Citation Nr: 1317097 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 10-48 787 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder ("PTSD"). 2. Entitlement to an initial rating in excess of 20 percent for degenerative arthritis of the lower thoracic spine. 3. Entitlement to service connection for eczema. REPRESENTATION Appellant represented by: James G. Fausone, Attorney at law ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from April 1967 to June 1971. These matters come before the Board of Veterans' Appeals ("Board") on appeal from an August 2009 rating decision issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Boston, Massachusetts, which granted service connection for PTSD with an initial 30 percent rating, effective January 16, 2009; granted service connection for degenerative arthritis of the lower thoracic spine with an initial 20 percent rating, effective January 16, 2009; and denied service connection for eczema. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's PTSD has been manifested by symptoms no greater than depressed mood, anxiety, chronic sleep impairment, suspiciousness, and infrequent flashbacks. 2. Throughout the period on appeal, the Veteran's degenerative arthritis of the lower thoracic spine has been manifested by forward flexion of the entire thoracolumbar spine limited to 30 degrees. 3. The most probative medical evidence of record demonstrates that the Veteran's eczema is the result of a disease, injury or event in service. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.27, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating of 40 percent, and no more, for degenerative arthritis of the lower thoracic spine have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2012). 3. Resolving all doubt in favor of the Veteran, his current eczema is the result of active duty service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the United States Court of Appeals for Veterans Claims ("Court") held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. For initial rating claims, where, as here, service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven; therefore, 38 U.S.C.A. § 5103(a) notice is no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess, 19 Vet. App. at 490-91; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). The Veteran was provided notice of the VCAA via a letter dated February 2009. This letter informed him of the types of information and evidence necessary to substantiate his initial service connection claims, as well as the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The letter also provided the Veteran with information concerning how VA establishes the effective date and disability rating elements of a claim, thus satisfying Dingess. The claims were subsequently readjudicated in a November 2010 Statement of the Case ("SOC"). Moreover, in light of the favorable decision for the claim of entitlement to service connection for eczema, any error in the timing or content of VCAA notice, if shown, would be moot. B.) Duty to Assist The Board is satisfied that the VA duty to assist has been met. The claims folder contains the Veteran's service treatment records and VA examination reports dated in March 2009 and May 2009. The claims file also contains the Veteran's statements in support of his claims. The Veteran has not referenced any outstanding, available records that he wanted VA to obtain or that he felt were relevant to the claims that have not already been obtained and associated with the record. Review of the March 2009 examination report shows that the examiner reviewed the complete claims folder, performed a comprehensive PTSD evaluation, interviewed the Veteran concerning his complaints and symptomatology, and provided the results of the clinical evaluation. Accordingly, the examination report is adequate upon which to base a decision in this case. Review of the May 2009 examination report demonstrates that the examiner performed a comprehensive physical examination, interviewed the Veteran concerning his associated complaints and symptomatology, reviewed diagnostic test results, and provided detailed examination findings. Although it appears that the examiner did not have access to the Veteran's claims folders, the Court has held that the absence of a claims file review does not necessarily render an examination inadequate or reduce the probative value of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when there is a factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed); Snuffer v. Gober, 10 Vet. App. 400 (1997). Here, because the examination report contains enough information for the Board to assess the claims and arrive at decisions that are favorable to the Veteran, the Board concludes that the examination report is sufficient upon which to make a decision on the claims. Accordingly, the Board finds that VA has fully complied with the notice and assistance requirements of the VCAA and its regulations. The appellant has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his appealed claims. Accordingly, the Board will proceed to a decision on the merits. II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit ("Federal Circuit") held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes ("DC") identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). A. Entitlement to an initial rating in excess of 30 percent for PTSD. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Veteran's service-connected PTSD has been evaluated under DC 9411. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to 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. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) ("DSM-IV"). The criteria for the current 30 percent rating are: Occupational and social impairment with occasional decrease 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, mild memory loss (such as forgetting names, directions, recent events). The criteria for a 50 percent rating are: 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. And, the criteria for a 100 percent rating are: 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, Diagnostic Code 9411 (2012). The Board must also consider the Global Assessment of Functioning ("GAF") scores that have been reported. 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); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV, p.32). GAF scores from 61 to 70 represent some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful personal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or co-workers). GAF 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). Lower GAF score represent a greater degree of psychological, social, and occupational functioning. Review of the claims folder reveals that the Veteran was afforded a VA PTSD examination in March 2009, at which time, he reported complaints of chronic sleep impairment (including nightmares), depression, and anxiety. He said he had been married from 1973-2006, but was now divorced. He said that his ex-wife claimed his excessive use of alcohol as a primary cause of the divorce. He further reported that he had been hospitalized for a week in December 2008 at a private facility for alcohol abuse and detoxification. He said he had two adult daughters and had a very good relationship with both of them. He added that he was also getting along better with his ex-wife. Although he said that he did not socialize with his co-workers, he did not report any specific work-related problems, adding that he had always worked, but never stayed at one employer for very long. He said he enjoyed walking, watching television and fishing, and had one "fishing buddy." Regarding a history of violence, he said that he had experienced no violent incidents in several decades. During the mental status evaluation, the Veteran was casually-dressed, tense and guarded. He had a full affect with depressed mood, and was fully-oriented to person, time and place. His thought content and process were unremarkable and insight and judgment were intact. He denied delusions and hallucinations, panic attacks, obsessive/ritualistic behavior, and suicidal or homicidal ideations. He did, however, admit to having resuming drinking alcohol, and described his daily intake as "quite a lot." His memory was deemed normal and the examiner found no problem with his activities of daily living due to the symptoms of a mental health disorder. The diagnoses were PTSD and alcohol abuse. The assigned GAF score was 49. The examiner appeared to emphasize how most of the Veteran's problems were related to his alcohol abuse, noting that his drinking had returned to an alcoholic level, which he opined put him at risk for several things, including mood instability. He further noted that the Veteran's father had been an alcoholic. He concluded that the Veteran's prognosis was fair to poor because the Veteran was very reluctant to obtain treatment for his PTSD and, in any event, would first need to deal with his alcoholism. In March 2009, three days after the VA PTSD examination, the Veteran was seen at the VA Medical Center ("VAMC") for an outpatient mental health consultation. At that time, he reported sleep difficulties, including nightmares, difficulty trusting others, and flashbacks when he is in the proximity of persons of Asian descent. He denied an exaggerated startle response. During the mental status evaluation, he was well-groomed, casually-dressed, pleasant, cooperative and maintained good eye contact. Speech was fluent, logical and of a normal rate and rhythm. Mood was stable and affect was calm. Thought process was goal-directed and organized. There were no memory, concentration or attention deficits noted. Insight was good and there was no evidence of psychosis, mania or paranoia. The Veteran denied suicidal or homicidal ideations. The diagnoses were alcohol dependency, depressive disorder, not otherwise specified ("NOS"), PTSD and nicotine dependency. The assigned GAF score was 65, noted to be both the current score and the score for the previous year. The claims folder contains no additional mental health records. During his March 2009 outpatient evaluation, the Veteran stated that he was not interested in mental health follow-up treatment of any kind. Also of record is a letter from the operations manager at the Veteran's place of employment, in which he praised the Veteran as a model employee, but noted that he had a hard time dealing with customers of Vietnamese descent. He also wrote that the Veteran did not attend social activities with other employees, seemed to have anxiety about being in unfamiliar places and seemed to only be comfortable with his everyday surroundings. Based on a review of the aforementioned evidence, the Board concludes that the preponderance of the evidence is against granting the Veteran's claim of entitlement to an initial disability rating in excess of 30 percent for PTSD under DC 9411. In this regard, the Board again notes that when there is a question as to which of two ratings shall be applied, the higher rating will be assigned only if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. With respect to the criteria for a 50 percent rating, the Board notes that, throughout the pendency of this appeal, there has been no probative evidence that the Veteran has demonstrated occupational and social impairment with reduced reliability and productivity due to such symptoms as circumstantial, circumlocutory, or stereotyped speech, panic attacks, difficulty in understanding complex commands, memory impairment, impaired judgment, or impaired abstract thinking. Moreover, while the Veteran appears to suggest that he has difficulty in establishing and maintaining effective work and social relationships, the fact that he was able to stay married for over 30 years and has a very good relationship with his adult children would appear to suggest otherwise; he also reported that he has developed a friendlier relationship with his ex-wife. In addition, while the letter from his employer suggests he does not like to attend social events, the fact that he was deemed a "model employee" strongly suggests that he presents no significant problems in his relationships with his co-workers or superiors. Indeed, the Veteran's mild social impairment cannot be the only basis for his disability rating during the pendency of the appeal. With respect to the criteria for a 70 percent rating, the Veteran's mental status evaluations were noted to be normal. There is also no competent evidence showing that the Veteran has suicidal ideation, obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, such as periods of violence, spatial disorientation, or neglect of personal appearance and hygiene. Moreover, in the context of awarding a 70 percent rating, 38 C.F.R. § 4.130 not only requires the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas, including work, school, family relations, judgment, thinking or mood. See Vazquez-Claudio v. Shinseki, ___ F.3d ___, No. 2012-7114, 2013 WL ____ (Fed. Cir. Apr. 8, 2013). While the Veteran has been diagnosed with a depressive disorder during the course of the appeal, there has been no evidence that would indicate that the mood disorder affects his ability to function independently at work, socially or in his activities of daily living. With respect to the criteria for a 100 percent rating, the evidence does not show that the Veteran has symptoms at the level of severity associated with a 100 percent rating. As discussed above, his mental status evaluations have consistently revealed no abnormalities during the pendency of this claim. There is also evidence showing that the Veteran suffers from gross impairment in thought processes or communication, persistent delusions or hallucinations, exhibits grossly inappropriate behavior, poses a persistent danger of hurting himself or others, or exhibits an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. In addition, there is no evidence that the Veteran has disorientation to time or place, or memory loss for the names of close relatives, his own occupation, or his own name. Thus, the Veteran does not have any of the symptoms associated with a 100 percent rating. In arriving at its conclusion that a higher initial disability rating for the Veteran's PTSD is not warranted, the Board has taken particular notice of the fact that its inquiry is not necessarily strictly limited to the criteria found in the VA rating schedule. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (the criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating). In this case, however, the Board has not identified competent evidence of symptomatology associated with the Veteran's service-connected PTSD that would enable it to conclude that the criteria for a higher initial disability rating have been approximated. The Board has also considered the Veteran's assigned GAF scores during the pendency of this appeal. Contrary to the assertion of the Veteran that the GAF score of 49 assigned during the VA examination should be determinative in his appeal for a higher disability rating, a GAF score is not determinative of the percentage rating to be assigned, as the rating depends on evaluation of all the evidence. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (March 31, 1995). In this case, as discussed above, the Board finds that the evidence of record more nearly approximates a finding of a moderate impairment during the course of the appeal. The Board has also considered the Veteran's contention that, because he has resumed his alcohol abuse, he should be awarded a higher disability rating for PTSD. In this respect, however, the Board notes that the Veteran is not service-connected for alcohol dependence and, as a result, the signs, symptoms, and impairment due to nonservice-connected alcoholism may not be considered for ratings purposes. Specifically, 38 C.F.R. § 4.14 provides that the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected disease is to be avoided. In addition to the VA examinations and outpatient treatment reports, as noted above, the Board has also considered the Veteran's personal statements regarding the severity of his disorder. In this regard, the Board is cognizant that the Court has repeatedly held that a veteran is competent to describe symptoms of which he or she has first-hand knowledge. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). As such, his assertions are entitlement to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Court has also held that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as evaluating the severity of a complex psychiatric disorder, such as PTSD. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As a result, his assertions do not constitute competent medical evidence. Finally, the Board has also considered the potential application of 38 C.F.R. § 3.321(b)(1) for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In this case, however, a comparison between the level of severity and symptomatology of the Veteran's condition with the established rating criteria shows that the rating criteria adequately describe the Veteran's symptomatology and disability level. The Board further observes that, even if the available schedular evaluation for the disability were inadequate (which it manifestly is not), the Veteran's disability has not been shown to cause marked interference with employment beyond that contemplated by the Schedule for Rating Disabilities; has not necessitated frequent periods of hospitalization; and has not otherwise rendered impractical the application of the regular schedular standards utilized to evaluate the severity of the disability. Thus, the Board finds that the requirements for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to a disability rating in excess of 30 percent for PTSD. As there is not an approximate balance of evidence, the "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). B. Entitlement to an initial rating in excess of 20 percent for degenerative arthritis of the lower thoracic spine. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2012). It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Id. With regard to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination; impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The Court has held that the Board must determine whether there is evidence of weakened movement, excess fatigability, incoordination, or functional loss due to pain on use or flare-ups when the joint in question is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); 38 C.F.R. § 4.40. Furthermore, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The fact that the revised criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). VA regulations provide a General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes) with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease as follows: For unfavorable ankylosis of the entire spine (100 percent); For unfavorable ankylosis of the entire thoracolumbar spine (50 percent); For unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine (40 percent); For forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine (30 percent); For forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); and For forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height (10 percent). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately, under an appropriate diagnostic code. Id., Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is zero to 30 degrees; left and right lateral flexion are zero to 30 degrees; and left and right lateral rotation are zero to 30 degrees. Id., Note (2); see 38 C.F.R. § 4.71a, Plate V. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. 68 Fed. Reg. 51,443, Note (2) (Aug. 27, 2003). The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, disability is evaluated as follows: With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, assignment of a 60 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, assignment of a 40 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months, assignment of a 20 percent evaluation is warranted. With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months, assignment of a 10 percent evaluation is warranted. The notes for rating intervertebral disc syndrome under this regulation state as follows: Note (1): an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. The Veteran's thoracic spine disability has been evaluated under DC 5242, degenerative arthritis of the spine, under the General Rating Formula for Diseases and Injuries of the Spine. Under Note (6), DC 5242 also refers to DC 5003. Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes. However, when the limitation of motion of the specific joint or joints is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applicable for each such major joint or group of minor joints affected, to be combined, not added, under DC 5003. Review of the claims folder shows that, in February 2009, the Veteran was seen for an initial visit at the VAMC with complaints of low back and joint pain. The assessment was back pain, and plan was for the Veteran to undergo an x-ray of the lumbosacral spine. There are no additional records, however, demonstrating further treatment for the Veteran's back. In May 2009, the Veteran was afforded a VA/QTC examination, at which time, he reported low back pain and numbness. He denied stiffness or a loss of bladder or bowel control and said he was not receiving any treatment for the condition. He said he worked as a plumber and truck driver when plumbing work was slow, and had lost many days of work due to pain from twisting, lifting and bending. Upon physical examination, the Veteran's posture was within normal limits, but he had a slight limp when walking over 30 feet. Examination of the thoracolumbar spine revealed symmetry of motion with normal curvature, with objective evidence of radiating pain on movement, tenderness and muscle spasm. Straight leg raises were positive on the right, but negative on the left. There was no ankylosis of the lumbar spine. Forward flexion was to 30 degrees; extension was to 10 degrees; right lateral flexion was to 30 degrees; left lateral flexion was to 30 degrees with pain; right rotation was to 40 degrees; and left rotation was to 60 degrees. The examiner noted that the joint function of the spine was additionally limited by pain, fatigue, weakness and lack of endurance after repetitive use; pain was noted to have a major functional impact. The examiner further observed that repetitive use additionally limited the joint function by 15 degrees. There was no sign of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement. The neurological examination was within normal limits. Lumbar spine x-ray findings were also within normal limits (although, the examiner subsequently noted in the examination report that there were x-ray findings of degenerative arthritis changes of the mid and lower thoracic spine). The diagnosis was degenerative arthritis of the mid and lower thoracic spine. Based on a review of the evidence of record, the Board concludes that the criteria for a disability evaluation of 40 percent, and no more, for degenerative arthritis of the lower thoracic spine under DC 5242 have been met. In this regard, as noted above, forward flexion of the thoracolumbar spine to 30 degrees or less warrants a disability rating of 40 percent under the General Rating Formula for Diseases and Injuries of the Spine. Here, the only medical evidence of record demonstrates that the Veteran's forward flexion of the thoracolumbar spine was limited to 30 degrees. As noted above, the Board must also consider whether a separate rating is warranted for any associated neurologic abnormalities. In this regard, however, although the Veteran reported numbness associated with his back disability during the VA examination, there was no objective evidence of neurological impairment. The Board has also considered whether a higher schedular rating is warranted under any other diagnostic code, but finds no other diagnostic code applicable. With regard to assigning a higher disability rating based on functional loss as contemplated by the Court's holding under DeLuca v. Brown, as discussed above, the Board has considered the Veteran's complaints of pain, and additional findings of pain, fatigue, weakness, lack of endurance and joint motion limited by 15 degrees following repetition. However, the Board observes that there is no medical evidence showing that the Veteran's low back disability has had a significant effect on either his occupational or activities of daily living greater than that contemplated by the rating being assigned by this decision. See Francisco v. Brown, supra. While he told the VA examiner that his disability resulted in his losing many days of work, there is no probative evidence of record to substantiate this assertion. As discussed above, the Veteran was afforded proper VCAA notice of the evidence necessary to establish his claim prior to the initial adjudication of his claim and likely could have obtained proof of missed time from work as easily as he was able to obtain the letter written for him by his operations manager for his PTSD claim. The Board has also considered the potential application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In the present case, the evidence demonstrates that the rating criteria under DC 5242 clearly contemplate the Veteran's current symptoms, as discussed above. A higher evaluation is provided for more severe symptomatology. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). In summary, the Board concludes that, as the evidence clearly demonstrates that the Veteran's degenerative arthritis of the lower thoracic spine is of greater severity than the previous rating decision established, a 40 percent rating is warranted under DC 5242. C. Entitlement to service connection for eczema. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. Symptoms, and not treatment, are the essence of any evidence of continuity of symptomatology The U.S. Court of Appeals for the Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran contends that he developed eczema during active duty. Review of his service treatment records shows that he was seen for a rash on the face in March 1969, although, there a diagnosis was not made. There are no further treatment records for the condition and the Veteran's May 1971 separation examination showed findings for the skin within normal limits. Although the Veteran was seen at the VAMC in February 2009 for an initial consultation, there is no indication that he complained of, or was found to have eczema at that time. In May 2009, the Veteran was afforded a VA/QTC examination, at which time, he reported that he had had eczema since 1968 while serving in the field in Vietnam. He said the condition occurred intermittently, as often as weekly, with each occurrence lasting three (3) days; he said he had experienced 50 such occurrences in the previous year. He added that he used over-the-counter topical corticosteroids to treat the condition. He denied any functional impairment from the disorder. Upon examination, the skin was found to be abnormal with crusted lesions on the forearms and over the forehead. It was noted that the rash covered an area of less than six (6) square inches. There was no ulceration, exfoliation, tissue loss, induration, inflexibility, hypopigmentation, hyperpigmentation or limitation of motion. The size of exposed areas was noted to be 4 percent of the Veteran's exposed skin and only 1 percent of his whole body. The skin lesions were not associated with any systemic disease or nervous condition. The VA examiner opined that the Veteran's eczema was related to his Vietnam service; his rationale was that the Veteran did not have eczema prior to service. In this regard, the Board again observes that the VA/QTC examiner did not have access to the Veteran's claims folders and, thus, was unable to review his service treatment records prior to providing his opinion that the Veteran's eczema was related to Vietnam service. Rather, he appears to have based his opinion on the Veteran's self reports of having been treated for eczema during service. While the Court has held that the mere transcription of a claimant's statements regarding medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional (see LeShore v. Brown, 8 Vet. App. 406, 409 (1995)), here, as discussed above, review of the Veteran's service treatment records corroborate that he was diagnosed with a face rash during service. As such, remand for another examination or opinion in order to allow an examiner to review the service treatment records would serve no purpose. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Here, as the basis for the May 2009 VA examiner's opinion appears to be correct (i.e., the Veteran was treated for a rash in service), the Board finds the opinion to be sufficient. Moreover, the Veteran has reported that he has experienced eczema ever since service. He is competent to report that he had a rash on his face during service and in the years thereafter. There has been no evidence to question his credibility. Charles v. Principi, 16 Vet. App. 370 (2002); Buchanan v. Nicholson, 451 F.3d 1331 (2006). A competent examiner has provided a nexus between the current disability and service. See McManaway v. West, 13 Vet. App. 60, 66 (1999), vacated on other grounds sub nom. McManaway v. Principi, 14 Vet. App. 275 (2001). Accordingly, and keeping in mind the "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b), the Board finds that service connection for eczema is warranted given the evidence of a current skin disability which has been linked to service. ORDER Entitlement to a disability evaluation in excess of 30 percent for PTSD is denied. Entitlement to an initial rating of 40 percent, and no more, for degenerative arthritis of the lower thoracic spine, is granted, subject to the laws and regulations governing the payment of monetary awards. Entitlement to service connection for eczema is granted. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs