Citation Nr: 1329464 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 10-34 694 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to an increased rating for adjustment disorder with depressed mood currently rated as 30 percent disabling. 4. Entitlement to an increased rating for gastritis currently rated as 10 percent disabling. 5. Entitlement to a compensable rating for post-surgical multiple lipoma removal scars. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant, spouse, and mother ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty service from October 2001 to January 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In August 2012, the Veteran testified at a hearing before the Board. In November 2012, the Board remanded the Veteran's claims for additional development. The issue of entitlement to a compensable rating for post- surgical multiple lipoma removal scars is REMANDED to the RO via the Appeals Management Center in Washington, D.C. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran does not have a low back disability that is attributable to active service. 2. The Veteran does not have a left knee disability that is attributable to active service. 3. The Veteran's adjustment disorder with depressed mood is manifested by depressed mood, chronic sleep impairment, and some disturbances of motivation and mood. 4. The Veteran's gastritis is manifested by mild esophagitis and gastritis in the body and antrum of the stomach. CONCLUSIONS OF LAW 1. The Veteran does not have a low back disability that is the result of disease or injury incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. The Veteran does not have a left knee disability that is the result of disease or injury incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for a rating in excess of 30 percent for adjustment disorder with depressed mood have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9440 (2012). 4. The criteria for a rating in excess of 10 percent for gastritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.114, Diagnostic Code 7307 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claims. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claims; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in April 2009, June 2009, December 2012, January 2013, and February 2013. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the May 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred during service if the disorder became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The chronicity provisions are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has that disability. That evidence must be medical unless it relates to a condition as to which lay observation is competent. 38 C.F.R. § 3.303(b) (2012). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran claims that he has a low back disability and a left knee disability as a result of injuries incurred in service. Specifically, he indicated that he was involved in a motorcycle accident during service and has had low back and left knee pain since that time. The Veteran's service treatment reports (STRs) reflect that the Veteran reported left knee pain in June 2003. He denied any serious injury to his knee at that time and was assessed with left knee pain likely chondromalacia. In August 2003, the Veteran was involved in a motorcycle accident and sustained road rash to his left knee. He was noted to have been cut off by the truck in front of him and he slid under the truck and the truck ran over his leg. He was noted to have full range of motion of the left knee with a 6 centimeter superficial abrasion, no erythema, and no edema. Later in August 2003, the Veteran reported pain in his back following the motorcycle accident. The Veteran also reported back pain for two days after stepping wrong while carrying his three year old daughter in December 2004. He was assessed with acute thoracic muscle sprain at that time. The Veteran reported low back pain in July 2005. He denied trauma to his back at that time and following a physical examination he was assessed with low back pain without radicular symptoms. Private treatment reports from Baptist Memorial Medical Center dated in June 2003 reflect that the Veteran was seen for pain in the left side of his back which began after he was lifting and turning while working with heavy carburetor parts. He was assessed with lumbar strain at that time. In May 2007, he reported achy pain in his left lower back. He denied chronic back pain at that time and following a physical examination he was assessed with left lower back pain, musculoskeletal in nature. The Veteran reported back pain in January 2010 and lumbar pain in March 2010 and following physical examinations he was assessed with back pain and lumbar pain, respectively at those times. VA outpatient treatment reports reflect that x-rays of the lumbosacral spine revealed minimal sclerotic changes at the left sacroiliac joint in October 2006 and October 2007. In October 2006, the Veteran reported back pain for several days after doing more lifting. X-rays were reported to be negative and he was assessed with back pain. In June 2008, the Veteran was noted to have been seen four days prior at an outside hospital for a left knee sprain resulting from a motor vehicle accident. He was prescribed a left knee brace. In May 2009, x-rays of the lumbosacral spine revealed questionable spondylolysis at L5 on the left side and mild arthritis changes at the right-sided facet joint at L5/S1. In September 2010, the Veteran was seen for a report of chronic low back pain since 2003 with a normal magnetic resonance imaging (MRI) of the lumbar spine in 2009 with the exception of a unilateral pars defect at L5. Physical examination was noted to be normal. Private treatment reports from Ozark Health reflect that the Veteran reported left knee pain following a motor vehicle accident in December 2008. In February 2009, he reported low back pain and no history of injury. He was assessed with chronic back pain following a physical examination. At a June 2009 VA examination, the Veteran was noted to have been involved in a motorcycle accident in August 2003 at which time he sustained abrasions to his legs. The Veteran reported that his left knee and back began bothering him around the time he left service. The examiner recollected that he had treated the Veteran in his private practice in the 2005 to 2006 timeframe and the Veteran did not report any complaints regarding his knees or back at that time. Following a review of the claims file, medical history provided by the Veteran, and review of x-rays and an MRI of the lumbar spine, the examiner assessed the Veteran with chronic lumbar sprain with incidental finding of L5 pars defect that he believed was developmental and not related to the injury in service. He opined that it was less likely than not that the current back symptoms were related to the motorcycle accident in service. The examiner also assessed the Veteran with left knee arthralgia and opined that it was less likely than not related to the motorcycle accident in service. The examiner noted that following the accident in service the Veteran served for three more years and did not report any significant complaints related to his left knee and sustained "road rash" to his knee at the time of the motorcycle accident. He also noted that the Veteran's main complaints following the accident in service were related to his hand and left heel which both required surgery in the 2005 to 2006 timeframe. At a June 2011 VA examination, following review of the claims file, statements of the Veteran, and a physical examination which included x-rays, the examiner assessed the Veteran with chronic lumbar sprain with spondylolysis (pars defect, L5). The Veteran reported low back pain after his motorcycle accident in service. The examiner opined that it was less likely than not that the Veteran's current back problem was a result of, secondary to, or in any way related to his active duty service. He indicated that the absence of complaints regarding the Veteran's back during service (with the exception of several reports which resolved and unrelated to the motorcycle accident) led him to believe that the Veteran's active duty service was not a causative factor in the development of his back pain. The examiner noted that the Veteran's congenital defect was symptomatic and was a legitimate diagnosis but was not aggravated by service. At an August 2012 hearing before the Board, the Veteran testified that he was seen for reports of back pain during service and was treated with an injection and pain medication at those times. He indicated that the back condition has been chronic since the accident in service. He testified that he has sought treatment for his back since service. The Veteran denied post-service motor vehicle accidents or work injuries. The Veteran's mother indicated that the Veteran did not have any problems with his back prior to the motorcycle accident in service. She testified that he self-medicated after the accident in service. The Veteran indicated that his knee problems resulted from his back because he has sciatica which started soon after the accident in service. The Veteran indicated that he also banged up his knees in the motorcycle accident so the knee pain could be related to the accident. He testified that he has seen many doctors and some have indicated that his back could be related to service and his knee could be related to his back or the accident in service. He denied any injuries to his knee after service. At a March 2013 VA spine examination, the Veteran was noted to have a diagnosis of chronic lumbar sprain. Following a review of the claims file, relevant medical history, report of symptomatology from the Veteran, and physical examination including x-rays and review of a 2009 MRI, the examiner indicated that it was less likely than not that the Veteran's current back disability was incurred in service. The examiner's rationale was that although the Veteran reported that his back pain began in service following the motorcycle accident, review of the record does not substantiate this claim. Moreover, the Veteran was seen for minor low back problems unrelated to the accident during service. At a March 2013 VA examination, the Veteran was noted to have a diagnosis of left knee chondromalacia. Following a review of the claims file, relevant medical history, report of symptomatology from the Veteran, and physical examination including x-rays, the examiner indicated that the Veteran's knee examination was normal and it is less likely than not that the Veteran has a knee disability related to his active duty service. The examiner noted that the Veteran was seen for possible chondromalacia of the left knee on one occasion in service with no other complaints of knee pain. A. Low Back Disability In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for a low back disability. The competent evidence of record does not show a relationship of the Veteran's claimed low back disability and his period of active service. The medical evidence of record shows that the Veteran was treated in service for reports of low back pain on several occasions. The complaints appear to have been acute and transitory in nature as no chronic back disability was diagnosed during service. Moreover, the records do not contain any opinion linking a chronic low back disability to the Veteran's period of service. Multiple VA examiners have concluded that it is less likely than not that the Veteran's low back disability is related to his service. The Veteran has not submitted any competent evidence which provides a basis for the conclusion that the Veteran's claimed low back disability is related to his period of service. Finally, there is no evidence that arthritis manifested to a compensable degree within one year of the Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309 (2012). The Board acknowledges the Veteran's report of continuous low back pain since service and although the Veteran contends that he has a low disability related to his active service, he has submitted no competent medical evidence or opinion to corroborate that contention. 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinion is not competent to provide the requisite etiology of the claimed low back disability because those matters require medical expertise. 38 C.F.R. § 3.159(a)(1) (2012); Duenas v. Principi, 18 Vet. App. 512 (2004); Bostain v. West, 11 Vet. App. 124 (1998); Stadin v. Brown, 8 Vet. App. 280 (1995). Therefore, his statements regarding his claimed low back disability being related to service are not competent as he is not medically qualified to provide evidence regarding a matter requiring medical expertise, such as an opinion as to etiology. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for a low back disability, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). B. Left Knee Disability In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for a left knee disability. The competent evidence of record does not show a relationship of the Veteran's claimed left knee disability and his period of active service. The medical evidence of record shows that the Veteran was treated in service for a report of left knee pain which was assessed as chondromalacia on one occasion. The treatment related to the motorcycle accident refers to an abrasion of his left knee. Moreover, the records do not contain any opinion linking a chronic left knee disability to the Veteran's period of service. Multiple VA examiners have concluded that it is less likely than not that the Veteran's left knee disability is related to his service. The Veteran has not submitted any competent evidence which provides a basis for the conclusion that the Veteran's claimed left knee disability is related to his period of service. Finally, there is no evidence that arthritis of the left knee manifested to a compensable degree within one year of the Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309 (2012). The Board acknowledges the Veteran's report of continuous left knee pain since service and although the Veteran contends that he has a left knee disability related to his active service, he has submitted no competent medical evidence or opinion to corroborate that contention. 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinion is not competent to provide the requisite etiology of the claimed left knee disability because those matters require medical expertise. 38 C.F.R. § 3.159(a)(1) (2012); Duenas v. Principi, 18 Vet. App. 512 (2004); Bostain v. West, 11 Vet. App. 124 (1998); Stadin v. Brown, 8 Vet. App. 280 (1995). Therefore, his statements regarding his claimed left knee disability being related to service are not competent as he is not medically qualified to provide evidence regarding a matter requiring medical expertise, such as an opinion as to etiology. Moreover, the Board finds the Veteran's report of chronic left knee pain since service to be not credible as the Veteran denied any accidents following service at the time of his Board hearing and the post-service treatment records reflect that the Veteran was involved in a motor vehicle accident and sustained an injury to his left knee at that time. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for a left knee disability, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). III. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where entitlement to compensation has already been established and an increase in the assigned rating is at issue, it is the present level of disability that is of primary concern. Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7. Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service- connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). A. Adjustment Disorder with Depressed Mood The Veteran contends that his adjustment disorder with depressed mood warrants a higher rating. The Veteran's adjustment disorder with depressed mood has been rated under Diagnostic Code 9440 (chronic adjustment disorder). The criteria of Diagnostic Code 9440 provide for a 100 percent rating where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The criteria provide for a 70 percent rating where the evidence shows occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence) spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. The criteria provide for a 50 percent rating where the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria provide for a 30 percent rating where the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self- care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health and illness. A GAF score of 51-60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 41-50 is defined as 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). A GAF score of 31-40 is indicative of 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.) Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV). The Veteran testified at a hearing before the Board in August 2012 at which time he indicated that his psychiatric disability had increased in severity since his last examination in 2006. He also indicated that he was in treatment at VA for his psychiatric disability. VA outpatient treatment reports reflect that a pre-operative note unrelated to treatment for any psychiatric disabilities indicates that the Veteran was alert and oriented in three spheres in December 2010. The Veteran was in group therapy for addiction beginning in January 2012. The Veteran was assigned a GAF score of 40 by an addiction specialist at a group session in July 2012. However, no clinical examination of the Veteran's psychiatric symptoms was included with the assessment. A mental health counselor who prepared a review of the Veteran's record for Veteran's Treatment Court assessed the Veteran with a GAF score of 45 in November 2013. The Veteran was noted to meet with a group for substance abuse therapy once per month. He was assessed with a GAF score of 45 at a group session held in February 2013. No clinical examination of the Veteran's psychiatric symptoms was included with the assessment. The records are negative for any individual therapy treatment and reference treatment for substance abuse and for Veteran's Treatment Court. At a VA examination in March 2013, the Veteran was noted to have a diagnosis of adjustment disorder with depressed mood related to chronic physical pain. The examiner assigned a GAF score of 56. The examiner reviewed the claims file and conducted a clinical evaluation of the Veteran. The examiner indicated that the Veteran's overall level of impairment was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; symptoms controlled by medication. The examiner indicated that the Veteran's psychiatric symptoms included depressed mood, chronic sleep impairment, and disturbances of motivation and mood. The Veteran indicated that he was separated from his third wife and has two biological children and two stepchildren, one of whom lived with the Veteran. He reported that he shared custody of the children with his spouse and helped his mother with her flea market on occasion. He also reported that he shared his car with his spouse and ran errands daily. He reported little motivation and frequent awakenings from sleep due to pain. The Veteran indicated that he last worked as an electrician/welder in December 2008 but left the job after he totaled his truck and had no transportation to work. He was ultimately unable to go back to work due to his physical impairments. Having reviewed the complete record, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under 38 C.F.R. § 4.130, Diagnostic Code 9440 at any time during the pendency of this appeal. In essence, the medical evidence, consisting of testimony from the Veteran, a VA examination report dated in March 2013; and VA outpatient treatment reports; shows findings consistent with depressed mood, sleep impairment, and some disturbances of motivation and mood. However, the Veteran's disability was not manifested by flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks; difficulty in understanding complex commands; impaired judgment; impaired short- or long-term memory; or impaired abstract thinking. The Veteran endorsed depression, trouble sleeping, and disturbances of motivation and mood when examined by VA in March 2013. He indicated that he was separated from his spouse, lived with his stepson, and shared custody of his three children. He also indicated that while he has little motivation to get up due to pain, he runs errands daily, occasionally helps his mother with her flea market, and shares his car with his wife. With respect to the Veteran's GAF scores, the VA examination reports and VA outpatient treatment reports document GAF scores ranging from 40 to 56 which contemplate symptoms ranging from moderate to severe. The Board notes GAF scores are not, in and of themselves, the dispositive element in rating a disability, and the Board generally places more probative weight on the specific clinical findings noted on examinations and which do not demonstrate a degree of impairment consistent with more than a 30 percent rating. As noted, when the Veteran was assessed with GAF scores in the 40s, no clinical symptomatology was included in the assessments. The kinds of symptoms the Veteran experiences more nearly approximate the criteria for a 30 percent rating. Consequently, the Board finds that a rating in excess of 30 percent is not warranted. The Board finds that this evidence supports no more than a 30 percent rating under Diagnostic Code 9440, which contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events). The Board finds that the evidence does not support a finding that the Veteran has occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Accordingly, the Board finds that the criteria for a rating in excess of 30 percent are not met. The preponderance of the evidence is against the claim and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Gastritis The Veteran contends that his service-connected gastritis warrants a higher rating. The Veteran's gastritis is rated as 10 percent disabling under Diagnostic Code 7307, hypertrophic gastritis. 38 C.F.R. § 4.114. Under Diagnostic Code 7307, a 10 percent evaluation is warranted when there is chronic gastritis with small nodular lesions, and symptoms. A 30 percent evaluation is warranted when there is chronic gastritis with multiple small eroded or ulcerated areas, and symptoms. These criteria are conjunctive, not disjunctive; thus all criteria must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). At a May 2009 VA examination, the Veteran reported a sour taste with some burning in his esophagus and heartburn. He denied diarrhea but endorsed occasional constipation and vomiting. He denied melena, bright red blood per rectum, hematemesis, or coffee-ground emesis. He indicated that his weight varied by ten pounds and that his appetite was fair. Following a physical examination, the examiner assessed the Veteran with gastritis. The examiner indicated that the Veteran's gastritis does not affect his occupation as he was unemployed. At a hearing before the Board in August 2012, the Veteran testified that most morning he wakes up and throws up bile. He indicated that he is unable to eat breakfast due to his gastritis. His spouse indicated that she has had to stop the car for the Veteran to throw up. VA treatment reports reflect that the Veteran reported that he was only able to eat twice a week and had weight loss. An esophagogastroduodenoscopy (EGD) or upper endoscopy performed in December 2012 revealed mild esophagitis and gastritis in the body and antrum. He was advised to continue Protonix and Ranitidine and avoid the use of nonsteroidal anti-inflammatories (NSAIDs). The examiner indicated that the differential diagnoses included cholelithiasis/chronic cholecystitis versus NSAID induced gastritis versus cyclical vomiting syndrome. At a March 2013 VA examination, the Veteran was assessed with gastritis. The examiner noted that the Veteran had a problem with vomiting. He indicated that an EGD performed in December 2012 revealed mild esophagitis and gastritis in the body and antrum of the stomach. The Veteran's weight was noted to be up three pounds in a year. At the examination, the Veteran reported continuous abdominal pain and recurrent vomiting. The Veteran denied incapacitating episodes due to his stomach condition. The examiner indicated that the Veteran's gastritis impacts his ability to work in that he vomited frequently and had constant abdominal pain. Having reviewed the complete record, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under 38 C.F.R. § 4.114, Diagnostic Code 7307 at any time during the pendency of this appeal. The evidence as reported above does not more closely approximate a 30 percent rating under the applicable Diagnostic Codes. 38 C.F.R. § 4.7. The results of the EGD revealed mild gastritis with no evidence of multiple small eroded or ulcerated areas. Although the Veteran has chronic gastritis with symptoms of frequent vomiting and constant abdominal pain, as noted above, the criteria set forth in Diagnostic Code 7307 are conjunctive. See Melson v. Derwinski, 1 Vet. App. 334 (1991). Therefore, a 30 percent evaluation is not warranted. 38 C.F.R. § 4.114. Accordingly, the Board finds that the criteria for a rating in excess of 10 percent are not met. The preponderance of the evidence is against the claim and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Extraschedular Consideration The Board has considered whether an extraschedular rating is warranted in this case. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993); 38 C.F.R. § 3.321(b)(1) (2012). Factors for consideration in determining whether referral for an extraschedular rating is necessary include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1) (2012). The Board finds that referral is not warranted in this case. The evidence of record does not show that the Veteran's service-connected psychiatric disorder and gastritis markedly interfere with employment, beyond that contemplated in the assigned rating, or cause frequent periods of hospitalization. While the most recent VA examiner indicated that the Veteran's gastritis impacts his ability to work in that he vomited frequently and had constant abdominal pain, these findings are not tantamount to marked interference with employment. Moreover, the service- connected psychiatric disorder and gastritis have not required frequent periods of hospitalization. Consequently, the Board finds that the evidence does not show that the criteria for referral for consideration of an extraschedular rating are met because marked interference with employment and frequent hospitalizations are not shown. 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to an increased rating for adjustment disorder with depressed mood currently rated as 30 percent disabling is denied. Entitlement to an increased rating for gastritis currently rated as 10 percent disabling is denied. REMAND A review of the claims file reveals that a remand is unfortunately once again necessary before a decision on the merits of the claim of entitlement to a compensable rating for post-surgical multiple lipoma removal scars can be reached. The Veteran contends that his service-connected post- surgical multiple lipoma removal scars warrant a compensable rating. The Veteran's claim was remanded to afford the Veteran a VA examination in order to assess the nature and severity of the service-connected scars. The Board specifically requested the examiner to describe the scars that were residuals of lipoma excision and include a description of location, size, and appearance of each scar, to include commenting on any symptomatology or functional impairment associated with the scarring. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand requests. Stegall v. West, 11 Vet. App. 268 (1998). At a March 2013 VA examination, the examiner indicated that the Veteran had three linear scars on the dorsal forearms which measured 0.1 by 1.5 centimeters (cm). A linear scar of the left mid-back was 0.2 by 2.0 cm and a linear scar of the right low back was 0.2 by 2.2 cm. The total body area affected was less than 1 percent. The Veteran also had a linear scar on the right thigh measuring 2 cm and a linear scar of the left flank measuring 12 cm. The examiner did not address any symptomatology reported by the Veteran nor did he include any reference to whether the scars were unstable or painful. Consequently, another examination is necessary to determine the nature and severity of the service-connected post-excision lipoma scars. Associated with the claims file are VA outpatient treatment reports dated through March 2013. Because there may be outstanding VA medical records that contain information pertinent to the Veteran's claim, an attempt to obtain any VA records dated since March 2013 should be made. 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain any VA outpatient treatment reports dated since March 2013. If the Veteran identifies any other relevant medical records, those records should be obtained. Any negative responses should be associated with the claims file. 2. Schedule the Veteran for an appropriate examination of the skin. The claims file must be provided to the examiner, the examiner must review the claims file prior to the examination, and the examiner should indicate that a review of the claims file was accomplished. The examiner must specifically describe the scars that are residual of lipoma excision. This must include a description of the location, size, and appearance of each scar, to include commenting on any symptomatology or functional impairment associated with the scarring including whether the scars are painful or unstable. A complete rationale is required for any opinion provided. 3. Then, readjudicate the claim. If action remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs