Citation Nr: 1321200 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 09-42 923 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for dermatitis. 2. Entitlement to an initial disability rating higher than 30 percent for post-traumatic stress disorder (PTSD). 3. Entitlement to disability ratings for tension headaches higher than 0 percent from June 3, 2009, and 30 percent from January 6, 2011. 4. Entitlement to an initial disability rating higher than 0 percent for acne. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from February 2004 to June 2009. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Waco, Texas Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a June 2009 rating decision the RO denied service connection for dermatitis. The RO granted service connection for PTSD and assigned a 30 percent disability rating, granted service connection for tension headaches and assigned a 0 percent rating, and granted service connection for acne and assigned a 0 percent rating. In a February 2013 rating decision the RO increased the rating for tension headaches to 30 percent effective January 6, 2011. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. Dermatitis treated during service resolved during service without residual pathology. 2. The Veteran's PTSD has produced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but has not kept her from generally functioning satisfactorily and has not reduced her reliability and productivity. 3. From June 3, 2009, to January 5, 2011, the Veteran's tension headaches were not prostrating attacks. 4. From January 6, 2011, some of the Veteran's tension headaches have been prostrating attacks, but she has not had very frequent prostrating and prolonged attacks productive of severe economic inadaptability. 5. The Veteran's acne is superficial and not deep and does not produce disfigurement of the head, face, or neck. CONCLUSIONS OF LAW 1. No post-service dermatitis was incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The Veteran's PTSD has not met the criteria for a disability rating higher than 30 percent. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 3. From June 3, 2009, to January 5, 2011, the Veteran's tension headaches did not meet the criteria for a disability rating higher than 0 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2012). 4. From January 6, 2011, the Veteran's tension headaches have not met the criteria for a disability rating higher than 30 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8100. 5. The Veteran's acne does not meet the criteria for a disability rating higher than 0 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7828 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Dermatitis The Veteran essentially contends that she has dermatitis that began during service. In an April 2009 claim the Veteran sought service connection for several disorders including "dermatitis/acne." In a June 2009 rating decision the RO granted service connection for acne and denied service connection for dermatitis. The Veteran appealed the denial of service connection for dermatitis. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The United States Court of Appeals for Veterans Claims has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the 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. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. During service the Veteran was seen in a service clinic in February 2007 for a rash with itching on both ankles. The treating clinician observed small red areas on the ankles. The clinician's impression was dermatitis. In notes of subsequent outpatient treatment later in 2007 and in early 2008 dermatitis was included in the Veteran's list of problems, but the condition of the Veteran's skin was not discussed. In December 2008 the Veteran was seen for acne on her chin area. The treating clinician prescribed a topical medication. Later in December 2008 the Veteran reported an occasional burning sensation in her right leg and the sensation that the leg fell asleep. A clinician observed linear streaks on the leg. In a January 2009 dermatology consultation a clinician found that the discoloration on the leg was livedo reticularis. In March 2009, just prior to completion of a one year deployment in Afghanistan, the Veteran had a health assessment. At that time she reported that she had been seen in sick call for skin diseases or rashes, that she had been placed on quarters or limited or light duty for skin diseases or rashes, and that she was still bothered by skin diseases or rashes. The Veteran had a medical examination for VA claims purposes in May 2009, before her separation from service. She reported having had a skin condition since 2006 that was diagnosed as dermatitis. She indicated that the condition affected the skin on her face and upper back. She stated that her back and chin had itching. The examiner observed superficial acne on the face and upper back. The examiner stated that the skin lesions were not associated with systemic disease. The examiner concluded that for the Veteran's claimed condition of dermatitis the diagnosis was acne. In a February 2010 statement the Veteran's representative asserted that the May 2009 VA examination showed dermatitis on the Veteran's face and upper back. On VA examinations on January 6, and January 27, 2011 the Veteran reported having acne symptoms on her back and face. On each examination the examiner described the skin disorder as acne. On VA examination in January 2013 the examiner noted that the Veteran was treated with topical creams for chronic acne. The examiner observed papular acne lesions on the Veteran's face, neck, and back. The examiner's diagnosis was chronic superficial acne. In a June 2013 brief the Veteran's representative wrote that the May 2009 VA examination showed dermatitis around the mouth and upper back area. The representative indicated that the Veteran argues that service connection is warranted for dermatitis because she was treated for dermatitis of the ankles during service and because on VA examination there was a post-service diagnosis of dermatitis. Service connection is established for the Veteran's acne. She has appealed for service connection for dermatitis as well. Her service treatment records show that she had dermatitis on her ankles in 2007. Later in service, however, treatment notes reflect acne on her face and livedo reticularis on her leg, but no ongoing dermatitis. The Veteran has argued through her representative that the May 2009 VA examination showed dermatitis on her face and upper back. In the examination report, however, the examiner noted that the skin condition was claimed as dermatitis, but stated that the diagnosis was acne. Post-service examinations also have shown acne but not dermatitis. With respect to dermatitis there is no evidence of a current disability. As the Veteran does not have post-service dermatitis the Board must deny her claim for service connection for dermatitis. Ratings The Veteran appealed the initial disability ratings that the RO assigned for her PTSD, tension headaches, and acne, and the higher rating that the RO assigned for a later period for her tension headaches. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, 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. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In addition, 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 claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board will consider the evidence for the entire period since separation from service and will consider whether higher ratings are warranted for any period. PTSD The rating schedule provides for evaluating mental disorders such as PTSD under a General Rating Formula for Mental Disorders, which follows: 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 .......................... 100 percent 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 ............................................. 70 percent 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 ........................... 50 percent 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) ..................................................... 30 percent Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication ............................. 10 percent A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication ................................ 0 percent 38 C.F.R. § 4.130. In treating and evaluating mental disorders, mental health professionals sometimes assign a Global Assessment of Functioning (GAF) score. The GAF scale is a scale of psychological, social, and occupational functioning a hypothetical continuum of mental health and illness. It is provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Assessments on the GAF scale are not to include impairment in functioning due to physical or environmental limitations. Clinicians have assigned the Veteran GAF scores of 60 and 70. GAF scores of 61 to 70 are for some mild symptoms (e.g., depressed mood and mild insomnia) or moderate 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. GAF scores of 51 to 60 are for 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). DSM-IV. The Veteran was diagnosed with PTSD during service. She served in Iraq and Afghanistan and witnessed and was in vehicle explosions. She had a VA mental health examination in April 2009, before separation from service. At that time she was soon to be on terminal leave pending discharge. She had been on different medications for PTSD and was currently on a new medication. She stated that she had recurrent distressing dreams of traumatic events. She reported that she felt detached and estranged from others. She indicated that she was irritable and had outbursts of anger. She reported difficulty sleeping and daily consumption of six to twelve beers. The examiner found that the Veteran was oriented and that her affect, mood, speech, and concentration were within normal limits. The Veteran did not report having panic attacks, delusions, hallucinations, or obsessional rituals. Her thought processes appeared appropriate, her judgment was not impaired, and her memory was within normal limits. She had passive suicidal ideation. The examiner listed a diagnosis of PTSD and assigned a GAF score of 60. The examiner indicated that the Veteran's PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. On a VA PTSD review examination in October 2010 the Veteran indicated that she continued on medication for PTSD. She stated that after service she had worked in a restaurant. She reported had been unemployed since August 2010 but that she was undergoing background checks for a job in law enforcement. She reported that she recently got engaged and was living with her fiancé. She indicated that she had differences with her fiancé, and that she got away and spent time at a friend's house to keep from arguing. She stated that she had nightmares but that flashbacks were rare. She indicated that her mood was stable. She denied suicidal ideation or psychotic symptoms. She reported having reduced her alcohol consumption. She reported that in her restaurant job she felt disrespected and had some arguments with coworkers. She indicated that she was irritable and upset by small matters. She stated that she worried a lot and sometimes lost her motivation. She related having nightmares about three times a week. The examiner observed that the Veteran was oriented and had no impairment of thought process or communication. The examiner found that the Veteran's mood was mildly irritable. The examiner assigned a GAF score of 60 for the Veteran's PTSD. The examiner found that the Veteran's PTSD produced occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks. On a VA PTSD review examination in February 2011 the Veteran stated that she continued on medication for PTSD. She reported that she worked full time as a police officer. She stated that she lived with her fiancé and had a few close friends. She reported that when she became upset at home or had trouble sleeping she cleaned excessively. She indicated that she had tension in her relationship with her fiancé. She reported irritability and feelings of detachment from others. She related having sleep disturbances and having nightmares with night sweats one to four times per week. She also reported having anhedonia and worry. The examiner observed that the Veteran was oriented and had spontaneous speech, normal affect and mood, and unremarkable thought process and content. On testing the Veteran had mild difficulties with word repetition and her memory was moderately impaired. The examiner stated that the Veteran's current mental disorder was more consistent with an anxiety disorder than with PTSD, but that her current disorder was a continuation and residual of her partially remitted PTSD. The examiner assigned a GAF score of 70. The examiner stated that the Veteran's PTSD and anxiety disorder produced occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Examination reports have provided a fairly thorough picture of the extent of the Veteran's impairment due to PTSD. She has had anxiety, irritability, sleep disturbance, and nightmares. She has had some difficulties at work and socially but generally has been able to obtain and hold employment and interact with others. Examiners have consistently found that her PTSD produces occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. From separation from service forward she has had a disability picture consistent with the 30 percent rating that is in effect. She has not had panic attacks, abnormal speech, impaired judgment or other manifestations that reduce her general reliability and productivity. The preponderance of the evidence shows a disability picture that does not meet the criteria for a rating higher than 30 percent. The Board therefore denies the appeal for a higher rating. Tension Headaches The RO has evaluated the Veteran's tension headaches under 38 C.F.R. § 4.124a, Diagnostic Code 8100, as comparable to migraine headaches. The rating criteria under that code are as follows: With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability ..................................... 50 percent With characteristic prostrating attacks occurring on an average once a month over last several months ..................................................... 30 percent With characteristic prostrating attacks averaging one in 2 months over last several months ............ 10 percent With less frequent attacks ........................ 0 percent On VA examination in May 2009 the Veteran reported that when headaches occurred she was able to go to work but required medication. She stated that she addressed the headaches by taking lots of Motrin and applying pressure. She indicated that headaches occurred about two times per week and lasted about nine hours. She stated that head pain was accompanied by nausea, upset stomach, dry heaving, irritability, and fatigue, and that during headaches it was difficult to perform daily functions. The examiner diagnosed tension headaches. The examiner indicated that the headaches had no effect on the Veteran's usual occupation. VA examinations on January 6 and 27, 2011, addressed the manifestations and effects of the Veteran's headaches. On January 6 the Veteran reported having headaches that lasted from a couple of hours to a whole day and that occurred three times a day. She related feeling lightheaded and having nausea during headaches. On January 27 she stated that headaches lasted from an hour to a day and had occurred two to three times per month over the preceding year. She reported that during headaches she was light sensitive and occasionally had nausea. She stated that less than half of the attacks were prostrating. On the 2009 examination the Veteran indicated that her headaches and accompanying symptoms made it difficult to perform daily functions, but she stated that she was able to go to work during the headaches. The examiner concluded that the headaches had no affect on her work. The evidence thus indicates that at that time the Veteran's headaches did not rise to the level of prostrating attacks. By the preponderance of the evidence her headaches as of that time did not meet the criteria for a rating higher than 0 percent. The January 2011 examinations provided evidence that some of the Veteran's headaches were prostrating attacks. The January 6th and 27th reports contain differing accounts as to how frequently headaches occurred; but on the 27th the Veteran indicated that less than half of the attacks were prostrating. Based on that statement the prostrating attacks were not so very frequent and prolonged as to produce severe economic inadaptability. Therefore the evidence to date does not support a rating higher than 30 percent at any time. Acne The RO has evaluated the Veteran's acne under 38 C.F.R. § 4.118, Diagnostic Code 7828, which provides as follows: Deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck ..................................................... 30 percent Deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck ... 10 percent Superficial acne (comedones, papules, pustules, superficial cysts) of any extent .................. 0 percent Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. For scars or other disfigurement of the head, face, or neck to be rated at least 10 percent disabling, there must be visible or palpable tissue loss and either gross distortion or asymmetry of a nose, chin, forehead, eye, eyelid, ear, cheek, or lip, or at least one of eight listed characteristics of disfigurement must exist. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2012). Those characteristics are: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1). Color photographs are to be considered when evaluating under the criteria for scars or disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (3). On VA examination in May 2009 there was acne of the face and back. There were shedding and crusting around the mouth. There was no exudation and no ulcer formation. The Veteran reported that at times her back itched too much for her to wear a bra, which limited her from vigorous activities at such times. The examiner observed superficial acne on the forehead, cheeks, chin, and upper back. The acne had papules, pustules, and superficial cysts. There were no scars on the head, face, or neck. On VA examination in January 2011 the Veteran had superficial acne with comedones, papules, pustules, and superficial cysts, on the face, back, and shoulders. On VA examination in January 2013 the examiner observed a few superficial papular acne lesions on the face, neck, and back, with slight blackish pigmentation of the cheeks. There were no cystic lesions and no unstable areas. The examiner stated that there was no disfigurement. Color photographs of the Veteran's face and back were taken. They are associated with the claims file. The photographs do not show any scars on the Veteran's face, neck, or head. The examination reports show that from separation from service forward the Veteran has had superficial acne but has not had deep acne. Her acne therefore has not met the criteria for a rating higher than 10 percent under Diagnostic Code 7828. She has not had visible or palpable tissue loss and either gross distortion or asymmetry of any part of her face. Her head, face, and neck have not had any of the characteristics of disfigurement. Specifically, those areas have not had any scars, abnormal texture, missing underlying tissue, or indurated or inflexible skin. The very slight darkening on her cheeks visible in the photographs involves areas less than six square inches. Her acne therefore has not produced compensable disfigurement of the head, face, or neck. In summary, the preponderance of the evidence is against a rating higher than 0 percent for acne. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). Neither the Veteran's PTSD, his tension headaches, nor his acne has required frequent hospitalizations or has markedly interfered with employment. The rating schedule criteria address the Veteran's PTSD symptoms and resulting occupational and social impairment. The rating schedule criteria for the Veteran's headaches address the existence and frequency of prostrating attacks and effects of such attacks on work. The rating schedule criteria for acne address the acne comedones, papules, pustules, and superficial cysts that the Veteran has on her face, neck, and back. The rating criteria for PTSD, headaches, and acne each provide for higher ratings for greater impairment than is present in this case. The regular rating criteria thus are sufficient to the circumstances of this case. It is not necessary to refer the ratings for PTSD, tension headaches, or acne for consideration of extraschedular ratings. The Board has considered whether the record raises the issue of unemployability, such that unemployability must be considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A review of the record reveals that the Veteran holds full time employment as a police officer. She has not indicated that her PTSD, tension headaches, and acne make her unable to hold employment. In this case, then, the record does not raise the issue of unemployability. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran 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, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The Court has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran VCAA notice in an April 2009 letter, issued before the June 2009 initial unfavorable decision on the claims on appeal. That letter addressed the information and evidence necessary to substantiate claims for service connection and informed the Veteran how VA assigns disability ratings and effective dates. The letter also addressed who was to provide the evidence. The claims file contains the Veteran's service treatment records and the reports of VA examinations. The Veteran has had examinations that are adequate to address the issue of service connection for dermatitis and the ratings for her PTSD, tension headaches, and acne. Neither the Veteran nor her representative has identified any potentially relevant evidence that is not associated with the claims file. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claims on appeal, as well as the avenues through which she might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, she was provided with a meaningful opportunity to participate in the claims process, and she has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of the claims on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). ORDER Entitlement to service connection for dermatitis is denied. Entitlement to a disability rating higher than 30 percent for PTSD is denied. From June 3, 2009, to January 5, 2011, a disability rating higher than 0 percent for tension headaches is denied. From January 6, 2011, a disability rating higher than 30 percent for tension headaches is denied. Entitlement to a disability rating higher than 0 percent for acne is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs