Citation Nr: 1323676 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 09-45 953 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for headaches, secondary to service-connected psychiatric and physical disabilities. 2. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) (previously diagnosed as panic disorder). 3. Entitlement to a compensable rating for erectile dysfunction. 4. Entitlement to a higher rating for a left thigh graft donor site scar, evaluated as noncompensably disabling from December 4, 1985, and 20 percent disabling from October 11, 2006. 5. Entitlement to a disability rating in excess of 10 percent for second degree burns of the right hand and thumb. 6. Entitlement to an increased rating for left inferior lip scar, rated as noncompensably disabling prior to June 8, 2009, and 10 percent disabling effective from June 8, 2009. 7. Entitlement to a rating in excess of 40 percent for second and third degree burns of the upper abdomen, thorax, and neck, to include sensory loss. 8. Entitlement to a rating in excess of 20 percent for third degree burns of the right upper extremity, including sensory loss. 9. Entitlement to a rating in excess of 20 percent for limitation of motion of the neck secondary to first and second degree burn scars. 10. Entitlement to a rating in excess of 20 percent for limitation of motion of the right shoulder secondary to second and third degree burns. 11. Entitlement to a rating in excess of 10 percent for limitation of motion of the right elbow secondary to second and third degree burns. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran had active service from August 1979 to December 1985. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in April 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In a subsequent rating decision, dated in November 2009, the RO granted higher ratings for three disabilities on appeal, previously evaluated as noncompensably disabling, as follows: a disability rating of 20 percent a left thigh graft donor site was granted, effective from October 11, 2006; a disability rating in excess of 10 percent for second degree burns of the right hand and thumb was granted, effective October 11, 2006; and a disability rating of 10 percent for a left inferior lip scar was granted, effective from June 8, 2009. The Veteran has continued his appeal for still-higher ratings. See AB v. Brown, 6 Vet. App. 35 (1993). The Virtual VA paperless claims processing system includes a March 2011 rating decision that denied service connection for arthritis of the right hand. The rating decision describes a February 2011 report of VA examination, which is not associated with either the Virtual VA or paper claims file, and which contains physical examination findings that may be relevant to the Veteran's claim for an increased rating for residuals of second and third degree burns scars of the right hand and right thumb. The February 2011 VA examination was conducted after the issuance of a statement of the case in this matter in November 2009; a supplemental statement of the case has not been issued. In this decision the Board denies the Veteran's claims for a compensable rating for erectile dysfunction and for a higher rating for a left thigh graft donor site scar, and denies a rating in excess of 70 percent for service-connected PTSD (previously diagnosed as panic disorder). The remaining issues on appeal are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's left thigh graft donor site scar is superficial, is not tender or painful, is of an area of less than 929 square centimeters, and is not productive of limitation of range of motion, neurological disability, or any other manifestation uniquely addressable under rating codes other than those indicated for rating of scars. 2. The Veteran's service-connected erectile dysfunction is not associated with deformity of the penis. 3. At no time during the period subject to this appeal has the Veteran's service-connected PTSD (previously diagnosed as panic disorder) been manifested by total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. CONCLUSIONS OF LAW 1. The criteria for a higher rating for a left thigh graft donor site scar, evaluated as noncompensably disabling from December 4, 1985, and 20 percent disabling from October 11, 2006, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.118, Diagnostic Codes 7803 & 7804 (2002) (as in effect prior to August 30, 2002) & Diagnostic Code 7802 (2008) (as in effect from August 30, 2002). 2. The criteria for a compensable rating for erectile dysfunction are not met. 38 U.S.C.A. §§ 1114(k), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 3.350(a), 4.7, 4.115b, Diagnostic Code 7522 (2012). 3. The criteria for a disability rating in excess of 70 percent for psychiatric disability, variously diagnosed, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice as to a claim for service connection for sexual dysfunction was provided in December 2006. In April 2007, service connection for erectile dysfunction was granted; thus, the claim was not only substantiated, it was proven, and the purpose of VCAA notice had been served. The claim for a compensable initial rating arises from a notice of disagreement received in August 2007; no additional VCAA notice obligation arises from the receipt of a notice of disagreement. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises upon receipt of a notice of disagreement). Similarly, in April 2007, service connection for a left thigh graft donor site scar was granted; thus, the merits of the claim were not only substantiated, they were proven. The claim for a higher initial rating arises from a notice of disagreement received in August 2007; no VCAA notice obligation arises from the receipt of the notice of disagreement. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises upon receipt of a notice of disagreement). VCAA notice as to the claim for an increased rating for psychiatric disability was also provided in December 2006. The VCAA notice letter explained the evidence necessary to substantiate the Veteran's claims for increased ratings. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the December 2006 VCAA notice letter from VA was provided prior to initial adjudication of the Veteran's claims and explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). With regard to the duty to assist, the claims file contains service treatment records, reports of post-service treatment, and reports of VA examinations. See 38 U.S.C.A. § 5103A(a)-(d). With respect to the VA examination, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it should ensure that the examination or opinion is adequate. There is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); see Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). Examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo, 26 Vet. App. at 105. In the present case, the December 2006 and January 2007 VA examinations pertaining to the Veteran's left thigh graft donor site scar, psychiatric disability and erectile dysfunction are based on an accurate history, adequate review of the claims file, examination findings that address the pertinent rating criteria, and fully reasoned explanations for the opinions provided. As a consequence, the examination reports are adequate for adjudication of the Veteran's claims and are of a high probative value. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. Essentially, all available evidence that could substantiate each claim has been obtained. There is no indication in the claims file that there are additional available relevant records that have not yet been obtained. Merits of the Claims The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Disability evaluations are determined 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 Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In every instance where the schedule does not provide a noncompensable evaluation for a diagnostic code, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Here, as will be discussed further below, there is no evidence that the level of severity of the Veteran's erectile dysfunction, PTSD (previously diagnosed as panic disorder) or left thigh graft donor site scar have changed to a degree that would warrant a rating higher than that currently assigned; as a result the Board will not assign staged ratings for the disabilities at issue. The Board notes that the RO assigned a staged rating of 20 percent for the Veteran's left thigh graft donor site scar, effective from October 11, 2006. The matter of whether this staged rating was appropriate is not for adjudication as it is not within the Board's jurisdiction. The Board's jurisdiction is limited to adjudicating whether a rating higher than that currently assigned is warranted. Higher Rating for Left Thigh Graft Donor Site Scar In an April 2007 RO rating decision, the RO granted service connection for a left thigh graft donor site scar, and assigned a noncompensable evaluation effective from December 4, 1985. In August 2007, the Veteran submitted a notice of disagreement with the rating assigned. A statement of the case was issued in November 2009 and a VA Form 9 was received in November 2009. As will be discussed further below, also in November 2009, the RO granted a higher rating of 20 percent for the left thigh graft donor site scar, effective from October 11, 2006. In July 2002 VA published new regulations for evaluation of skin disabilities. 67 Fed. Reg. 49590-49599 (July 31, 2002). The revised regulations became effective August 30, 2002. Thus, for the period prior to August 30, 2002, the Veteran's disability must be rated under the older criteria, regardless of whether the new criteria are more favorable to his claim; while, for the period from August 30, 2002, forward, the veteran's claim should be rated pursuant to the set of criteria that is more favorable to his claim. See VAOPGCPREC 3-2000. Effective October 23, 2008, the rating criteria for skin disabilities were again revised. 38 C.F.R. 4.118 as revised effective October 23, 2008, provides that a veteran who VA rated under diagnostic codes 7800, 7801, 7802, 7803, 7804, or 7805 before October 23, 2008, can request review under diagnostic codes 7800, 7801, 7802, 7804, and 7805, irrespective of whether the veteran's disability has increased since the last review. In the event of such a request, VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic codes 7800, 7801, 7802, 7804, and 7805. A request for review pursuant to this rulemaking will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. In the present case, the current appeal arises from a rating decision dated in April 2007, and the Veteran has not requested review under Diagnostic Codes 7800, 7801, 7802, 7804 and 7805 as revised effective October 23, 2008. As a result, these revisions are not for consideration in the current appeal. See 38 C.F.R. § 4.118 (2012). The Veteran experienced significant burns to the chest, neck, and upper extremities in 1983, during active service. Extensive color photographs of the Veteran's burn scars of the chest and upper extremities are included with the service treatment records in the claims file; they are faded color photographs printed on Kodak paper. It is not clear when they were taken. However, no photograph of the left thigh donor graft site is included. A December 1984 Medical Board report indicates that in October 1984 the Veteran underwent release of a hypertrophic burn scar over the sternal region and placement of a split-thickness skin graft over the sternum (donor site-left thigh). The Veteran was recommended for medical discharge due to hypertrophic burn scars of the anterior chest wall, neck, and right upper arm and hand. It was noted that the Veteran had no limitation of motion of his extremities, though his hypertrophic scar of the chest wall was found to limit him in the function of his existing duty. No mention is made of a left thigh graft donor site scar. Several detailed records of evaluation and treatment from October 1984 forward make no mention of disability attributable to the left thigh skin graft donor site. As noted, the Veteran was discharged from active service in December 1985. At a March 1986 VA examination for burn scars, no burn scar of the left lower extremity was indicated and the residuals of the left thigh graft donor site scar were not examined or evaluated. Unretouched color photographs of burn scars taken in March 1986 did not include the left thigh graft donor site scar. At a September 1987 VA examination, the Veteran was noted to have on the anterior left thigh an area where skin grafts were obtained. The area was described as being 19 square inches, being normally healed, and showing hyperpigmentation. At a May 1993 VA examination of the Veteran's scars, the left thigh graft donor site scar was not noted by the examiner. At a July 1996 VA examination, it was indicated that the Veteran had an inverted V-shape of skin graft which had been removed from his left thigh, which was well-healed. At a VA examination in December 2006, the Veteran's scar at the graft donor site of the left thigh was noted to be level, measuring about 22 cm by 21 cm (462 sq. cm) with disfigurement and hyperpigmentation of more than six square inches. There was no tenderness, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, abnormal texture, inflammation or edema. Criteria as in effect prior to August 30, 2002 Under the criteria in effect prior to August 30, 2002, a 10 percent rating is assigned for superficial scars that are poorly nourished, with repeated ulceration, or that are tender and painful on objective demonstration. 38 C.F.R. § 4.118, Diagnostic Code 7803 (Scars, superficial, poorly nourished, with repeated ulceration), 7804 (Scars, superficial, tender and painful on objective demonstration) (2002). Scars may also be rated based on the limitation of function of the part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2002). The Board has considered whether, under 38 C.F.R. § 4.118, as in effect prior to August 30, 2002, a higher rating that that currently assigned is warranted for any period from December 4, 1985 (the day following the Veteran's discharge from active service), to the present time. VA examinations of record show that the area of the left thigh donor graft site is well-healed and hyperpigmented. There is no showing of any resulting limitation of motion. The area of the scar is 21 cm x 22 cm. The donor graft site is well healed. The scar area is superficial, since the underlying tissue is not affected. VA examinations show that there is no there is no tenderness, pain, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, abnormal texture, inflammation or edema. Under the rating criteria as in effect prior to August 30, 2002, the Board notes that Veteran's scar is shown to be superficial and nontender. As no underlying tissue damage is shown, the scar is a superficial scar and the appropriate rating code is Diagnostic Code 7802 (Scars, other than head, face, or neck, that are superficial and do not cause limited motion) (2002). As the left thigh donor site scar is not a scar of the head, face or neck, Diagnostic Code 7800 (Scars, disfiguring, head, face or neck) is not for consideration. As the scar is not a burn scar, Diagnostic Codes 7801 (Scars, burns, third degree) and 7802 (Scars, burns, second degree) are not for consideration. See 38 C.F.R. § 4.118 (as in effect prior to August 30, 2002). With consideration of the VA examination results, the Board finds that there is no basis under the criteria as in effect prior to August 30, 2002, to support a 10 percent rating. A 10 percent rating is not warranted under Diagnostic Code 7803 because the area of the superficial scar is not poorly nourished and there is no repeated ulceration. A 10 percent rating is not warranted under Diagnostic Code 7804 because the areas of the superficial scar are not tender and painful on objective demonstration. A compensable rating is not warranted under Diagnostic Code 7805 because the scar is not productive of limitation of motion. See 38 C.F.R. § 4.118 (2002) (as in effect prior to August 30, 2002). Because the preponderance of the evidence shows that the criteria for a compensable rating are not met under the criteria as in effect prior to August 30, 2002, a rating in excess of the currently assigned ratings is not warranted based on these criteria. See 38 C.F.R. § 4.31 (a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met). Criteria as in effect from August 30, 2002, forward The Board finds that a rating under revised Diagnostic Code 7800 ((Burn scar(s) of the head, face or neck; scar(s) of the head face or neck due to other causes; or other disfigurement of the head, face, or neck) is not appropriate because the Veteran's left thigh donor site scar is not a scar of the head, face or neck. The Board finds that a rating under Diagnostic Code 7801 (Burn scar(s) or scar(s) due to other causes, not of the head, face or neck, that are deep and nonlinear) is not appropriate because the Veteran's scar of the left thigh donor site is not deep. A deep scar is one associated with underlying soft tissue damage. See Diagnostic Code 7801, Note (1). Conversely, a superficial scar is one not associated with underlying soft tissue damage. See Diagnostic Codes 7802-7804, Note 1. The scar is shown not to be deep because the underlying tissue is not affected, as evidenced by the facts that, at the December 2006 VA examination, there was no tenderness, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, abnormal texture, inflammation or edema, and that at all other times when the scar has been specifically discussed it is indicated to be well-healed with the only described manifestation being hyperpigmentation. This is consistent with prior VA examination results that indicate the site to be well-healed. The Board acknowledges that in a rating decision dated in November 2009 the RO rated the Veteran's left thigh donor graft scar as 20 percent disabling, effective from October 11, 2006, under Diagnostic Code 7801. As a result, the RO found the scar to warrant a 20 percent disability rating, apparently because it was of an area greater than 12 square inches (77 square centimeters). A December 2006 VA examination report indicates that the left thigh scar was a donor graft site, measured at 22 by 21 cm with disfigurement and hyperpigmentation of more than six square inches, and that there was no tenderness, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, abnormal texture, inflammation or edema associated with the left thigh scar. However, the RO misinterpreted the evidence as a result of the next sentence in the same paragraph of the examination report, which pertains to the Veteran's overall condition, rather than the left thigh only, and states that there was a burn scar present, that it was a third degree burn scar, as "described above," and that there was no scar on the face. The RO misconstrued the December 2006 VA examination report as showing that the Veteran's left thigh graft donor site scar was a deep third-degree burn scar. The RO erroneously found in its November 2009 rating decision that the left thigh scar was a deep scar resulting from a third-degree burn. As discussed above, rating under Diagnostic Code 7801 is not appropriate, because the evidence, from the service treatment records and multiple VA examination reports, is overwhelming to show that the scar is a well-healed superficial donor graft site scar. The Veteran, who is competent to report the nature and symptoms of the scar area, both by history at VA examinations and in correspondence, has not indicated otherwise. Evaluation under the revised Diagnostic Code 7804 (scar(s), unstable or painful) is not appropriate because VA examination results show that the Veteran's left thigh graft donor site scar is neither unstable nor painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Evaluation under Diagnostic Code 7805 (Scars, other (including linear scars) and other effects of scars evaluated under 7800, 7801, 7802, and 7804) is not warranted because there are no factors for consideration other than those indicated in the above-listed rating criteria. The area is not productive of any limitation of motion or neurological impairment or any other impairment uniquely addressable under rating codes other than those indicated for rating of scars. The appropriate rating code under 38 C.F.R. § 4.118 as revised effective from August 30, 2002, is therefore Diagnostic Code 7802 (Burn scar(s) or scar(s) due to other causes, not of the head, face or neck, that are superficial and nonlinear). The left thigh donor site scar is shown to be 22 cm x 21 cm, or 462 square centimeters, which is less than the 929 square centimeters that would warrant a 10 percent rating for this scar, so that a compensable rating is not warranted under 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). For the foregoing reasons, the Board finds that the rating criteria as in effect both before and after August 30, 2002, support no more than a noncompensable (zero percent) rating for the Veteran's left thigh graft donor site scar. As a result, the preponderance of the evidence is against higher ratings than those currently assigned-a noncompensable rating from December 4, 1985, to October 10, 2006, and a 20 percent rating from October 11, 2006, forward. Accordingly, a higher disability rating is not warranted for the Veteran's left thigh graft donor site scar. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application in resolution of this aspect of the Veteran's appeal. Other Considerations In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court of Veterans Appeals held that service connection for distinct disabilities resulting from the same injury could be established so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. This is not a case similar to Esteban, in which the injury involved disfigurement of the face, a tender and painful scar, and facial muscle injury interfering with mastication; the symptomatology for those three problems was distinct and separate. Here the Veteran's left thigh graft donor site scar is well-healed with no pain or tenderness or muscular or neurological manifestations. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the rating criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the rating criteria specifically include the manifestations of the Veteran's service-connected disability. He has a superficial, well-healed left thigh graft donor site scar that is 462 square centimeters and superficial with hyperpigmentation, but is not a scar not of the head, face or neck, and is not productive of limitation of motion or other additional manifestations. The rating criteria consider these manifestations directly and assign a noncompensable rating for such a scar. As the rating schedule and applicable laws and regulations reasonably contemplate the disability picture, referral to the Director, Compensation and Pension, for extraschedular consideration is not warranted. Higher Rating for Erectile Dysfunction Service connection has been granted for loss of use of a creative organ (erectile dysfunction) that is related to the medications he takes for his service-connected psychiatric disability. As a result, the Veteran is currently in receipt of special monthly compensation under 38 U.S.C.A. § 1114, subsection (k) and 38 C.F.R. § 3.350(a) for loss of a creative organ. SMC is a statutory award, in addition to awards based on the schedular evaluations provided by the diagnostic codes in the VA Rating Schedule. On appeal the Veteran seeks a compensable schedular rating pursuant to 38 C.F.R. 4.115b, Diagnostic Code 7522, which provides that deformity of the penis with loss of erectile power is rated 20 percent disabling. Thus, two distinct criteria are required for a compensable rating pursuant to Diagnostic Code 7522: loss of erectile power and deformity of the penis. It is undisputed that the Veteran's service-connected erectile dysfunction has not involved deformity of the penis, but rather is attributable to his service-connected psychiatric disability and the medications he receives for it. Since the service-connected disability involves no deformity of the penis, the preponderance of the evidence indicates that the criteria for next higher rating of 20 percent under Diagnostic Code 7522 are not met or approximated for any period subject to this appeal. Fenderson v. West, 12 Vet. App. 119 (1999). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Accordingly, a compensable initial rating pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7522, is not warranted. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the rating criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the rating criteria specifically include the manifestations of the Veteran's service-connected disability. With loss of use of a creative organ but no deformity of the penis, special monthly compensation is warranted but a schedular evaluation pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7522, is not. As the rating schedule and applicable laws and regulations reasonably contemplate the disability picture, referral to the Director, Compensation and Pension, for extraschedular consideration is not warranted. Increased Rating Psychiatric Disability The Veteran's psychiatric disability is currently rated as PTSD (previously diagnosed as panic disorder), under the General Rating Formula for Mental Disorders. Pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and 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); and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. A veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas." Id. The Board is to consider the Global Assessment of Functioning (GAF) scores that have been reported in recent years. 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 American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32). GAF scores from 91 to 100 represent superior functioning in a wide range of activities. GAF scores from 81 to 90 represent absent or minimal symptoms. GAF scores from 71 to 80 represent no more than slight impairment of in social, occupational or school functioning. GAF scores of 61 to 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or schooling functioning (e.g., occasionally truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes). At VA treatment in February 2006, the Veteran was wearing a black shirt and tennis shoes. He appeared his stated age. He was cooperative and maintained good eye contact. He answered questions willingly and appropriately. Speech was of normal rhythm and rate, clear, understandable, and spontaneous. Mood was euthymic and affect was appropriate to content of speech with neither increased nor decreased range of intensity. Sensorium was clear. He was alert and oriented to person, place time and purpose. Concentration was intact. Recent and remote memory was intact as evidenced by conversation. Thought process was coherent, logical, and goal-directed. There were no current auditory or visual other misperceptions, no delusions, and no paranoia. He denied suicidal and homicidal ideation. The diagnosis was panic disorder, stable. His psychiatric medications were continued. Current global assessment of the functioning was evaluated as 70. At a VA examination in January 2007, the Veteran was noted to be a reliable historian. On mental status examination, orientation was within normal limits. Appearance and hygiene were appropriate. Behavior was appropriate. Affect and mood were normal. Communication was within normal limits. Speech was within normal limits. Concentration was within normal limits. Panic attacks were noted to be present and to occur less than once per week. The attacks consisted of anxiety symptoms. There was no suspiciousness present. There was no delusional history present. At the time of examination, there were no delusions observed. There was no history of hallucinations. At the time of examination, there were no hallucinations observed. Obsessional rituals were absent. Thought processes were appropriate. Judgment was not impaired. Abstract thinking was normal. Memory was within normal limits. Suicidal ideation was absent. Homicidal ideation was absent. The examiner noted that the Veteran was seeing a psychiatrist every three months and required continuous treatment for his disability. He had not received psychotherapy over the past year. He was receiving psychiatric medications. He had not been required to make any emergency room visits for his psychiatric condition. The examiner diagnosed the Veteran as having PTSD, as a consequence of sustaining burns during active service. Global assessment of functioning was 45. The examiner found that the Veteran was mentally capable of managing benefit payments in his own best interest. Mentally, he did not have difficulty performing activities of daily living. The examiner opined that the best description of the Veteran's current psychiatric impairment was: psychiatric symptoms cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily with routine behavior, self-care and normal conversation. The examiner supported this conclusion with reference to the following symptoms: anxiety, panic attacks weekly or less often and chronic sleep impairment. He had no difficulty understanding commands. He appeared to pose no threat of persistent danger or injury to self or others. At VA treatment in April 2007, the Veteran was diagnosed as having a panic disorder, near its baseline stable state. His mood seemed mildly depressed. Affect was appropriate to content of speech. Sensorium was clear. He was alert and oriented to person, place and purpose. Concentration was intact per history. Recent and remote memory was also intact per history. The Veteran's treatment has continued since that time with similar findings by treatment providers. At VA psychiatric treatment in April 2009, the Veteran was diagnosed as having a panic disorder, continuing near his baseline stable state. There were no significant changes since his last appointment. He denied acute problems with confusion, drastic mood swings, or uncontrolled anxiety or insomnia. Still he had several panic attacks per week, on the average, but felt there were still fairly well-controlled with medications. He was noted to spend quality time with his children, and reported no acute stressors in his home life at present. There were no reported or observed medication side-effects and he felt that his current medication regimen was helpful. He was fairly well-groomed and casually dressed. He had good eye contact, was fairly spontaneous, and had normal speech. His mood appeared euthymic, with appropriate affect and lability. He was oriented. Recent and remote memory was intact. There was some circumstantiality and tangentiality. There were no hallucinations or delusions, and there was no suicidal or homicidal ideation. Global assessment of functioning was assed as 65. His medications were continued. The Veteran is currently rated at 70 percent due to service-connected PTSD (previously diagnosed as panic disorder). The disability is currently rated under the diagnostic code for PTSD, Diagnostic Code 9411. The applicable rating criteria are those set forth under the General Formula for Mental Disorders. Under these criteria, to meet or approximate the criteria for the next higher rating of 100 percent would require total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. The Veteran's GAF scores in recent years, ranging from 45 to 70 and predominantly ranging from 60 and 65, and the examination and treatment reports associated with the GAF scores, are not consistent with a rating greater than the current 70 percent rating. That is, while such scores reflect symptoms in the mild to serious range, a 100 percent evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. The Veteran's GAF scores and the findings underlying them do not reflect gross impairment in thought processes or communication, nor are they consistent with total occupational and social impairment. Id. The VA psychiatric treatment and examination records show that the Veteran has constructive relations within his family, that his thinking process and communication are intact and appropriate; that he has no delusions or hallucinations; that he behaves appropriately; that he presents no persistent danger of hurting himself or others; that he is able to perform his activities of daily living; that he grooms appropriately; that he is fully oriented; and the his recent and remote memory are intact. The Veteran is competent to describe his symptoms, and the examination findings as to symptoms are consistent with the histories at VA examinations and treatment and correspondence received from the Veteran. The preponderance of the evidence shows that the Veteran has not experienced total occupational and social impairment, and the criteria for a 100 percent rating for psychiatric disability are not met or approximated for any period during the pending of the Veteran's claim. Accordingly, a rating in excess of 70 percent for psychiatric disability is not warranted for any time during the pendency of the Veteran's claim; neither a higher staged rating for a separate period nor an increased rating for the full period subject to his appeal is appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application in resolution of this aspect of the Veteran's appeal. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected psychiatric disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the rating criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here the Veteran's social and occupational impairment due to symptoms such as panic attacks, anxiety, depression, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships are directly contemplated in the applicable rating criteria. Accordingly, referral to the Director, Compensation and Pension Service, for extraschedular consideration is not warranted. ORDER Entitlement to a higher rating for a left thigh graft donor site scar, evaluated as noncompensably disabling from December 4, 1985, and 20 percent disabling from October 11, 2006, is denied. Entitlement to a compensable initial rating for erectile dysfunction is denied. Entitlement to a rating in excess of 70 percent for service-connected PTSD (previously diagnosed as panic disorder) is denied. REMAND As noted, the Virtual VA paperless claims processing system includes a March 2011 rating decision that denied service connection for arthritis of the right hand. The rating decision describes a February 2011 report of VA examination that post-dates the November 2009 statement of the case issued in this appeal. The February 2011 VA examination report is not associated with either the Virtual VA or paper claims file, and from a reading of the March 2011 RO rating decision the examination report likely contains findings that are relevant to the Veteran's claim for an increased rating for residuals of second and third degree burns scars of the right hand and right thumb. The indicated findings include range of motion of the fingers, and decreased grip strength and dexterity of the right hand. The report of a February 2011 examination should be associated with the VA paper or Virtual VA claims file and considered in connection adjudication of the Veteran's claim. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that VA medical records are considered to be constructively contained in the claims folder and must be obtained before a final decision is rendered). A supplemental statement of the case should be issued that takes into consideration these examination results. See 38 C.F.R. § 19.31. A June 2009 VA examination report indicates that as a result of service-connected burn residuals there is disfigurement of the base of the neck and upper chest with a contiguous scarring. The examiner indicated that photographs would be made of this area. See 38 C.F.R. § 4.118, Note 3 (take into consideration unretouched color photographs when evaluating under criteria for burn scars or other disfigurement of the head, face or neck). However, there is no further indication in the examination report that such photographs were taken as planned and such photographs are not associated with the claims file. As a result, the examination report should be returned for corrective action. 38 C.F.R. § 4.2. If such photographs were taken, the RO should seek to obtain any color unretouched photographs taken at the June 2009 VA examination and associate them with the claims file. See June 2009 VA examination report associated with VA paper claims file, page 118 (indicating such photographs would be taken); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (relevant VA medical records are considered to be constructively contained in the claims folder and must be obtained before a final decision is rendered). If not, a new set of such photographs should be taken. In addition, the June 2009 VA examination did not include examination of the Veteran's service-connected third degree burn scars of the right arm and forearm. Thus, the most recent VA examination for these burn scars is from December 2006, over six years ago, and in May 2013 the Veteran's representative contended that the level of severity is greater than currently evaluated. Corrective action with respect to this aspect of the June 2009 VA examination report is warranted as well. 38 C.F.R. § 4.2. The Veteran should be afforded a new VA examination to assess the current nature, extent and severity of this disability, both as it pertains to the nature and extent of the scars and to limitation of motion of the elbow and leg attributable to the scarring. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95. At a December 2006 VA examination, the Veteran was diagnosed as having migraine headaches. The examiner opined that the Veteran's migraines were not caused by his service-connected panic disorder and burns with scars. He elaborated that there was no clinical evidence to support a finding that a panic disorder or burns were related to migraines. However, the examiner did not provide an opinion as to whether the Veteran's headaches may be chronically worsened by his service-connected psychiatric disability and burns with scars. Accordingly, a new examination and opinion is warranted. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc) (secondary service connection by reason of aggravation); 38 C.F.R. § 3.310 (disabilities that are proximately due to, or aggravated by, service-connected disease or injury); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (the Board is not competent to supplement the record with its own unsubstantiated medical conclusions as to whether the veteran had any disorder that was related to his period of active service, and if the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions). Also, December 2008 and May 2009 VA treatment records indicate that the Veteran underwent a private MRI due to his history of chronic headaches, and that the MRI results were needed. On remand, the RO/AMC should seek to obtain any potentially relevant records of treatment that have not been previously associated with the claims file. See 38 U.S.C.A. § 5103A(a)-(c). Additionally, in a statement associated with his November 2009 VA Form 9, the Veteran asserted that his headaches were due to medications he received for service-connected disabilities. A medical opinion as to this aspect of the Veteran's claim should be obtained. See 38 U.S.C.A. § 5103A(d). Accordingly, the case is REMANDED for the following action: 1. Request the Veteran to identify all records of VA and non-VA health care providers who have treated his headaches or his service-connected residuals of in-service burns, but which may not have been previously obtained by the RO. After obtaining any appropriate authorizations for release of medical information, the RO/AMC should seek to obtain any potentially relevant and available records that have not been previously received from each health care provider the Veteran identifies. The records sought should include a private report of an MRI of the brain conducted with reference to the Veteran's chronic headaches (as discussed in December 2008 and May 2009 VA records of treatment) and any associated private records of treatment. The records sought should include any additional potentially relevant records of VA treatment. The Veteran should also be advised that with respect to private medical evidence he may alternatively obtain the records on his own and submit them to the RO/AMC. 2. If available, associate with the claims file the unretouched color photographs that a June 2009 VA examiner indicated would be taken in connection with examination of the Veteran's disfiguring scars. 3. Associate with the claims file the report of a February 2011 VA examination of the Veteran's right hand, as described in a March 2011 RO rating decision associated with the Virtual VA claims file. 4. Once all available relevant medical records have been received, make arrangements with the appropriate VA medical facility for the Veteran to be afforded a VA examination for the purpose of determining whether he has current headache disability that is caused or chronically worsened by service-connected physical or psychiatric disabilities. The RO/AMC should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed, to include a December 2006 report of VA examination; VA records of treatment from February 2006, August 2006 (indicating a history of headaches for the past year), August 2008 (indicating that the Veteran had undergone a private MRI of the brain six months earlier due to his history of chronic headaches but that the Veteran needed results of the MRI), December 2008, and April 2009. If obtained, the examiner should also review the private report of an MRI of the brain conducted approximately in the year 2008 and any associated records of treatment. The examiner should provide an opinion as to whether it is at least as likely as not (whether there is a 50 percent or greater probability) that the Veteran's headaches are caused or chronically worsened by his service-connected psychiatric disorder or residuals of burns with scars. The examination should also provide an opinion as to whether it is at least as likely as not (whether there is a 50 percent or greater probability) that the Veteran's headaches are caused or chronically worsened by medications he receives for his service-connected psychiatric disorder or residuals of burns with scars. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner should provide a fully reasoned explanation for his or her opinions, based on established medical principles and his or her clinical experience and medical expertise. 5. Once all available relevant medical records have been received, make arrangements with the appropriate VA medical facility for the Veteran to be afforded a VA examination for the purpose of evaluating the current severity of his service-connected residuals of burns with associated scars. The RO/AMC should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed. As the June 2009 VA examiner indicated that there was some disfigurement associated with the Veteran's service-connected scars, and that the taking of unretouched color photographs was warranted, the new examination report should include unretouched color photographs of the scars. The examiner should indicate range of motion of the Veteran's right hand and affected fingers, neck, right shoulder, and right elbow. The examiner should perform full range of motion studies of the affected joints and comment on the functional limitations caused by pain, flare-ups of pain, weakness, fatigability, and incoordination. To the extent feasible, any additional functional limitation should be expressed as limitation of motion in degrees. The examiner should indicate the size of the residual scars and whether the scars are deep (whether they affect underlying tissue). The examiner should indicate whether the scars are tender or painful. The examiner should indicate any neurological impairment or impairment of sensation resulting from the service-connected scars, such as numbness, chronic pain, burning or tingling associated with the scars. For the left lower lip scar the examiner should indicate whether the scar is visible and whether there is any disfigurement or impairment of motion or sensation associated with the scar. The Veteran has contended that he has disfigurement, tingling and loss of sensation in the area of the scar. Since the Veteran has contended he has disfigurement in the area of the scar, while a VA examiner has indicated the scar of the lip is not visible, the unretouched color photographs should include a picture of this area. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner should provide a fully reasoned explanation for his or her opinions, based on established medical principles and his or her clinical experience and medical expertise. 6. Readjudicate the issues on appeal. If any benefit sought remains denied, provide the Veteran and his representative a supplemental statement of the case and an appropriate period of time for response. Thereafter, subject to current appellate procedure, the case must be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is otherwise notified by the RO/AMC. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs