Citation Nr: 1322277 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 08-12 279 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a separate compensable rating for numbness of the right lower extremity, as due to service-connected traumatic arthritis, lumbosacral spine. 2. Entitlement to a compensable rating for scar, status post resection, left fifth metatarsal and excision plantar wart. 3. Entitlement to a higher initial evaluation for posttraumatic stress disorder (PTSD) with depressive disorder, rated as 30 percent disabling from January 3, 2006. ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from September 1968 to September 1990. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2006, January 2007, and June 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Board notes that in the June 2009 decision, the RO awarded the Veteran service connection for PTSD and assigned a 10 percent disability rating, effective January 3, 2006. In an April 2010 decision, the Board determined that the Veteran had filed a notice of disagreement as to the disability rating assigned and the matter was remanded for issuance of a statement of the case (SOC). In a January 2011 rating decision, the RO increased the Veteran's PTSD disability rating to 30 percent, effective January 3, 2006. An SOC was issued that same month and the Veteran thereafter filed a VA Form 9 (Appeal to the Board of Veterans' Appeals). Also remanded by the Board in April 2010 were the issues of entitlement to a separate compensable rating for numbness of the right lower extremity, as due to service-connected traumatic arthritis, lumbosacral spine and entitlement to a compensable rating for scar, status post resection, left fifth metatarsal and excision of plantar wart. Upon completion of the required development, the matters were readjudicated via a January 2011 supplement SOC (SSOC) and the case was returned to the Board in May 2013. FINDINGS OF FACT 1. The Veteran's complained of numbness of the right lower extremity is not a manifestation of his service-connected traumatic arthritis, lumbosacral spine. 2. The Veteran's scar, status post resection, left fifth metatarsal and excision of plantar wart, has been manifested by subjective complaints of pain; there is no objective evidence of limitation of function to a compensable degree, pain or instability. 3. Before February 13, 2009, the Veteran's PTSD was manifested by symptomatology resulting in a mild level of overall social and occupational impairment. 4. Since February 13, 2009, the Veteran's PTSD has been manifested by symptomatology resulting in a moderate level of overall social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for a separate compensable evaluation for numbness of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 2. The criteria for an initial compensable evaluation for scar, status post resection, left fifth metatarsal and excision plantar wart, have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, Diagnostic Codes 5284; 4.118, Diagnostic Codes 7805 (2006). 2. Prior to February 13, 2009, the criteria for an initial evaluation in excess of 30 percent for service-connected PTSD with depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.16, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for a 50 percent disability rating for service-connected psychiatric disability have been met since February 13, 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For increased rating claims, the VCAA requires only generic notice, that is, 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. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2012); Dingess v. Nicholson, 19 Vet. App. 473 (2006). At the outset, the Board notes that VA's General Counsel has held that VCAA notice is not required for downstream issues. VAOPGCPREC 8-2003. Additionally, the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, 19 Vet. App. at 490. As the Veteran's current appeal with respect to his PTSD disability rating stems from a disagreement with a downstream element, no additional notice is required because the purpose that the notice is intended to serve has been fulfilled. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding the Veteran's claims for a separate compensable rating for numbness of the right lower extremity and for a compensable rating for his scar, the Board finds that VA fulfilled its duty to notify via letters dated in March 2006, September 2006, and October 2010. As to any error with respect to the timing of notice, the Veteran's claims were readjudicated after the most recent notice letter was sent, effectively curing any error in this regard. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (holding that timing error can be effectively "cured" by providing any necessary VCAA notice followed by a readjudication of the claim). Notably, the Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the notice letters provided to the Veteran comply with the requirements of 38 U.S.C.A. § 5103(a), and Vazquez-Flores, supra, and afforded the Veteran a meaningful opportunity to participate in the development of his claims. Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claims. All available relevant evidence pertaining to the Veteran's claims has been obtained. The evidence includes his VA treatment records, private medical evidence, VA examination reports, records from the Social Security Administration, and statements from the Veteran. The Veteran has not alleged that there is any additional outstanding evidence pertinent to the matters currently before the Board and the Board is also unaware of any such evidence. Further, the Veteran has been afforded several VA examinations in connection with the matters on appeal. A review of the examination reports shows that they contain all relevant and necessary information to evaluate the Veteran's disabilities in the context of the rating criteria and throughout the relevant time period. All necessary testing was also conducted and the VA examiners' conclusions are supported by the evidence of record and reasons stated in the examination reports. The Veteran has also not indicated a worsening of any symptomatology since the most recent VA examinations of record. The Board is satisfied that the examination reports, along with the private and VA treatment reports of record, contain sufficient evidence for the Board to decide the Veteran's current claims. Thus, the Board has properly assisted the Veteran by affording him adequate VA examinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Cox v. Nicholson, 20 Vet. App. 563 (2007). II. Separate Rating - Numbness of Right Lower Extremity At the outset, the Board notes that the Veteran is in receipt of service-connected disability benefits for traumatic arthritis of the lumbosacral spine. Under the General Rating Formula for Diseases and Injuries of the Spine, associated objective neurologic abnormalities are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2012). The Veteran is also separately evaluated for numbness of the left lower extremity, related to his service-connected traumatic arthritis of the lumbosacral spine. He now seeks entitlement to a separate evaluation for numbness of the right lower extremity, which he alleges is a manifestation of his traumatic arthritis of the lumbosacral spine. Evidence relevant to the determination of whether the Veteran is entitled to a separate evaluation for numbness of the right lower extremity shows that the Veteran has complained of numbness and tingling in his lower extremities, bilaterally. The report of an April 2006 VA spine examination records the Veteran's complaints of back pain that radiated posteriorly to both knees, right worse than left, and numbness in his feet and hips. The examiner stated his belief that the Veteran's pain and numbness in his lower extremity was related to his lumbosacral spine. During a May 2006 VA neurological examination, the Veteran complained of waxing and waning low back pain with intermittent numbness in the lateral thighs. He denied radiation but stated that his hip joints hurt. Upon examination of the Veteran and review of his medical history, the examiner stated that he could find no evidence of radicular deficits related to the lumbar spine, but that there was evidence of peripheral polyneuropathy unrelated to spine or joint disease. VA treatment records indicate complaints of radiating low back pain and bilateral lower extremity numbness and tingling and note diagnoses of cervical and lumbar stenosis and possible peripheral neuropathy. An April 2007 treatment record noted that the Veteran had been seen in the neurosurgery clinic on multiple occasions for cervical and lumbar stenosis and for complaints of numbness and tingling in his hands and feet. It was indicated that he had no radicular findings. Results of a June 2008 electromyography (EMG)/nerve conduction study showed a mild to moderate degree of polyneuropathy. In January 2009, the Veteran presented to the VA neurology clinic with complaints of severe pain in both feet. The examiner noted a history of hypertension, gout, lumbar stenosis, cervical radiculopathy, surgery on the left foot/left great toe, and multiple broken bones in the feet. The assessment was multiple factorial pain in his feet, the possible causes of which were noted to be neuropathy, autoimmune, previous surgery on his left great toe, and/or fractures. The report of a February 2009 VA joints examination recorded the Veteran complaints of numbness and tingling in both legs to his knees. For neurological findings, the report refers to the January 2009 neurology clinic note. A VA neurological examination was conducted in November 2010, during which the Veteran reported constant pain in his low back that radiated down the outside of his thighs to his knees. He also reported a burning sensation in his feet and indicated intermittent numbness in his right lateral leg into his foot and intermittent neck pain. The VA examiner noted numbness in the feet from peripheral neuropathy. The examiner reviewed the Veteran's medical history, noting the June 2008 EMG and a past magnetic resonance imaging scan showing extensive multilevel degenerative spine and disc disease. Examination of the Veteran revealed full motor strength in all lower extremity muscle groups, with normal tone, bulk, dexterity, and coordination. Vibration sense was moderately impaired at the ankles and sensory examination was decreased to temperature and pin prick in a stocking distribution and bilateral L5 and S1 distributions. The examiner found evidence of polyneuropathy with moderate, incomplete sensory loss in the feet. The examiner stated that although the polyneuropathy was of undetermined etiology, the abnormal sensory studies on the June 2008 EMG effectively excluded lumbar radiculopathy as the cause. The examiner went on to state that the mild incomplete sensory loss bilaterally at the L5 and S1 distributions was suggestive of lumbar radiculopathy, but that an EMG was needed to make this finding. An EMG was ordered and in a December 2010 addendum to the examination report, the examiner indicated that results of the EMG showed absent left sural sensory nerve action potential. The right was noted to be very low in amplitude, compound motor action potential amplitudes were very low, and all but the left peroneal "F" wave were absent and it was delayed. Needle examination of the lower extremities, bilaterally, showed motor unit potentials of the distal muscles to be prolonged and there was no spontaneous activity. Electrophysiology showed rather severe mixed demyelinating and predominantly axonal sensorimotor polyneuropathy, which the examiner opined was unlikely related to the spine and more likely due to peripheral nerve disease. The examiner indicated that denervation changes were more consistent with polyneuropathy than radiculopathy/polyradiculopathy and there was little evidence to support the presence of significant lumbar radiculopathy. Overall, the Board finds that the preponderance of the evidence weighs against the assignment of a separate compensable rating for numbness of the right lower extremity. This is so because the evidence fails to attribute the Veteran's complained of right lower extremity numbness to his lumbar spine disability. Rather, the evidence suggests that the Veteran has polyneuropathy and/or some other peripheral nerve disease that is unrelated to his lumbar spine disability. Notably, the May 2006 VA examiner found no evidence of radicular deficits related to the lumbar spine, but did note evidence of peripheral polyneuropathy unrelated to spine or joint disease. Results of June 2008 EMG showed a mild to moderate degree of polyneuropathy and the November 2010 VA examiner explained why the abnormal sensory studies on the June 2008 EMG effectively excluded lumbar radiculopathy as the cause. In light of the medical findings of record, the Board can find no basis upon which to award a separate compensable rating for numbness of the right lower extremity, as due to service-connected traumatic arthritis, lumbosacral spine. In this regard, the Board has considered the report of the April 2006 VA spine examination, wherein the examiner stated his belief that the Veteran's pain and numbness in his lower extremity was related to his lumbosacral spine. However, the examiner provided no basis for the opinion and a neurological examination conducted the following month yielded no evidence of radicular symptoms. Moreover, although the Veteran is in receipt of a separate rating for numbness of the left lower extremity, that award was made in December 2003, based upon a VA examiner's conclusion that the Veteran experienced neurological symptoms in his left lower extremity related to his degenerative disc disease. Since that time, a significant amount of evidence has been developed, which evidence suggests that the Veteran's complained of numbness in his right lower extremity is unrelated to his lumbar spine disability. As such, the fact that the Veteran is in receipt of a separate rating for numbness of the left lower extremity is not probative of the issue at hand, as multiple clinicians have concluded that the Veteran's neurological symptoms of the right lower extremity are attributable to polyneuropathy likely due to peripheral nerve disease unrelated to the lumbar spine. III. Increased Rating Claims Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). "Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern." Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. For increased rating claims, staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7 (2012). A. Scar The Veteran has been service-connected for a scar, status post resection, left fifth metatarsal and excision of plantar wart, since October 2, 1990, which disability has been evaluated as noncompensably disabling under 38 C.F.R. § 4.118, DC 7805. In January 2006, the Veteran filed an informal claim for an increased rating, stating that his "little toe joint that was removed in the military [was] now hurting [him] when he walk[s]." He thus contends that a compensable rating is warranted. The Board notes that the criteria for rating disabilities of the skin, to include scars, have undergone a revision during the pendency of the Veteran's claim, which revision was made effective from October 23, 2008. See 73 Fed. Reg. 54,708-12 (Sept. 23, 2008). However, the changes apply only to applications for benefits received by VA on or after October 23, 2008, or to claims where a Veteran requests review under the new criteria. As the current claim was received prior to October 23, 2008, and no such request for review under the new criteria has been made in this case, those revisions do not apply. Id. Accordingly, the Board will consider whether the Veteran is entitled to an initial compensable rating under the applicable criteria effective prior to October 23, 2008. The relevant evidence of record shows that the Veteran was afforded a VA examination in December 2006, the report of which notes a history of pain in the left fifth toe area; a resection of part of that toe and of a bone spur in 1982 or 1983; and a history of a plantar wart on the left fifth toe. His then-current symptoms were noted to be a constant ache, the severity of which was weather dependent, in his left foot, as well as feelings of numbness, coldness, and tingling. The Veteran also reported an "odd sensation," partly due to different pressure points in the left foot. The Veteran denied flare-ups and indicated an ability to engage in all activities of daily living unassisted, but with some difficulty. He indicated that when he went shopping, he would need to find a place to sit down because of his aching left foot. He denied the use of assistive devices, but reported the use of special shoes and inserts for treatment related to his gout, which the examiner stated had no effect on the left fifth metatarsal. Physical examination of the left foot appeared grossly normal. The plantar surface was smooth and the ankle appeared normal. The drawer and inversion/eversion tests, although slightly decreased, appeared normal without pain, and the arch was nontender on palpation and percussion. The anterior portion of the Veteran's foot was painful on manipulation, especially in the distal metatarsal area. The examiner indicated that the left fifth toe was in its appropriate place and that the shape appeared within normal limits, although small. It was noted that the left fifth toe moved when other toes moved, but that when resistance was applied to the left toe there was virtually no strength or function. There was a small, hyperpigmented scar on the dorsum of the left foot over the fifth metatarsal area, which scar measured three centimeters by two millimeters wide. The scar neither tender nor affixed to the underlying structures, nor was it tender or depressed. There was also no associated rash. The examiner was unable to identify any abnormal weightbearing signs. Manipulation of the distal foot evoked subjective tenderness, which appeared repeatable, but there was no objective evidence of pain with movement of the left big toe. There was also no evidence of hammertoes, hallux valgus, clubfoot, or pes planus. Neurological examination was normal and the pulses were intact and normal. The examiner indicated that the Veteran had had a good result with some minimal arthritic symptoms and determined the Veteran's incapacity to be mild. VA treatment records show that the Veteran presented with complaints of left foot pain in April 2007. It was noted that prior x-rays were negative, but a bone scan was positive. X-rays taken at that time revealed a displaced fracture of the midshaft of the second metatarsal with questionable stress fracture at the base of the third and fourth. There was no obvious reason for the Veteran to have sustained a stress fracture. However, he was noted to have osteoarthritis of the great toe. Private treatment records dated in May 2007 noted that the Veteran ambulated with an antalgic gait and had difficulty tying his shoes and getting out of his car. These findings were, however, related to a right knee disability, as opposed to anything related to his left fifth metatarsal and/or prior excision of plantar wart. A June 2008 treatment entry indicated that the Veteran had polyneuropathy of his feet. Subsequent treatment records relate the Veteran's complaints of left foot pain to his polyneuropathy and/or compensating for right foot injuries. The Veteran was afforded another VA examination February 2009. He reported having undergone a resection of the left fifth metatarsal bone with excision of a plantar wart in 1983, after which his pain was eliminated on walking. He denied any treatment, problems, or periods of incapacitation associated with the scar. He also denied the use of orthotics or special shoes and stated that there had been no recurrence of the plantar wart. Functionally, it was noted that the Veteran was independent in his activities of daily living, transfers, and ambulation. He stated that his scar did not cause a restriction of activities. Examination of the left foot revealed a well-healed, hyperpigmented 7 by .025 centimeter scar that was smooth, flat, and stable. There was no pain on examination, no adherence to the underlying tissue, no inflammation, edema or keloid formation, no ulceration, chronic skin changes, or skin breakdown, no swelling of the left foot, and no residual of the plantar wart. Pulses were present. The examiner also noted no deformities of the foot or loss of motion from the scarring. Prior to October 23, 2008, DC 7805 provided that a scar was to be evaluated based upon limitation of function of the affected part, which, in this case, would be the left fifth metatarsal. Thus, the Board will consider whether the Veteran is entitled to the compensable rating under the regulatory criteria then extant pertaining to disabilities of the feet, which are found at 38 C.F.R. § 4.17a, DCs 5276 through 5284. Based on the December 2006 and February 2009 VA examination reports and evidence contained in the VA treatment records, the Board finds that the Veteran is not entitled to a compensable rating for his service-connected scar under DC 7805, based on limitation of function of the affected part. This is so because the evidence fails to demonstrate that the Veteran's function limited is limited to compensable level. The evidence most favorable to the Veteran is the December 2006 VA examiner's finding that the Veteran's incapacity was mild in nature. Notably, under the applicable DC, for a compensable rating to be warranted, the Veteran must have a moderate foot injury. See 38 C.F.R. § 4.71a, DC 5284 (pertaining to other foot injuries and providing for 10, 20, and 30 percent evaluations for moderate, moderately severe, and severe foot injuries, respectively). As to other DCs pertaining to disabilities of the foot, because the evidence fails to show flatfoot, claw foot, hallux valgus, hallux rigidus, or hammer toe, DCs 5276, 5278, 5280, 5281, and 5282 are not for application. See 38 C.F.R. § 4.71a, DCs 5276, 5278, 5280, 5281, 5282 (2012). Further, there is no evidence of malunion or nonunion of the fifth metatarsal bone, as required for a rating under DC 5283. See 38 C.F.R. § 4.71a, DC 5283 (2012). The Board has also considered whether the December 2006 VA examiner's finding that there was virtually no strength or function of the left fifth toe when resistance was applied could support a rating under DC 5277, pertaining to weak foot, but finds that it does not because that regulation requires bilateral weak foot and although the Veteran has right foot symptomatology, there is no evidence that the Veteran's right foot has been affected by his service-connected scar. See 38 C.F.R. § 4.71a, DC 5277 (2012). The Board has also considered the Veteran's complaints of left foot pain. In accordance with 38 C.F.R. § 4.73, DC 5279, a singular 10 percent rating is warranted for "metatarsalgia, anterior (Morton's disease), unilateral, or bilateral." 38 C.F.R. § 4.73, DC 5279 (2012). Morton's disease is defined as "a form of foot pain, metatarsalgia caused by compression of a branch of the plantar nerve by the metatarsal heads." Dorland's Illustrated Medical Dictionary 1281 (31st Ed. 2003). In this regard, the Board finds no evidence by which to conclude that the Veteran's complaint of left foot pain is due to the compression of a branch of the plantar nerve by the metatarsal heads. Rather the evidence suggests that the Veteran's foot pain is due to polyneuropathy and/or stress fractures unrelated to his service-connected disability. Overall, the Board finds that the Veteran's scar over the left fifth metatarsal does not limit his function to a compensable degree. Notably, during the most recent examination, there was no loss of motion due to the scar and the Veteran denied any problems associated with the scar. The Veteran has stated that the scar does not restrict his activity and he is noted to be able to undertake all activities of daily living. The Veteran also has not indicated a worsening of symptoms since the most recent examination and the evidence does not suggest that the Veteran's scar, as opposed to an unrelated foot disability, has resulted in any additional limitation of function. Consequently, based on the evidence of record since the award of service connection, an initial compensable evaluation is not warranted under DC 7805 for the Veteran's scar, status post resection, left fifth metatarsal and excision of plantar wart. It should also be pointed out that applicable regulations provide that a superficial scar (one that is not associated with underlying soft tissue damage), that is painful on examination warrants a 10 percent rating under the pre-2008 version of 38 C.F.R. § 4.118, DC 7804 (2007). Here, although manipulation of the distal foot evoked subjective tenderness on examination in December 2006, there is no indication that the Veteran's scar itself, as opposed to the musculoskeletal component, has at any time during the claims period been in any way painful. Accordingly, a compensable rating under DC 7804 is not warranted at any point during the pendency of the Veteran's claim. A compensable rating was also warranted under the pre-2008 version of 38 C.F.R. § 4.118, DC 7802 for a superficial scar, other than head face or neck, that does not cause limited motion, because at no time has the Veteran's scar measured 144 square inches or more. 38 C.F.R. § 4.118, DC 7802 (2007). Further, as there is no evidence that the Veteran's scar results in a limitation of motion or has been unstable, the pre-2008 versions of 38 C.F.R. § 4.118, DCs 7801 and 7803 are not for application. 38 C.F.R. § 4.118, DCs 7801, 7803 (2007). Consequently, there is no basis under any potentially applicable DC for an award of a compensable rating for the Veteran's scar, status post resection, left fifth metatarsal and excision of plantar wart. There is also no evidence of symptomatology related to the Veteran's scar that falls outside of the schedular criteria found in the rating schedule for the considered DCs. In this regard, the Board notes that the Veteran's complained of left foot pain, numbness, and tingling has been attributed to something other than his scar. Thus, as there is no evidence demonstrating an exceptional disability picture such that the available schedular evaluations for the Veteran's scar, status post resection, left fifth metatarsal and excision plantar wart, are inadequate, referral for extraschedular consideration is not required. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); 38 C.F.R. § 3.321(b)(1) (2012). B. PTSD The Veteran has been in receipt of VA disability compensation for PTSD with depressive disorder since January 3, 2006, which disability has been evaluated as 30 percent disabling under 38 C.F.R. § 4.130, DC 9411. The Veteran asserts that a higher rating is warranted. In his VA Form 9, he stated his belief that his PTSD should be evaluated as 70 percent disabling. Under DC 9411, a 30 percent rating is assigned for 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). 38 C.F.R. § 4.130, DC 9411 (2012). A 50 percent rating is assigned when there is 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. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, 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. See 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability arising 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(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). A review of the evidence relevant to the determination of the appropriate rating for the Veteran's psychiatric disability shows that in January 2006, he presented for a primary care visit, during which time a PTSD screen was performed. At that time, the Veteran reported nightmares, avoidance behavior, heightened startle response, and feelings of detachment. The PTSD screen was positive and it was noted that the Veteran had had no prior psychiatric treatment. The Veteran reported living with his wife of 37 years. It was noted that they slept in different rooms on account of the Veteran's snoring. The Veteran reported his marriage to be a good evolution, but voiced concerns about how much more of his behavior his wife would be willing to put up with. He indicated a good relationship with his two children and grandchildren, but stated that his relationship with his father was not a good one. Thereafter, the Veteran was seen for a trauma recovery program consultation. It was noted that he did not meet the diagnostic criteria for PTSD diagnosis, but was found to have an adjustment disorder. In April 2006, the Veteran began group therapy. A mental health treatment plan note indicated that the Veteran felt no acute distress and reported improved mood, sleep, irritability, anxiety and social isolation since beginning medication. He endorsed sleep disturbances, but indicated that that was related to chronic pain and possible sleep apnea, as opposed to trauma memories. Socially, it was noted that he kept busy attending bible study classes and his grandchildren's sporting event. A GAF (Global Assessment of Functioning) score of 67 was recorded. Group therapy treatment notes show that the Veteran was an active member of the group when he attended sessions. There is a notation that the Veteran was experiencing problems with short term memory, likely related to his medication. The Veteran underwent a VA PTSD examination in October 2006. His then-current symptoms were noted to be depressed mood, irritability, worry, crying spells, decreased libido, intrusive thoughts and flashbacks, hypervigilance, exaggerated startle response, and feelings of dread, which symptoms had mildly improved since starting group therapy. He denied combat-related nightmares, and suicidal and homicidal ideation. The examiner indicated the severity of the Veteran's symptoms to be moderate. It was noted that the Veteran had been married for 37 years, which marriage was described as stable, but the Veteran indicated being dissatisfied due to the lack of intimacy. Mental status examination revealed that the Veteran was casually dressed, well groomed, alert and oriented times three. There was no guarding or evasiveness and his psychomotor activity was normal. His affect was restricted, his speech normal, his thought processes and content were goal directed and coherent, his insight was fair, and his judgment good. The Veteran described his mood as doing what he needed to do to get through the day. Suicidal and homicidal ideation was denied and there was no evidence of obsessions, compulsions, psychosis, or hallucinations. There were some problems with recent and short-term memory, but remote memory was intact. A GAF score of 65 was recorded, which the examiner indicated was reflective of mild impairment in industrial and social functioning. The examiner noted transient and expectable reactions to psychosocial stressors, and stated that the Veteran's overall quality of life was compromised secondary to chronic pain. As to social functioning, the Veteran was noted to have meaningful interpersonal relationships with family and friends. Occupationally, it was indicated that the Veteran was unemployed secondary to physical disability. The examiner stated that mental status finding did not demonstrate any major limitations that would preclude employment. VA treatment notes dated between October 2006 and July 2008 record GAF scores ranging from 62 to 67. The Veteran continued to participate in group therapy and reported symptoms consistent with those outlined above. It was noted that the Veteran was fairly high functioning, with anger issues as a social impediment. A March 2007 treatment note revealed that the Veteran and his wife had both recently resigned from leadership positions and attendance at their church due to conflict with their new pastor. In June 2007, the Veteran was noted to have a negative PTSD screen. At that time, he denied recent nightmares, feelings of avoidance, detachment, numbness, and being constantly on guard or startling easily. Similar findings were noted during a November 2008 primary care visit. The Veteran was afforded another VA PTSD examination in February 2009. At that time, he reported trouble sleeping, nightmares two to three times a week, a heightened startle response (although less severe than in the past), chronic feelings of dysphoria, avoidance behavior, and intermittent thoughts of suicide, with no plan or past attempts. The Veteran denied hallucinations and paranoid thoughts. The examiner stated that that the Veteran's psychiatric symptoms were "low moderate" in terms of severity and had a mild effect on his employability. Mental status examination revealed that the Veteran was goal-directed, maintained good eye contact, had a restricted affect and a depressed mood, was alert and oriented times three, and was able to concentrate. His recent memory and immediate recall were also intact. The examiner noted that the Veteran's social functioning was slightly limited and his industrial function was limited due to issues with chronic pain, stating that the effect of his PTSD on his industrial functioning was insignificant at that time. A GAF score of 60 was assigned. VA treatment notes dated from July 2009 to September 2010 show that the Veteran was honored as a Veteran at his granddaughter's softball game and attended a Veterans Day program at her school. It was noted that the Veteran experienced some anger over other veterans also being honored who had not served in the same capacity as he had. Group therapy treatment notes dated during this time record GAF score ranging from 60 to 65. The Veteran was afforded another VA PTSD examination in November 2010. At that time, his symptoms were reported to be sleep disturbances, nightmares on a nightly basis, flashbacks most often while sleeping, irritability and anger, depression particularly when he was in pain, past thoughts of suicide, memories of Vietnam, an exaggerated startle response, impaired concentration, and hypervigilance. He denied paranoia, low self esteem, and a sense of foreshortened future. The examiner indicated that the Veteran's symptoms were moderate in nature and caused impairment in his social and industrial functioning. Regarding his social functioning, the examiner noted that the Veteran was married, participated in raising his grandchildren, and attended church on a regular basis, but did not otherwise socialize. He was able to maintain activities of daily living adequately. Mental status examination revealed that the Veteran was causally dress, appropriately groomed, pleasant, cooperative, alert, and oriented times three. His mood was described as tense, his affect restricted at times and fairly broad at others, and his insight and judgment were intact. Suicidal and homicidal ideation, hallucinations, and paranoia were denied, and there was no evidence of psychosis. The examiner assigned a GAF score of 60, and stated that the Veteran experienced moderate impairment in social and industrial functioning. As noted above, the Veteran's psychiatric disability has been evaluated as 30 percent disabling since January 3, 2006, under DC 9411. Upon review of the evidence, the Board finds that the Veteran's psychiatric disability has increased in severity during the appeal period, as evidenced by the decrease in GAF scores and the increase in symptoms reported. Thus, the Board finds that staged ratings are appropriate in this case. Given the outpatient treatment reports, the October 2006, February 2009, and November 2010 VA examination reports, and in consideration of the benefit-of-the-doubt doctrine, the Board finds that the Veteran meets the criteria for a 50 percent rating from February 13, 2009, the date of the VA examination during which the Veteran reported intermittent thoughts of suicide and the examiner assigned a GAF score of 60 and indicated that the Veteran's psychiatric symptoms were "low moderate" in terms of severity. The Board finds that prior to that date, the effect of the Veteran's PTSD symptoms on his overall social and occupational functioning was milder in nature, such that the 30 percent disability rating adequately compensated him for the severity of his PTSD. In this regard, the Board finds highly probative the GAF scores of record. In assessing the evidence of record, it is important to note that the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed.1994) (DSM-IV). A GAF score of 61-70 is defined as: "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." A GAF score of 51 - 60 is defined as: "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)." Id. Prior to the February 2009 VA examination, the Veteran's GAF scores ranged from 62 to 67, which indicated mild symptoms. The October 2006 VA examiner also assigned a GAF score of 65 and indicated that the Veteran's PTSD symptoms resulted in mild impairment in industrial and social functioning and VA treatment records notes the Veteran to be highly functioning and he several times had negative PTSD screens, which suggests that he was not experiencing certain symptoms during this time. The evidence also shows that the Veteran had a good relationship with his wife, children, and grandchildren, attended bible study classes and the October 2006 VA examiner also determined that the Veteran's PTSD did not demonstrate any major limitations that would preclude employment. The Board points out that in evaluating the severity of the Veteran's PTSD, "it is not the symptoms, but their effects, that determine the level of impairment." Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Here, the Board finds that the Veteran's symptoms had no more than a mild effect on his ability to function prior to February 13, 2009, as evidenced by the recorded GAF scores and October 2006 VA examiner's assessment, which level of impairment is adequately compensated by a 30 disability rating. Since February 13, 2009, however, the Board finds that the Veteran's PTSD more nearly approximates the criteria for a 50 percent rating, as evidenced by the assignment of GAF scores of 60 and the presence of more severe symptomatology, such as intermittent thoughts of suicide. The February 2009 VA examiner also indicated that the Veteran's PTSD impaired his social functioning and the November 2010 VA examiner similarly assigned a GAF score of 60 and indicated that the Veteran's symptoms were moderate in nature and impaired his social and industrial functioning. Accordingly, in consideration of the benefit of the doubt, the Board finds that a 50 percent rating is warranted since February 13, 2009. 38 C.F.R. § 4.130, DC 9411. Although the Board has determined that a 50 percent rating is warranted as of February 13, 2009, the Board cannot find that the evidence of record supports a rating greater than 50 percent at any time. Indeed, entitlement to a 70 percent rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazques-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). During the relevant time period, the Veteran exhibited few symptoms of like kind to those associated with a 70 percent disability rating, save for intermittent thoughts of suicide. The Veteran specifically denied homicidal ideation, symptoms of mania, panic disorder, agoraphobia, delusions, and hallucinations. Further, he was noted to be able to handle daily living skills, maintain personal hygiene, and maintain good relationships with his wife and family. His insight and judgment were also described as good or intact. Accordingly, because the evidence fails to show deficiencies in most areas due to symptoms equivalent in severity to those listed in the rating criteria for a 70 percent rating, the Board finds that a rating is excess of 50 percent is not warranted. The Board also finds that total impairment has not been shown at any point since, as evidenced by the fact that the Veteran maintains a relationship with his wife and grandchildren, and the evidence fails to indicate that the Veteran's PTSD has resulted in total occupational impairment. Accordingly, there is no basis upon which to assign a 100 percent rating See 38 C.F.R. § 4.130, DC 9411. The above determinations are based upon consideration of applicable rating provisions. The Board finds that the Veteran's disability level and symptomatology is adequately described by the rating criteria. Indeed, the Veteran's symptomatology, to include irritability, sleep issues, anger outbursts, depressed mood, diminished concentration, hypervigilance, heightened startle response, and decreased concentration, are exactly the type of symptomatology contemplated by the rating criteria set forth in DC 9411. Without sufficient evidence reflecting that the Veteran's disability picture is so "exceptional or unusual," such that the "the available scheduler evaluation for [his service-connected psychiatric disability] are inadequate," referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. Thun, supra; 38 C.F.R. § 3.321(b)(1). Lastly, the Board notes that the Veteran has been in receipt of a total disability rating based on individual unemployability due to service-connected disability since October 1, 2005. Consideration of whether such a rating is warranted as part of the Veteran's claims for increased ratings is therefore not necessary. ORDER Entitlement to an initial disability evaluation in excess of 30 percent for PTSD with depressive disorder prior to February 13, 2009, is denied. Entitlement to an initial disability rating of 50 percent for PTSD with depressive disorder is allowed as of February 13, 2009, subject to the regulations governing the award of monetary benefits. Entitlement to a separate compensable rating for numbness of the right lower extremity, as due to service-connected traumatic arthritis, lumbosacral spine, is denied. Entitlement to a compensable rating for scar, status post resection, left fifth metatarsal and excision plantar wart, is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs