorder, and alcohol abuse versus alcohol dependence. A GAF score of 50 was assigned. VA treatment records dated in June 2003 reflect that the Veteran was admitted for treatment of alcohol and cannabis use in the context of highly symptomatic PTSD. On mental status examination, the Veteran was alert, responsive and cooperative. He was fully oriented without evidence of cognitive inefficiency. His speech was logical, coherent and goal-directed. There was no suggestion of abnormal ideation. His affect was blunted but acceptably modulated with a modest range of not inappropriate display. He denied suicidal and homicidal ideation. Insight and judgment were acceptable. Multiaxial diagnoses included alcohol dependence, cannabis dependence and PTSD with depression. A GAF score of 38 was assigned. The Board has weighed and considered the GAF scores assigned during the entire rating period. The GAF score of 50 assigned in May 2003 reflects serious impairment. Although a GAF score of 38 was assigned in June 2003, the evidence reflects that the Veteran's symptoms were most consistent with the criteria for a 50 percent rating. The June 2003 treatment record indicated that the Veteran was fully oriented, without suicidal or homicidal ideation. His speech was logical and goal-directed. His judgment was acceptable. The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, 9 Vet. App. at 267; Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). The GAF score must be considered in light of the actual impairment and symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Board has reviewed all the lay and medical evidence of record and finds that, for the period from April 7, 2003 to April 4, 2007, the evidence is against an evaluation in excess of 50 percent. The Board finds that, during the period from April 7, 2003 to April 4, 2007, the Veteran's PTSD was characterized by difficulty sleeping, feeling down, sad affect, poor appetite, and being startled easily. The Veteran reported occasional suicidal thoughts, but no current intent. These symptoms are most consistent with occupational and social impairment with reduced reliability and productivity, which is contemplated by the 50 percent rating assigned for this period under DC 9411. 38 C.F.R. § 4.130. The Board also finds that the symptomatology for the rating period prior to April 4, 2007 does not more nearly approximate the criteria for the next higher 70 percent disability rating under Diagnostic Code 9411. The Veteran's PTSD was not characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. From April 4, 2007 The evidence reflects that, for the period from April 4, 2007, PTSD was characterized by unprovoked irritability, neglect of personal appearance and hygiene, and difficulty with maintaining work relationships. This symptomatology is contemplated by the 70 percent criteria for rating PTSD under Diagnostic Code 9411. 38 C.F.R. § 4.130. On April 4, 2007, the Veteran was seen by a private psychologist, F.K. The Veteran reported multiple angry interchanges at work that had almost resulted in his dismissal. He reported that he had an arrest record for fighting. Mental status examination showed that the Veteran was awake, alert and responsive. The Veteran was oriented times four. His mood was irritable. His affect was congruent. Reality testing was guarded. Thought content was reduced. His thought processes were intact. The Veteran's insight and judgment were guarded. His short-term memory and long-term memory were within normal limits. Attention was within normal limits. Language was coherent. The Veteran had a VA examination in May 2007. The Veteran reported sleep difficulties with nightmares. He reported that he was hypervigilant, had an irritable mood, and was short-tempered. He reported that he had a frequent desire to hit somebody and argued quite easily. The Veteran reported that he had been reprimanded on the job and put out of work for a month because of difficulties getting along with supervisors. The Veteran reported difficulty being in a crowd. The Veteran reported that he did get anxious and had panic feelings. He denied any recent suicidal ideation. On mental status examination in May 2007, the Veteran appeared to be in good reality contact and was oriented in all three spheres. There was no evidence of delusions or hallucinations in his thought content, and no recent suicidal or homicidal ideation. His general reasoning and judgment seemed adequate. His memory was fair for both recent and remote events. His affect was calm. A January 2011 report from Dr. Kellner indicated that the Veteran had sleep disturbances, insomnia and nightmares, and readily experienced hypervigilance. The Veteran had a VA examination in March 2011. The Veteran reported that PTSD significantly interfered with his daily activities. The Veteran reported that he considered it a success if he was able to shower and shave twice a week. He reported that it required an inordinate amount of motivation to take care of his personal hygiene. He reported that he was able to take care of activities around the house such as cooking and cleaning. The Veteran reported significant conflict with his co-workers and reported that he worked 7 to 9 days out of the month. The examiner assigned a GAF score of 32. The examiner noted that there was major impairment in several areas, including work, family relations, thinking, and mood. The examiner stated that the Veteran meets the criteria for posttraumatic stress disorder with symptoms of re-experiencing, avoidance, and hyperarousal. The Board has reviewed the lay and medical evidence of record and finds that, for the period after April 4, 2007, the evidence does not support an evaluation in excess of 70 percent. The record shows that, for the time period after April 4, 2007, the Veteran's PTSD was characterized by irritability, hypervigilance, anxiety and difficulty adapting to stressful circumstances in a work or work-like setting. The Board concludes that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating criteria under DC 9411. 38 C.F.R. § 4.130. The evidence does not show that the Veteran has 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. For these reasons, the Board finds that a preponderance of the evidence is against the appeal for an increased rating for PTSD in excess of 50 percent for the rating period from April 7, 2003 to April 4, 2007 and in excess of 70 percent after April 4, 2007. As there is a preponderance of the evidence against the Veteran's claim for an increased rating, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's hearing loss, shrapnel wound, dermatitis and tinea pedis, and PTSD. The schedular rating criteria for hearing loss specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns which are not demonstrated in this case, and as measured by both audiological testing and speech recognition testing. Speech recognition testing is a schedular rating criterion that recognizes such an inability to understand certain words in conversation. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court noted that, unlike the rating schedule for hearing loss, the extraschedular provisions did not rely exclusively on objective test results to determine whether referral for an extraschedular rating was warranted. The Court held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The May 2010 VA examination noted that the effect of the Veteran's hearing loss on occupational functioning and daily activities include that he has to ask people to repeat sometimes and feels like he can hear but cannot make out what is being said. The March 2011 VA examination noted that the effect of hearing loss on the Veteran's daily life was that he had to ask people to repeat. The rating criteria for scars consider the size of the scar, whether the scar is painful, unstable, or results in limitation of function of the affected area. The rating criteria for muscle injuries consider the history of the wound and objective findings and whether the muscle disability is slight, moderate, moderately severe, or severe. The rating criteria for dermatitis and tinea pedis consider the percentage of the entire body and exposed areas affected and whether systemic therapy is required. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested difficulty sleeping, feeling down, sad affect, poor appetite, and being startled easily, unprovoked irritability, neglect of personal appearance and hygiene, and difficulty with maintaining work relationships. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Because the schedular rating criteria is adequate to rate the Veteran's disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER New and material evidence not having been received, the appeal to reopen service connection for a left knee disorder is denied. An higher (compensable) initial rating for hearing loss is denied. An increased (compensable) rating for service-connected residuals of shrapnel wound of the left leg is denied. An initial rating in excess of 10 percent for dermatitis and tinea pedis of the feet is denied. An increased rating for PTSD, in excess of 50 percent prior to April 4, 2007, and in excess of 70 percent from April 4, 2007, is denied. ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs