Citation Nr: 1327006 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 09-40 291 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of compensation. 2. Entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of VA outpatient dental treatment. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to an increased rating for right shoulder rotator cuff tendonitis and acromioclavicular separation, currently rated 20 percent disabling. REPRESENTATION Appellant represented by: Justin G. Holbrook, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from August 2002 to July 2003. These matters come before the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In May 2013, the Veteran testified during a hearing at the Board; a transcript of that hearing is of record. At that time, the Veteran's attorney submitted additional evidence along with a waiver of initial RO review of this evidence. The Board will therefore consider this evidence in the first instance. 38 C.F.R. § 20.1403(c) (2012). For the reasons stated below, the issue of entitlement to an effective date earlier than August 25, 2008, for the grant of service connection for depression, been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of VA outpatient dental treatment, is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. In an April 2004 rating decision, the RO denied the Veteran's claim for entitlement to service connection for compensation for removal of right and left lower wisdom teeth. It was noted these were not the type of disorders subject to compensation. Appellant was notified. The Veteran neither appealed this decision nor submitted new and material evidence within the one year appeal period. 2. Evidence received since the April 2004 decision is cumulative of the evidence that was of record at the time of that decision. 3. The preponderance of the evidence reflects that the Veteran does not have PTSD and he has not identified with sufficient specificity a particular in-service stressor to which any PTSD could be related. 4. The symptoms of the Veteran's right shoulder disability have not more nearly approximated limitation to midway between the side and shoulder level or to 25 degrees from the side, or moderately severe muscle injury. CONCLUSIONS OF LAW 1. The April 2004 decision that denied the claim for entitlement to service connection for removal of right and left lower wisdom teeth is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.156(b), 20.1103 (2012). 2. Evidence received since the April 2004 decision is not new and material and the claim for entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of compensation, is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2012). 4. The criteria for a rating higher than 20 percent for right shoulder rotator cuff tendonitis and acromioclavicular separation have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DCs) 5201, 5203, 4.73, DC 5301 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a March 2008 pre-rating letter, the RO notified the Veteran of the evidence needed to substantiate the service connection and increased rating claims. This included a request for specific details regarding the stressful incident or incidents in service that caused the claimed PTSD. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 was amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). In any event, the March 2008 letter complied with this requirement. The Veteran has substantiated his status as a veteran. The Veteran was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims, in the March 2008 letter. In addition, in Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that, in the context of an application to reopen, VCAA notice (1) must notify a claimant of the evidence and information that is necessary to reopen the claim and (2) must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying benefit sought by the claimant. Id. at 11-12. Further, VA is required, in response to an application to reopen, to look at the bases for the denial in the prior decision and send a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. Id. As explained below, the RO did not treat the dental claim as an application to reopen and therefore did not send a Kent-compliant letter. While such notification errors are generally prejudicial, the Board finds that there was no prejudice in this case. As discussed below, the underlying claim the Veteran seeks to reopen is for entitlement to service connection for a dental disability for purposes of compensation and VA regulations preclude such compensation (as opposed to treatment). The Veteran did not indicate that he sought compensation for a compensable dental disability in connection with either the prior claim or this application to reopen. In fact, he indicated in his substantive appeal that he seeks treatment. As the Board cannot at this time adjudicate a claim for dental disability for purposes of VA outpatient dental treatment for the reasons stated below, and must deny the claim for compensation as a matter of law, there is no prejudice from lack of Kent notice and a remand for such notice would impose unnecessary burdens on VA adjudication system with no benefit flowing to the Veteran. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (citing Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991)). 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). In this case, VA obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records. During the pendency of the appeal, the Veteran submitted a copy of his November 2009 Social Security Administration (SSA) disability questionnaire answers. When the evidence indicates that the Veteran is in receipt of SSA disability payments, VA's duty to assist requires that it seek the SSA's disability determination and the medical records underlying it only when these records are relevant to the claims. See Golz v. Shinseki, 590 F.3d 1317, 1320-1321 (Fed. Cir. 2010). In this case, the evidence does not indicate that the Veteran is in receipt of SSA disability payments, only that he applied for them. A May 2010 VA treatment note indicated that the Veteran had applied for SSA disability and his case was under review. A June 2010 VA treatment note indicated the Veteran had applied for SSA disability, his case was under review, he had told his lawyers to drop his case, and that he was thinking of rescinding this decision. The Veteran did not indicate during the Board hearing or in statements to treatment providers that he was granted SSA disability, and he indicated in his January 2011 formal claim for a total disability rating based on individual unemployability (TDIU) that he did not receive or expect to receive either disability retirement benefits or workers compensation benefits. For the reasons set forth above, the Board finds that VA has mostly complied with the VCAA's notification and assistance requirements and its noncompliance with the Kent notice requirements was non-prejudicial. The claims on appeal are thus ready to be considered on the merits. Analysis Reopening Generally, a claim that has been denied in a final unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. The implementing regulation also provides that new and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). If such new and material evidence had been submitted and had not been acted upon, a claim could still be pending until a decision had been made on that evidence. See 38 C.F.R. § 3.160(c) ("pending claim" is "[a]n application, formal or informal, which has not been finally adjudicated"); see also Ingram v. Nicholson, 21 Vet.App. 232, 240 (2007) ("[A] claim remains pending-even for years-if the Secretary fails to act on a claim before him"). To comply with the directive of 38 C.F.R. § 3.156(b) that new and material evidence be treated as having been filed in connection with the pending claim, VA must evaluate submissions received during the relevant period and determine whether they contain new evidence relevant to a pending claim, regardless of whether the relevant submission might otherwise support a new claim. Bond v. Shinseki, 659 F.3d 1362, 1369 (Fed. Cir. 2011). For applications to reopen received after August 21, 2001, new evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (2000). In deciding whether new and material evidence has been submitted the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In April 2004, the RO denied the Veteran's claim for entitlement to service connection compensation for removal of the right and left lower wisdom teeth. It was essentially held that compensation was not payable for this disorder under the law. The Veteran was notified of this denial in a letter later that month but did not appeal, and did not submit new and material evidence within the one year appeal period. Therefore, this denial became final. See 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. In a January 2008 statement in support of claim (VA Form 21-4138), the Veteran asked that the RO consider service connection for "dental (wisdom tooth)." In its July 2008 decision, the RO addressed the claim on the merits, without discussing the prior denial. Where there has been a final prior denial, however, the Board has a jurisdictional responsibility to consider whether reopening of the claim is proper, regardless of whether the RO considered the claim on the merits. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). This is true even, where, as here, the RO afforded the Veteran a new medical examination. Woehlaert v. Nicholson, 21 Vet App. 456, 460-461 (2007) (the Board has the authority to deny a veteran's request to reopen previously adjudicated claim without reaching the merits based on its jurisdictional determination that veteran has presented no new and material evidence, even though the RO reopened the claim and ordered new medical examinations). As there has been a prior final denial for what is essentially the same claim, for entitlement to service connection for missing teeth for purposes of compensation, the Board will first address whether reopening of the previously denied claim is warranted. With regard to dental claims, VA regulations at the time of the prior denial provided that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381(a) (2004). Current regulations similarly provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities but may nevertheless be service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381(b) (2012). At the time of the April 2004 denial, the evidence before the RO included the STRs, which indicated that the Veteran had teeth numbers 17 and 32 (referred to as lower wisdom teeth or mandibular third molars) pulled during service, and a December 2003 VA dental examination. On the examination, the Veteran's only complaint was that after the extraction of these teeth, with difficult horizontal impactions, he had two large bony defects distal to the existing second molars, which he constantly has to clean with a syringe. On examination, there was evidence of missing bone at the extraction site of each extracted tooth. The examiner indicated that cleaning these areas would be difficult "because they both have quite large soft tissue defects in the area." He recommended that the Veteran be evaluated for bone grafting procedures into these areas in order to reduce bony defects so that they would not longer collect food impaction. Since the April 2004 denial, the evidence includes the February 2012 VA dental examination. On that examination, the examiner indicated that the Veteran had not been diagnosed with loss of any portion of the mandible or maxilla, malunion or nonunion of the maxilla, loss of teeth for reasons other than periodontal disease or other routine dental maladies, temporomandibular joint disorder, anatomical loss or injury of the mouth, lips, or tongue, osteomyelitis, osteoradionecrosis, or bisphosphonate-related osteocronosis of the jaw, oral neoplasm, periodontal disease, or any other oral or dental condition. The Veteran indicated that when his wisdom teeth were removed during service, they took away too much bone and that he had yearly dental care with no evidence of periodontal disease. Imaging and examination revealed normal bone levels around the wisdom teeth. The examiner indicated that there were no missing upper or lower teeth. There was no claims file review but a subsequent report of the same date indicated that minimal dental disease was present, with well restored dentition, and no abnormal bone loss in the third molar extraction sites. The examiner, who had also performed the December 2003 examination, indicated that the teeth were as well restored at the time of the examination as they were in the past. In his September 2009 substantive appeal (VA Form 9), the Veteran indicated that he was seeking one course of treatment for loss of his teeth in service. The above reflects that new and material has not been received since the April 2004 denial. The evidence is essentially cumulative with regard to the basis for the prior denial, which was that replaceable missing teeth does not constitute a disability for which service connection for compensation purposes can be granted. As none of the evidence received since the April 2004 denial indicates that the Veteran has such a dental disability, i.e., relating to the dental or oral conditions listed in 38 C.F.R. § 4.150 or due to trauma, the evidence is essentially cumulative and is therefore not new and material. The benefit of the doubt doctrine is thus not for application and reopening of the claim for entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of compensation, is therefore not warranted. Annoni v. Brown, 5 Vet. App. 463, 467 (1993) (the benefit of the doubt doctrine is doctrine is not applicable to applications to reopen a claim unless the threshold burden of submitting new and material evidence has been met). PTSD Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (requiring PTSD diagnoses to conform to the DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f). The Board notes that the Veteran was granted entitlement to service connection for depression in September 2010 and assigned a 70 percent rating, effective August 25, 2008, the date of the claim for entitlement to service connection for depression. While this does not preclude a claim for entitlement to service connection for PTSD, the Board must consider whether a separate grant of entitlement to service connection for PTSD is warranted under the facts of this case. See Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009) (considering the possibility that bipolar disorder and PTSD did not constitute the same disability, but rejecting this argument based on the facts of that case). Significantly, during the Board hearing (see hearing transcript, pp. 16-17) and in the post hearing brief (see pp. 5-7), the Veteran's attorney did not argue that the Veteran was entitled to a grant of entitlement to service connection for PTSD in addition to the grant of entitlement to service connection for depression. Rather, he argued that the RO failed to interpret the Veteran's January 2008 claim for entitlement to service connection for PTSD to include a claim for entitlement to service connection for depression. Had the RO done so, according to the Veteran's attorney, the Veteran would have been entitled to an earlier effective date for the grant of service connection, i.e., the January 2008 date of the claim for entitlement to service connection for PTSD rather than the August 2008 date of the claim for entitlement to service connection for depression. The Veteran's attorney is correct that what constitutes a claim cannot be limited by a lay veteran's assertion of his or her condition in the application, but must be construed based on the reasonable expectations of the non-expert claimant and the evidence developed in processing the claim. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). A claim for an earlier effective date on this basis has not, however, been decided by the RO or appealed by the Veteran. The regulations relating to the Board's jurisdiction presume that a determination has been made by the AOJ and that such determination has been properly appealed by the claimant. See 38 C.F.R. §§ 20.200, 20,201, 20.202 (an appeal consists of a timely filed notice of disagreement, expressing dissatisfaction with an AOJ determination, and, after a statement of the case has been furnished, a timely filed substantive appeal). The Board also notes that once there is a relevant final decision on an issue, there cannot be a "freestanding claim" for an earlier effective date. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). In other words, a claimant is not entitled to subsequently make an earlier effective date claim after a prior final denial was not properly appealed. As the Board does not have jurisdiction over the issue of entitlement to an effective date earlier than August 25, 2008 for the grant of entitlement to service connection for depression, to include whether such a claim has been properly raised, the issue is being referred to the AOJ for appropriate action as indicated in the introduction section of this decision above. As to the issue of entitlement to service connection for PTSD that is before the Board, having been adjudicated by the AOJ and properly appealed, the Veteran's attorney stated during the hearing, "It's not our claim that the clues [sic] and elements have been met and that [the Veteran] has a diagnosis of PTSD or qualifies for PTSD. It's very clear that he's been diagnosed multiple times and treated for depression and pain disorder under the DSM." Hearing transcript, p. 16. Similarly, when asked by the undersigned during the hearing if he had been diagnosed with PTSD by a clinician, the Veteran stated, "No, They - I don't think they've directly given me that diagnosis . . . but. . . they were able to . . . put me into . . . their program called PTSD . . . and the counselor there said, you are not technically PTSD. So, I guess it's, you know, yes and no." It therefore appears that neither the Veteran nor his representative contend that he meets all of the elements to establish a claim for entitlement to service connection for PTSD. The Board's review is not limited, however to contentions, but, rather, must review all issues reasonably raised from a liberal reading of all documents in the record. Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009); EF v. Derwinski, 1 Vet. App. 324, 326 (1991). There are, in fact, documents in the record containing diagnoses of PTSD. The Veteran's claim must be denied, however, because the preponderance of the evidence reflects that he does not have PTSD and that he has not identified with sufficient specificity a particular stressor to which any diagnosis of PTSD is related. Diagnoses of PTSD include in VA treatment notes and a problem list dated in November and December 2007. A November 2007 mental health clinic outpatient treatment note indicated that testing indicated the presence of depression and anxiety features that appeared to be outcroppings of longstanding developmental PTSD. A December 2007 mental status examination report contains an Axis I diagnosis of PTSD, alcohol/cocaine abuse. Empirical indicators of PTSD on the MMPI2 test were affirmative. Evaluation confirmed the pattern in his personal experience and history were very consistent with this PTSD impression. An April 2008 VA discharge summary indicated that the Veteran "is here for a long-standing history of physical abuse as a child. He also reports that while he was in the service, he was yelled at in a very harsh way which reminded him of his childhood abuse. He has no combat-related trauma." An October 2008 VA PTSD screening test was positive. A November 2009 SSA disability questionnaire contains a handwritten notation from a physician indicating that the Veteran suffers from depression and PTSD that had been only partially responsive to treatment. A May 2010 VA treatment note indicated that the Veteran had a had a history of depression and PTSD and had applied for SSA disability, with his application currently under review. There are also many treatment notes that contain diagnoses of other psychiatric disorders, such as an August 2007 VA treatment note with a diagnosis of mood disorder NOS and polysubstance abuse, an August 2007 VA treatment note with an Axis I diagnosis of major depression, NOS, and combination of drug dependence-remission, an October 2007 VA treatment note with a diagnosis of major depression, NOS, and an April 2010 VA treatment note contains an Axis I diagnosis of mood disorder. Significantly, the VA examination reports all contain diagnoses of psychiatric disorders other than PTSD. On the August 2010 VA examination, the diagnosis was depressive disorder, not otherwise specified. The physician who conducted the examination indicated that he had reviewed the claims file, electronic medical records, and medical literature and concluded that the Veteran's depression was likely related to his service connected physical disabilities and therefore service. The same physician again reviewed the evidence and examined the Veteran in January 2011 and again did not diagnose PTSD, but, rather, mood disorder not otherwise specified with anxiety features. On the February 2012 VA PTSD examination, the only diagnosis was depressive disorder, NOS, and the psychologist who conducted the examination specifically indicated that the Veteran did not have more than one mental disorder diagnosed. The psychologist indicated that she reviewed the claims file and electronic medical records, and that there were no stressors reported and therefore no stressors that were adequate to support a diagnosis of PTSD or indicate that the PTSD was related to fear of hostile military or terrorist activity. Under the PTSD diagnostic criteria the psychologist indicated there was no exposure to a traumatic event, no persistent avoidance of stimuli associated with trauma or numbing of general responsiveness, no persistent symptoms of arousal, and that the Veteran did not meet the full criteria for PTSD. In her remarks, the psychologist indicated that the Veteran did not have PTSD, there was no criterion A stressor, which the Veteran acknowledged at the beginning of the evaluation, and that the diagnosis was based upon his vague symptom reported, his presentation and review of records. At the time of the Board hearing, the Veteran submitted a forensic psychiatric evaluation by Dr. Kaye. After reviewing the Veteran's psychiatric history, Dr. Kaye diagnosed major depression, pain disorder associated with both psychological factors and a general medical condition, and polysubstance abuse in remission. He did not diagnose PTSD. The above reflects that the weight of the evidence is against a finding that the Veteran has PTSD. The most probative evidence indicates that the Veteran does not have PTSD, in particular the opinion of the February 2012 VA examiner, who gave the most thorough and reasoned explanation for the conclusion that the Veteran does not have PTSD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Moreover, Dr. Kaye and the August 2010/January 2011, who carefully reviewed the Veteran's psychiatric history and examined the Veteran, concluded that a diagnosis of PTSD was not warranted. The preponderance of the evidence thus reflects that the Veteran has not met the specific requirement of showing he has PTSD as well as the current disability requirement applicable to all service connection claims. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of present disability there can be no valid claim."). In any event, as indicated in the RO's May 2008 formal finding on a lack of information required to verify stressors in connection with the PTSD claim, the Veteran did not provide a specific stressor in response to the March 2008 letter asking for specific information in this regard. The only information regarding a stressor was the statement recounted in the April 2008 VA discharge summary indicating that while the Veteran was in the service, he was yelled at in a very harsh way which reminded him of his childhood abuse. As this statement does not provide precise information regarding the date or other facts surrounding a claimed stressor, and the Veteran declined to provide such information when asked, the evidence was insufficient to warrant further action by the RO or to constitute a valid stressor on which a diagnosis of PTSD could be based. See VA Adjudication Manual Rewrite, M21-1MR, Part IV, Subpart ii, Chapter 1, Section D, 15(c) (Sept. 29, 2006) ("at a minimum, the veteran must provide the following: a stressor that can be documented, the location where the incident took place, the approximate date (within a two month period) of the incident, and the unit of assignment at the time the stressful event occurred"). For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for PTSD. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Right Shoulder 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, as explained below, the uniform 20 percent rating is proper. The Veteran's right shoulder disability is currently rated under 38 C.F.R. § 4.71a, DC 5203. As the Veteran is receiving the maximum, 20 percent schedular rating under DC 5203, a higher schedular rating is not possible under this diagnostic code. The Veteran's attorney has argued that the Board should consider whether a higher rating is warranted under other potentially applicable diagnostic codes, in particular 38 C.F.R. § 4.71a, DC 5201 and 38 C.F.R. § 4.73, DC 5301. The Board agrees that such consideration is warranted. See Schafrath, 1 Vet. App. at 593. The Veteran's is right handed and it is his right shoulder disability that is at issue. Under DC 5201, limitation of motion of the dominant arm at the shoulder level warrants a 20 percent rating, limitation midway between the side and shoulder level warrants a 30 percent rating, and limitation of motion of the arm to 25 degrees from the side warrants a 40 percent rating. In addition, as noted by the Veteran's attorney, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. The evidence reflects that, even considering possible additional functional limitation due to flare-ups, the symptoms have not more nearly approximated limitation midway between the side and shoulder level. An October 2007 VA treatment note indicated chronic right shoulder pain, in particular with lifting and pulling backwards. A 2003 X-ray showing suspected old grade 2 acromioclavicular separation was noted. A December 2007 nursing admission assessment indicated that right upper extremity grip was weak. A January 2008 VA treatment note indicated that Spurling test (assessing nerve root pain) was negative, there was no tenderness to palpation over the acromioclavicular joint, negative cross body adduction test, positive Neer test (showing rotator cuff impingment), positive Hawkins test (showing subacromial impingement or rotator cuff tendonitis), discomfort without weakness in supraspinous testing, and infraspinatus and subscapularis testing was normal. The diagnosis was right shoulder rotator cuff tendinitis. A March 2008 VA treatment note indicated that the Veteran was able to elevate to 150 degrees, externally rotate to 45 degrees, and internally rotate to T11 bilaterally. There were positive Neer and Hawkins tests. There was no acromioclavicular joint tenderness to palpation and no biceps tenderness. The diagnosis was again right shoulder rotator cuff tendonitis. An April 2008 physical therapy note indicated that the Veteran reported no improvement from a month of physical therapy. Pain had not changed, range of motion had not improved, and the joint still popped. Active range of motion of the upper extremities was within full limits bilaterally, with shoulder flexion to 120 degrees and abduction to 80 degrees. Passive range of motion of the upper extremities was within full limits, with flexion to 140 degrees and abduction to 100 degrees. Passive range of motion was limited by pain. Manual muscle testing showed right shoulder flexion 4/5 with pain and right shoulder abduction 3-/5 with pain. The assessment indicated that there was decreased right shoulder strength, decreased right shoulder range of motion, decreased ability to perform activity with the arm elevated, and pain, which were likely the result of the rotator cuff tear. On the January 2011 VA examination, the Veteran complained of pain and limitation in his right shoulder and indicated that he had not sought evaluation and treatment for joint impairment since 2008. The Veteran was not receiving any prescribed medication or treatment and there was "no episode of flare-up." On examination, the Veteran was able to dress and undress without difficulty. Range of motion was flexion 90 degrees, abduction 90 degrees, external rotation 60 degrees, and internal rotation 60 degrees. The Veteran complained of pain throughout the range of motion, but there was no loss of motion on repetitive motion testing performed three times. The diagnosis was right shoulder impingement syndrome. On the February 2012 VA examination, the Veteran did not report that flare-ups impacted the function of the shoulder. Range of motion was flexion 90 degrees with no objective evidence of painful motion, abduction 90 degrees with no objective evidence of painful motion, with the same figures given after repetitive motion testing. There was no additional limitation in range of motion of the shoulder and arm following repetitive use testing. It was indicated that there was functional loss or impairment of the shoulder, specifically, less movement than normal and weakened movement. There was no localized tenderness or pain on palpation of the joints, soft tissue, or biceps. There was no guarding. Muscle strength testing was a normal 5/5 on abduction and forward flexion. There was no ankylosis of glenohumeral articulation. Hawkins and empty can test (indicating rotator cuff pathology including supraspinatus tendinopathy or tear) were positive. External rotation/infraspinatus strength test was negative. Lift off subscapularis test (showing subscapularis tendinopathy or wear) was positive. There was no history of mechanical symptoms or recurrent dislocation. Crank apprehension and relocation test (showing instability) was negative. There was no tenderness on palpation of the acromioclavicular joint and cross body abduction test was negative. There was no surgery or scars. There was no arthritis and the shoulder disability did not impact the Veteran's ability to work. During the Board hearing, the Veteran indicated that he has constant right shoulder pain that limited his ability to perform tasks in his daily life and causes him to use his left arm to pick things up. He indicated that he had gone in for shoulder surgery but it had been cancelled due to his smoking. The doctors indicated at that time that they might not be able to repair the tear. He did not experience the shoulder coming out of or separating from the joint, but he did have impingment because of a bone spur, but no dislocation. He did not have spasms, just pain and a pop. The pain was worse with activity. He underwent a nerve study but had not heard the results. He was told the muscle was diseased and something was damaged. The above evidence reflects that the Veteran is not entitled to a higher schedular rating under DC 5201. All range of motion testing figures indicated that the Veteran was able to extend his arm to at (90 degrees) or above the shoulder level, and at no time did the range of motion more nearly approximate limitation to midway between the side and shoulder level. Moreover, although the Veteran's attorney argued that pain and weakness in the shoulder have dramatically increased and caused significant constriction in motion and moderately severe impairment in the right shoulder, the evidence does not reflect that any reduction in motion has resulted in range of motion more nearly approximating midway between the shoulder and side, the requirement for the next higher, 30 percent rating under DC 5201. Rather, on the January 2011 and February 2012 VA examinations the Veteran indicated that he did not experience flare-ups, and there was no change in range of motion on repetitive motion testing. Nothing in the other medical evidence including treatment records or in the Veteran's testimony indicates that any of the DeLuca factors cause a reduction of range in motion that would result in motion more nearly approximating limitation to midway between the side and shoulder level. The April 2008 VA physical therapy note indicated that there was decreased right shoulder strength, decreased right shoulder range of motion, decreased ability to perform activity with the arm elevated, but did not indicate that motion was decreased to the extent necessary to more nearly approximate the criteria for a 30 percent rating under DC 5201. Moreover, the fact that the Veteran experiences constant pain or pain throughout the range of motion does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) ("pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system"). Higher rating are also warranted for ankylosis of scapulohumeral articulation and other impairment of the humerus under DCs 5200 and 5202. The evidence reflects that there have been no such symptoms during the appeal period. For example, a January 2008 right shoulder X-ray report indicated that the bone and joint structures appeared intact with no evidence of significant degenerative disease or soft tissue abnormality. There was mild separation of the acromioclavicular joint. A March 2008 right shoulder MRI showed evidence of a partial bursal sided tear of the right supraspinatus tendon. The other rotator cuff tendons were intact. The long head of the biceps tendon and glenoid labrum were unremarkable. Shoulder bulk was normal and there was no evidence of abnormal bone marrow signal intensity. Finally, DC 5301 provides that where there is moderate injury to muscle group I, the muscles of the shoulder girdle, trapezius, levator scapulae, and serratus magnus, which perform the function of upward rotation of the scapula and elevation of the arm above shoulder level, a 30 percent rating is warranted and where there is severe injury a 40 percent rating is warranted. To the extent that the Veteran's right shoulder disability can be rated by analogy to muscle injury, see 38 C.F.R. § 4.56 (describing factors relating to evaluation of muscle disabilities in terms of wounds from various types of projectiles), the evidence does not reflect that there was an approximation of moderate muscle injury. For example, a January 2008 VA treatment note indicated that Spurling test (assessing nerve root pain) was negative, an April 2008 manual muscle testing showed right shoulder flexion 4/5 with pain and right shoulder abduction 3-/5 with pain, and muscle strength testing was normal on the February 2012 VA examination. There is therefore no basis for a higher rating under DC 5301. The muscles control movement of the shoulder so separate muscle and motion evaluations are precluded by law. 38 C.F.R. § 4.14. As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. The discussion above reflects that there have been symptoms such as popping that are not contemplated by the applicable rating criteria. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is required. The Veteran did not claim and the evidence does not reflect, however, that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The January 2011 VA examiner indicated that there was no adverse impact on activities of daily living, the February 2012 VA examiner indicated that the shoulder disability did not impact the Veteran's ability to work and that he had not had surgery, and the Veteran did not indicate during the hearing that the right shoulder disability caused marked interference with employment or frequent hospitalization. Therefore, referral for consideration of an extraschedular rating for the right shoulder disability is not warranted. 38 C.F.R. § 3.321(b)(1). Finally, although the Veteran's formal claim for a TDIU was denied in September 2012 and is not before the Board on this appeal, a claim for a TDIU is deemed to have been submitted as part of any claim for a higher initial rating or an increased rating when evidence of unemployability is submitted at the same time as the claim and the Veteran seeks the highest rating possible. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, the evidence does not reflect the Veteran is unemployable due to his right shoulder disability and the issue of TDIU has therefore not been raised in connection with this claim. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's symptoms have not more nearly approximated the criteria for a rating higher than 20 percent under any potentially applicable diagnostic code at any time during the appeal period. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for an increased rating for right shoulder rotator cuff tendonitis and acromioclavicular separation must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Fagan, 573 F.3d at 1287. ORDER The application to reopen a previously denied claim for entitlement to service connection compensation for a dental disability, claimed as removal of wisdom teeth, for purposes of compensation, is denied. Entitlement to service connection for PTSD is denied. Entitlement an increased rating for right shoulder rotator cuff tendonitis and acromioclavicular separation, currently rated 20 percent disabling, is denied. REMAND In his January 2008 statement in support of claim (VA form 21-4138), the Veteran wrote, "dental (wisdom tooth)." In its July 2008 decision, the RO adjudicated the claim (actually an application to reopen) only as one for a dental disability for purposes of compensation. As noted, the Board must address all issues reasonably raised by a liberal reading of the record; consistent with this principle, a claim for service connection for a dental disability for purposes of compensation must also be considered to be a claim for service connection for a dental disability for purposes of VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 305-306 (1993). The regulation relating to service connection of dental conditions for treatment purposes was amended, effective February 29, 2012, in order to clarify existing regulatory provisions and to reflect the respective responsibilities of the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) in determinations concerning eligibility for dental treatment. See Proposed Rules, Dental Conditions, 76 Fed. Reg. 14,600 (Mar. 17, 2011); Final Rule, Dental Conditions, 77 Fed. Reg. 4469 (Jan. 30, 2012). The amended version of 38 C.F.R. § 3.381 clarifies that VBA will adjudicate a claim for service connection of a dental condition for treatment purposes after VHA determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests that VBA make a determination on relevant questions. 38 C.F.R. § 3.381(a) (2012). In this case, the RO explicitly adjudicated, and denied, the claim for entitlement to service connection for a dental disability for purposes of compensation, but did not explicitly address, or refer, the claim for entitlement to service connection for a dental disability for purposes of VA outpatient treatment purposes. Although the RO did not explicitly adjudicate the claim for service connection for a dental disability for purposes of VA Outpatient dental treatment, the Board finds that remand, rather than referral, is appropriate here. A remand with instructions to the RO to refer the claim to the VHA, which the regulation provides must make the initial determination on the claim, will better ensure that the claim is addressed promptly and efficiently and is therefore consistent with the uniquely pro-claimant principles underlying the veterans' benefits system. Nat'l Org. of Veterans Advocates, Inc. v. Sec'y of Veterans Affairs, 710 F.3d 1328, 1330 (Fed. Cir. 2013). Accordingly, the claim for entitlement to service connection for a dental disability, claimed as removal of wisdom teeth, for purposes of VA outpatient dental treatment, is REMANDED for the following action: 1. Refer the claim for dental treatment to the appropriate VA Medical Center (VAMC) to determine if the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161. 2. If the VAMC determines that the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests VBA make a determination, adjudicate the claim. If any benefit sought on appeal remains denied, furnish the Veteran and his attorney a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs