Citation Nr: 1310722 Decision Date: 04/01/13 Archive Date: 04/11/13 DOCKET NO. 09-24 706 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to a rating in excess of 50 percent for chronic adjustment disorder with mixed anxiety and depressed mood (adjustment disorder). 2. Entitlement to a rating in excess of 10 percent for a residual scar from a laceration of the scrotum (residual scar). 3. Entitlement to service connection for voiding dysfunction due to urinary frequency. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran had active duty service from October 1954 to September 1958. These issues come before the Board of Veterans' Appeals (Board) from an October 2008 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Hartford, Connecticut which denied the Veteran's claims for an increased rating for his adjustment disorder and a residual scar of the scrotum. In October 2010, the Board remanded this claim for further development, which included a decision review officer (DRO) hearing. The Veteran testified before a DRO in April 2012. A copy of the transcript has been reviewed and is in the file. In November 2012, the RO granted a separate evaluation for erectile dysfunction and assigned a noncompensable rating from May 1, 2012. Special Monthly Compensation (SMC) based on loss of use of a creative organ was also granted. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for voiding dysfunction due to urinary frequency is REMANDED to the RO via the Appeals Management Center (AMC). The Veteran will be advised if further action is required on his part. FINDINGS OF FACT 1. The adjustment disorder is manifested by difficulty establishing effective work and social relationships without deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. The residual scar is manifested by pain, but has not resulted in disfigurement of the head, face or neck, instability of the skin, affected an area of six square inches or 39 square centimeters or more or limited motion. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for adjustment disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The schedular criteria for a rating in excess of 10 percent for a residual scar have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DCs 7800-7805 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); Pub. L. 112-154, §§ 504(a)(1)-(2), 505(a)-(b) (Aug. 6, 2012) (to be codified at 38 U.S.C.A. §§ 5103(a)-(b), 5103A(b)-(c)); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, 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, 1277 (2009). In a pre-adjudication letter dated in March 2008, the RO notified the Veteran of the evidence needed to substantiate his claims. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The Veteran has substantiated his status as a Veteran. He was notified of all other elements of the Dingess notice, including the disability-rating and effective-date elements of his claim, in the March 2008 letter. No further development is required with respect to the duty to notify. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA has obtained all of the identified VA and private treatment records. In addition, he was afforded multiple VA examinations that contain all findings needed to rate his psychiatric and scar disabilities. The Board's remand was for efforts to obtain records of inguinal hernia surgery and afford the Veteran the DRO hearing. As noted, the hearing was provided. The AMC also obtained the surgery and treatment records. It thereby complied with the Board remand. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The Board finds that the duties to notify and to assist have been fulfilled. Rating criteria generally In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (2012). Also, the entire period is considered for the possibility of staged ratings. Consideration will be given to the possibility of separate ratings for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (2012). It is VA's defined and consistently applied policy to administer the law under a broad interpretation that is consistent with the facts shown in every case. 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. See, 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). When deciding claims for increased disability ratings, the Board must particularly consider the credibility of a claimant's statements reporting symptoms. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009) (noting that the Board's failure to discuss a veteran's report of a symptom, combined with a failure to address her credibility, rendered its statement of reasons or bases inadequate). Increased rating for adjustment disorder For this time period, the Veteran is currently assigned a 50 percent rating for adjustment disorder, which is rated under 38 C.F.R. § 4.130, DC 9499-9410, the schedule of ratings for mental disorders. In Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002), the Court held that the symptoms listed in the code do not "constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." The Board, is not required to "find the presence of all, most, or even some, of the enumerated symptoms" in order to assign a particular disability rating. Id. According to the applicable rating criteria, a 50 percent evaluation will be assigned with evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: a 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9400. A 70 percent evaluation will be awarded with evidence of 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 under the general formula for rating psychiatric disabilities 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 rating is assigned when there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9400. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) for Mental Disorders, Fourth Edition (DSM-IV), p. 32) and 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). In addition, the Court has held that a GAF score is only one factor in determining a veteran's disability rating. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003) (Steinberg, J., concurring). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores from 51 to 60 reflect more 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). A GAF score between 61 and 70 is assigned when an individual presents either some mild symptoms (e.g., depressed mood and mild insomnia); or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. See DSM-IV. The Veteran contended in his January 2009 NOD that he felt like a "freak" and said he was nearly killed due to his scrotal injury in service. He was treated poorly by the physician who treated his injury and fellow service members. He regretted not having children. He felt he lacked the ability to deal with his embarrassing problem. He related similar statements at the April 2012 DRO hearing. (Transcript, pp 14, 16.) When asked if he was suicidal he replied: "Earlier, maybe." (Transcript, p 16.) He refused treatment because of his job as an officer and because he didn't feel like it was going to go away. (Transcript, p 22.) "I like to think I'm pretty normal in the sense, psychologically speaking, except for the fact that when I go into this thought process of this ... condition, and then it preys on me . . ." Id. In December 2012, the Veteran complained of sleep impairment. However, he also said at the hearing that he didn't have self-destructive behaviors and his wife was supportive. (Transcript, p 15.) He was not going to VA for treatment and did not take medication. (Transcript, p 17.) He was happily married. Id. He felt inadequate as a police officer and his coworkers made fun of him but he did well on the job and received many commendations and positive letters from citizens about his "outstanding work with people in the community." (Transcript, p 19.) The relevant evidence shows the Veteran was given two VA examinations. In April 2008, the Veteran stated he had no history of psychiatric treatment. The Veteran tearfully stated he felt humiliated about his residual scar. His social functioning was somewhat affected and his occupational function was minimally affected. The examiner noted at the last examination (outside the appeal period), when he had been diagnosed as having an adjustment disorder with mixed anxious and depressed mood with GAF 50. At the current examination the Veteran's life circumstances and psychiatric symptoms were quite similar to before. When he thought about his scrotal injury, he got upset. He had ongoing embarrassment and shame about having to readjust himself in public. He only was upset when he thought about the injury; otherwise sleep was good and he was generally in a good mood. He currently was working full time and had a good relationship with his wife. He got upset when his coworkers teased him about his past injury. The Veteran reported heavy community charity involvement which the examiner said he minimized when questioned about it. He denied inappropriate behaviors, alcohol or drug use. He had no suicidal or homicidal ideation and no evidence of a thought disorders or hallucinations. His cognition appeared intact along with insight and judgment. The diagnosis was axis I adjustment disorder with mixed anxiety and depressed mood with a GAF of 67. In sum, generally positive social and occupational domains although some embarrassment and limitation of function due to the need to adjust himself because of his scar. In May 2012, Dr. S. wrote a letter stating that the Veteran had symptoms of anxiety and depression due to "intense memories of the traumatic event" and he had difficulties in his personal and professional relationships. He had nightmares. Dr. S. believed the Veteran's symptoms fulfilled the diagnostic criteria for PTSD. In June 2012, the Veteran was given a new VA examination. The examiner found he still had a diagnosis of Axis I adjustment disorder, chronic with mixed anxiety and depressed mood and a GAF of 70. Regarding functioning, a mental disorder had been formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social function or to require continuous medication. The examiner stated the Veteran would feel anxious and depressed when teased about his condition at work but then after a couple of hours the intensity of the emotion passed and he able to resume his usual business. He never had to leave work due to how he was feeling. The examiner also explained that after an evaluation, the Veteran did not meet the criteria for PTSD. He felt anxiety when co-workers poked fun at him (in the past year this might have happened a dozen times) and stated most of his age-related peers had retired. He did not meet criteria for clinical depression. He stated when he heard comments he got a little withdrawn and depressed and as the day went by it got better. The claims file and all records were reviewed. He was happily married with no children. He worked full time. He never sought treatment because he didn't want his co-workers to or family to know he was seeing a "shrink." He did have depressed mood, anxiety and chronic sleep impairment. The examiner explained this happened after being teased and was not a clinical depression or anxiety that was negatively impacting functioning. He described his own health as "pretty good for my age, I gotta be honest." A mental status examination was totally normal. He endorsed suicidal ideation during a period of financial difficulties but denied a plan or intent at the time; he was judged to be a low risk to himself and others. He looked forward to continuing to work because he felt it was the best therapy for his mental health. He had wife, other family and friends as social supports. The examiner concluded the Veteran had little to no functional impairment caused by his mental health. At age 77, he continued his successful career with the local police. Analysis Turning to the areas of deficiency required for a 70 percent rating, Dr. S. has stated that the Veteran had personal and professional relationship difficulties, but the evidence shows he had a "great" relationship with his wife, and there has been no reported impairment in relationships with other family member. He has earned accolades at work. His career has been described as successful. While he has described difficulties with co-workers, these difficulties have caused no reported diminution his ability to successfully maintain his job. As such, the weight of the evidence is against a finding that there are deficiencies in the areas family relations or work. There have been no reports that the Veteran has attempted schooling, and there is no evidence of deficiencies in this area. He has been found to have no deficiencies in thinking and there is also no other evidence of deficiency in this area. Examinations have not shown that the Veteran's judgment is intact, nor is there other evidence of deficiencies in this area. His speech has been described as logical and goal directed and there have been no reports of abnormal thinking. The Veteran's mood has been described as anxious on VA examinations and Dr. S. described the Veteran as having increasing depression and anxiety. These findings and the Veteran's reports provide evidence of deficiencies in the area of mood. As just discussed; however, the evidence is against a finding that the Veteran has deficiencies in most of the areas needed for a 70 percent rating. There have been differing opinions as to whether the Veteran meets the criteria for PTSD; but all of the Veteran's psychiatric impairment, regardless of diagnosis has been considered in deciding the Veteran's appeal. The Board has considered the Veteran's GAF scores of 70 and 67, but such scores are not evidence of increased impairment. Instead they indicate a disability that is mild. The Board does not find deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. See Bowling, 15 Vet. App. at 11-14. There has been no time during the period beginning one year prior to the current claim for increase when staged ratings would be warranted. Hart, 21 Vet. App. at 509-510. The weight of the evidence is against a finding that the Veteran's psychiatric disability approximates the criteria for a rating in excess of 50 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Increased rating for residual scar During the pendency of this appeal (the Veteran filed his claim in January 2008), the criteria for evaluating disabilities of the skin were revised, effective October 23, 2008. The new rating criteria for evaluation of scars are applicable only to claims received by VA on or after October 23, 2008 or when the Veteran asks for review under the new criteria. See 73 Fed. Reg. 54708 (September 23, 2008); 77 Fed. Reg. 2909-2910 (January 20, 2012). The Veteran's date of claim was in January 2008 and he has not requested review under the newer criteria. As a result the regulations under 38 C.F.R. § 4.118 prior to October 23, 2008 are in effect. Prior to October 23, 2008, under 38 C.F.R. § 4.118, DC 7801 applied to scars other than the head face or neck that were deep or that caused limited motion; for a 10 percent rating under this code the area had to exceed 6 square inches or 39 square centimeters. 38 C.F.R. § 4.118 (2008). An increase is warranted when the area or areas exceed twelve square inches or 77 square centimeters. Id. DC 7802 applies when four requirements are met. The scar or scars must be 1) on a part of the body other than the head, face or neck; 2) must be superficial; 3) must not cause limited motion; and must cover an area of 144 square inches or 929 square centimeters or greater. If the criteria are met, a 10 percent rating is warranted. Id. DC 7803 applies to scars that are superficial and unstable but only provides a 10 percent rating. Note (1) explains that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) defines a superficial scar as a scar that is not associated with soft tissue damage. This definition is essentially the same for DCs 7802 and 7804 except these codes specify "underlying soft tissue damage." Id. Similarly, DC 7804 applies when a scar is superficial and painful upon examination, but also only applies to a 10 percent rating. Id. (The Veteran is currently rated under DC 7804.) Finally, if there is other limitation of function, the scar should be rated on that limitation. 38 C.F.R. § 4.118, DC 7805 (2008). The Veteran contends that because of his service-connected scar, he could not sit long without adjusting himself. (Transcript, p 3.) As he aged he felt his scrotum had gotten more sensitive. If they went to dinner, he had to leave the restaurant to re-adjust. Id. He also would have to readjust at work; he was a police officer. (Transcript, p 4.) He claimed his scar "never healed." Id. But he received no current treatment for his scar and it did not weep fluid; it was just sensitive. (Transcript, p 6.) He also described urinary dripping as a problem. (Transcript, p 7.) He had a hernia operation and his testicles were large which increased sensitivity of the scar. (Transcript, p 12.) The DRO suggested the possibility of nerve involvement because the Veteran claimed his sensitivity was worse. (Transcript, p 31.) The DRO asked if the scar was unstable or if it opened up and leaked; the Veteran denied this happened. (Transcript, p 32.) He often had to readjust in public. (Transcript, p 33.) His clothing had to be loose or it rubbed and bothered him. Id. The evidence shows the Veteran was given a VA examination in March 2008. Genitalia were of normal size. There was a three to four centimeter scar on the skin of the right hemiscrotum that extended from the base of the penis diagonally to the median raphae. There was no dimpling or drainage. The scar was non-tender and the testes were of normal size lie and consistency. The history of the injury was given and past treatment and examinations were noted by the examiner. He had no frequency or incontinence problems. No surgery or other genitourinary issues. He sometimes slept poorly and was tearful in discussing his readjustment issues. The examiner found the scar examination was unchanged from the prior examination. The impression was scrotal laceration with chronic hypersensitivity and hyperawareness which was likely as not a superficially cutaneous neuropathy with moderate residual functional impairments. In May 2008, Dr. D. noted that the Veteran was seen for many years by former partner, Dr. Maloney. Dr. D. reviewed records and noted that an October 1997 note showed that the Veteran suffered a laceration to the scrotum in the 1954. Since that time the Veteran had sensitivity to the right side of the scrotum which was associated with the scar. In February 2010, Dr. M. stated that the Veteran underwent left inguinal hernia surgery. His recovery was influenced by his scrotal injury; however, his further recovery was to be rapid, uneventful and complete. His treatment records from the same month showed he had typical swelling and ecchymosis and was moving his bowels and urine without difficulty. A follow up record shows a successful repair of recurrent left inguinal hernia. The wound was healing well with no evidence of inflammation or infection. He took no Percocet since surgery. Ecchymosis and swelling were diminishing. Dr. M. did not determine that his residual scar played a role, but noted the Veteran thought so. Dr. M. stated a letter would describe his postoperative status. In March 2010, Dr. S. also stated the Veteran had hernia surgery and said this recovery consisted of painful swelling of the left groin and scrotum but the swelling subsided. He still had pain there. Slow recovery was related to his "traumatic injury to the scrotum and testicle." "Normal lymphatic and venous channels were likely disrupted by the old trauma and repair resulting in inadequate drainage of the recent surgical site and subsequent pain and swelling." In May 2012, Dr. S. wrote a letter stating the Veteran had difficult urination manifesting as incontinence, hesitation, weak stream and nighttime urgency due to "trauma to his scrotum and testicles." He had constant scrotal pain that made sitting "impossible" and often had to reposition his body. In May 2012, the Veteran was given another VA examination so the scar could be observed and his claims regarding erectile dysfunction, nerve involvement, and voiding/urinary frequency could be addressed. Upon examination, the Veteran had one painful scrotal scar that was not unstable. The scar was along the hemiscrotum inferiorly. The linear scar length was nine centimeters. The scar impacted the Veteran's ability to work because it was tender and painful. He had to readjust to alleviate pain and sensitivity. The examiner stated it was at least as likely as not that the scar "increased in severity." To this end, the examiner stated the Veteran likely sustained superficial nerve damage resulting in the painful scar. A negative opinion was given on voiding dysfunction. The opinion on erectile dysfunction was initially contradictory, but in an October 2012 VA addendum the examiner found erectile dysfunction was related to the scar (see November 2012 RO rating). The examiner did diagnose urinary incontinence; the Veteran had a voiding dysfunction that caused leakage which was due to an overactive bladder. He did not wear absorbent material. The examiner noted that a 1997 ultrasound of the scrotum showed he had a small cyst in his right epididymis. The history of scar was noted. The reproductive examination also showed that the penis, testes, epididymis and prostate were totally normal. The examiner did state that the scrotum was sensitive to touch during the examination. The Veteran was to limit standing and sitting due to scrotal sensitivity. The Veteran asserted he had a sedentary job which accommodated him. The Board finds that no increased rating is warranted based on the residual scar. 38 C.F.R. § 4.118, DC 7801. The scar does not exceed 6 square inches or 39 square centimeters in size; there's no evidence that it causes limited motion of the scrotum itself; and it's not unstable. It is a painful scar; however, the scar is already being rated under DC 7804. No increase is available under these codes. The examiners in both the March 2008 and May 2012 reports stated the scar had some nerve involvement. The only reported manifestation of the nerve involvement is pain and discomfort in the scrotum. A compensable rating is potentially available for nerve impairment manifested by pain. 38 C.F.R. § 4.123, 4.124 (2012). The Veteran's scar rating; however, has also been provided on the basis of pain. Regulations preclude pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes. 38 C.F.R. § 4.14 (2012). Pyramiding does not occur when the rating criteria are wholly separate, but in this case the rating criteria overlap and separate ratings would constitute pyramiding. Hence, the weight of the evidence is against a finding that the Veteran's scar approximates the criteria for a rating in excess of 10 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Extraschedular In exceptional cases, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be awarded. 38 C.F.R. § 3.321 (b)(1) (2012). For an extraschedular evaluation, there generally must be a "finding that the case presents such an exceptional or unusual disability picture." Id. In Thun v. Peake, 22 Vet. App. 111 (2010), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. The schedular rating criteria reasonably describe the Veteran's psychiatric disability and symptoms related to his residual scrotal scar. Thun, 22 Vet. App. at 115. The psychiatric disability is manifested by reported difficulties at work and in social relationships. The psychiatric rating criteria contemplate impairment in social and occupational functioning. The scar is manifested by pain, which is specifically contemplated in the rating criteria. Rice Entitlement to a total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2012). As the record makes clear the Veteran is maintain full time employment, and there is no evidence that the employment is marginal. Further discussion of a total disability rating for individual unemployability is unnecessary. See Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009) (question of entitlement to TDIU does not arise unless there is evidence of unemployability). ORDER Entitlement to a rating in excess of 50 percent for chronic adjustment disorder with mixed anxiety and depressed mood is denied. Entitlement to a rating in excess of 10 percent for a laceration of the scrotum is denied. REMAND In a November 2012 rating decision the RO denied entitlement to service connection for urinary frequency. In December 2012, The Veteran submitted a statement in which he expressed disagreement with the denial. The agency of original jurisdiction has not issued a statement of the case with regard to this issue. The Board is required to remand the appeal to the AOJ for the issuance of such a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the appeal is REMANDED for the following: The AOJ should issue a statement of the case with regard to the issue of entitlement to service connection for voiding dysfunction due to urinary frequency. The issue should not be certified to the Board unless a sufficient substantive appeal is received. The Veteran has the right to submit additional evidence and argument on the matter 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. 2012). ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs