Citation Nr: 1335221 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-19 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to service connection for a kidney disorder, (claimed as kidney stones), to include as secondary to service-connected diabetes mellitus (DM). 2. Entitlement to service connection for peripheral neuropathy (PN) of the bilateral lower extremities (also claimed as a balance disorder), to include as secondary to DM. 3. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with conversion disorder (also diagnosed as anxiety disorder, not otherwise specified, and undifferentiated somatoform disorder). 4. Entitlement to a rating in excess of 30 percent for acne vulgarus. 5. Entitlement to a rating in excess of 20 percent for DM with early diabetic nephropathy, hypertension, and impotence. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) for the period from February 8, 2005, to May 5, 2008. REPRESENTATION Appellant represented by: Penelope E. Gronbeck, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to May 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decision of the Togus, Maine, Regional Office (RO) of the Department of Veterans Affairs (VA). By rating action in March 2008, service connection was granted for PTSD, and assigned a 30 percent rating, effective May 25, 2006. The Veteran appealed and the claim ensued at that time. By rating action in February 2010, in pertinent part, the 30 percent rating in effect for PTSD was increased to 70 percent, effective May 25, 2006. In a May 2010 rating decision, the 30 percent rating in effect for service-connected acne vulgarus was confirmed and continued, as was the 20 percent rating in effect for DM. That decision also denied service connection for PN of the lower extremities (also claimed as a balance problem) and entitlement to a TDIU. As to the issues numbered #2 and #3 on the title page, a videoconference hearing was held in June 2010 before the undersigned Veterans Law Judge (VLJ), sitting in Washington, D.C. A copy of the transcript of that hearing is of record. Testimony was also provided as to an additional issue which has since been granted and is no longer before the Board. As for the claim for a TDIU, a review of the record reflects that entitlement to special monthly compensation (SMC) benefits based on being housebound as set forth under 38 U.S.C.A. § 1114(s) (2012) and a 100 percent rating for service-connected coronary heart disease (CAD) were assigned, effective from May 5, 2008, in a February 2010 rating action. Additionally, in the most recent rating decision in April 2013, the RO granted entitlement to SMC based on loss of a creative organ, effective from May 5, 2008. The Board notes that the U.S. Court of Appeals for Veteran's Claims (Court) has held that a claim for a TDIU is generally a rating theory and not a separate claim for benefits. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board also notes that bifurcation of a claim is generally a matter within VA discretion. See Tyrues v. Shinseki, 23 Vet. App. 166, 176 (2009) (en banc) (holding that it is permissible for the Secretary to bifurcate a request for benefits on the basis of direct service connection from the request on the basis of presumptive service connection); see also Rice, 22 Vet. App. at 45, n. 7. The Board finds, however, in this case, as a result of the 100 percent schedular rating and SMC benefits awarded in the April 2013 rating action, effective from May 5, 2008, there is no remaining issue to be resolved as to a bifurcated TDIU issue from that date forward and it need not be addressed as a separate matter for appellate review. See Green v. West, 11 Vet. App. 472, 476 (1998), see also Bradley v. Peake, 22 Vet. App. 280 (2008). In other words, the grant of SMC for loss of creative organ as well as a 100 percent schedular rating for heart disease moots the TDIU issue from the date where both SMC and a 100 percent rating became effective. In effect, the Veteran's TDIU claim is only on appeal for the period prior to May 5, 2008. And as there is no evidence that the Veteran filed a formal or informal claim of entitlement to a TDIU prior to February 8, 2005, the claim for entitlement to a TDIU is limited to the period from February 8, 2005, to May 5, 2008. The Board notes that the RO acknowledged that the claim for a TDIU was limited to the dates between February 8, 2005, and May 5, 2008, in the November 2012 statement of the case (SOC). Thus, the claim for a TDIU is as listed on the title page of this decision. The following determinations are based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDINGS OF FACT 1. A kidney disorder, claimed as kidney stones, was first noted many years after service separation; there is no medical nexus linking the condition to a service-connected disability. 2. Although the Veteran has complained of PN symptoms in the toes and feet and reported impaired coordination and tingling, the competent medical evidence, to include neurological exam with electromyography (EMG) testing, show no evidence of PN of the lower extremities with a balance disorder. 3. The Veteran's PTSD has not resulted in total occupational and social impairment due to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 4. Acne vulgarus involves less than 40 percent of the face and neck, but all of the back; treatment includes oral and/or topical medications, and acnes has resulted in mild and insignificant scarring over the back. The Veteran has never asserted that any of his scars were painful and there is no evidence of such. 5. The Veteran's DM is manifested by no more than the requirement for insulin and restricted diet; required regulation of activities due to DM is not demonstrated. 6. The Veteran's service connected disabilities render the Veteran unemployable for the period from June 6, 2005, to May 5, 2008. (It is noted that the Veteran was employed until June 5, 2005.) CONCLUSIONS OF LAW 1. A kidney disorder, claimed as kidney stones, was not incurred in or aggravated by active service, and are not proximately due to or the result of service-connected disease or injury, and may not be presumed to have so incurred. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. PN of the lower extremities was not incurred in or aggravated by active service, and are not proximately due to or the result of service-connected disease or injury, and may not be presumed to have so incurred. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for an initial evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). 4. The criteria for an evaluation in excess of 30 percent for acne vulgarus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.118, DCs 7804, 7806, 7828 (2012). 5. The criteria for entitlement to an evaluation in excess of 20 percent for DM have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3, 4.7, 4.119, DC 7913 (2012). 6. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to TDIU for the period from June 6, 2005, to May 5, 2008, have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.340, 3.321, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Initially, as to the claim for a TDIU, in light of the above-noted legal authority, and in light of the Board's favorable disposition of this matter, the Board finds that all notification and development action needed to fairly resolve the claim has been accomplished. As to the additional claims on appeal, first, VA has a duty under the VCAA to notify a claimant and any designated representative of the information and evidence needed to substantiate a claim. In this regard, letters to the Veteran from the RO (to include letters in February 2006, March 2006, October 2006, July 2009, August 2009, and September 2009) specifically notified him of the substance of the VCAA, including the type of evidence necessary to establish entitlement to service connection on a direct and presumptive basis, and of the division of responsibility between the Veteran and VA for obtaining that evidence. Consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VA essentially satisfied the notification requirements of the VCAA by way of these letters by: (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claims; (2) informing the Veteran about the information and evidence VA would seek to provide; (3) and informing the Veteran about the information and evidence he was expected to provide. Second, VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012). The information and evidence associated with the claims file consist of his service treatment records (STRs), VA medical treatment records, private post-service medical treatment records, Social Security Administration (SSA) records, VA examination reports, and statements and/or testimony from the Veteran and his representative. There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, supra. During the June 2010 hearing, in relevant part, the presiding VLJ identified the issues on appeal that were addressed at the time of the hearing, and the testimony of the Veteran, to include the questions posed by his accredited representative, focused on the elements necessary to substantiate the current appellate claim; i.e., the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims as to service connection for a kidney condition and for an increased rating for PTSD. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. Next, as to the issues on appeal, whether the claims is for service connection or for an increased rating, specific VA medical examinations and opinions pertinent to the issues on appeal were obtained. Specifically, over the course of the appeal, exams were conducted in February 2008, August 2009, November 2011 (PTSD), September 2009 (DM and acne), December 2011 (DM, kidneys, and skin), November 2012 (acne), and March 2010 (PN). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the above VA examination reports, in toto, to be thorough and adequate upon which to base decisions with regard to the Veteran's claims. ON each occasion, the VA examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable laws and regulations and/or rating criteria. See 38 C.F.R. § 3.327(a) (2012); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to these claims. Service Connection in General Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection for certain chronic disorders, such as nephritis, may be established based on a legal "presumption" by showing that that disability manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Additionally, when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310 (2012). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. A Kidney Disorder to Include Kidney Stones It is the Veteran's primary contention that he has a chronic kidney disorder, to include kidney stones, secondary to his service-connected DM. In the alternative, it is argued that this condition had its onset during service. The STRs are negative for report of, treatment for, or diagnosis of a chronic kidney disorder, to include renal calculi. Post service private records reflect the diagnosis of kidney stones in the mid-1990s and recurring treatment since that time (to include surgical intervention and the taking of medications). When being examined for DM by VA in August 2006, the examiner noted that the Veteran had renal stone, status post multiple surgical procedures for renal stones. He added that this condition was unrelated to DM. The examiner was contacted in January 2007 for an addendum opinion regarding aggravation. He opined that the Veteran's kidney stones had not been worsened by his DM. Additional VA examination was conducted in December 2011 regarding their etiology. The examiner noted that there were no kidney stones at that time. It was his opinion that kidney stones were not secondary to DM. For rationale, it was noted that the Veteran's kidney stones predated his DM. Subsequently dated treatment records, to include virtual documents, dated through 2013, continue to show recurring kidney stones. The weight of the evidence here reflects that kidney stones were not shown during service or until many years later. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 200) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). See also Mense v. Derwinski, 1 Vet. Ap. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance J. concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder. Further, the Veteran filed VA disability compensation claims in the 1960s, 1970s, and 1980s, and never filed a claim for kidney stones. Service connection may be granted when the evidence established a medical nexus between active duty service and current complaints. In this case, there is no competent evidence of record that the chronic kidney disorder shown, (kidney stones), are related to service on a direct basis, nor has the Veteran contended such. His primary assertion is that his kidney disorder is secondary to service-connected DM. To this end, VA exam reports, as detailed above, have not attributed his kidney stones to his DM. The VA examiner in 2011 rationaled that the Veteran's kidney stones predated his DM. Thus, the chronic kidney disorder could not be attributed to DM. This opinion corroborates the 2006 VA examiner's opinion. A reasonable reading of the record is that the Veteran's kidney disorder (kidney stones) is not secondary to service-connected DM. To the extent that the Veteran's contentions may be construed as asserting a kidney diagnosis and an etiology opinion therefor, the Board finds that these contentions do not provide a basis for allowance of the claim. In addressing lay evidence and determining what, if any, probative value may be attached to it, attention must be directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469. The United States Court of Appeals for Veterans Claims (Court) has held that veterans are competent to offer statements as to the continuity and severity of symptoms arising from his or her injuries. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (holding that lay evidence is competent with regard to a disease or injury with "unique and readily identifiable features" that are "capable of lay observation."); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (holding that a veteran is competent to report as to onset and symptoms of a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (holding that a veteran is competent to report as to onset and symptoms of tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (holding that a veteran is competent to report as to the onset and symptoms of flatfoot). Proper disposition of the Veteran's claim in this case, however, turns on the complex medical matters of whether the Veteran has a current kidney disorder (a medical diagnosis) and whether there is a relationship between the diagnosed kidney disorder (recurring kidney stones), for which service connection is sought, and either service or service-connected disability. These medical matters are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is not shown to be other than a layperson without the appropriate medical training and expertise, he is not competent to render a probative (persuasive) opinion on these medical matters. See, e.g., Bostain v. West, 11 Vet. App. 124, 127. See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, to the extent that the Veteran looks to his own assertions to establish both a chronic kidney disorder and a positive etiology opinion, the Board concludes that the Veteran's lay assertions in this regard have no probative value. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012); Gilbert, supra. Therefore, the Board is unable to identify a reasonable basis for granting the Veteran's claim. Bilateral Peripheral Neuropathy of the Lower Extremities It is also contended that bilateral PN of the lower extremities, also claimed as a balance disorder, is secondary to service-connected DM. In the alternative, the Board will also look to determine if this condition, if present, had its onset during service. In an August 2009 statement, primarily in support of his claim for an increased rating for DM, the Veteran alleged that his symptoms included numbness in the legs. The RO accepted this as a claim for PN of the lower extremities, also subsequently claimed as a balance disorder. The STRs are negative for report of, treatment for, or diagnosis of numbness or tingling of the lower extremities. The Veteran underwent VA examination in September 2009 to address the severity of his service-connected DM and its complications. The Veteran reported symptoms of PN to include loss sensation, pain, gait abnormality, and tingling. The Veteran reported that these symptoms started in approximately 2005 when he developed symptoms in both feet. Current symptoms, primarily aching and tingling) increased with activity. He also reported trouble with his sense of balance in recent years. He sometimes fell due to decreased sensation in his feet. Additional symptoms in his feet included numbness, tingling, and pain. On examination there was sensory function in the feet was decreased. Detailed reflex exam of the lower extremities showed left knee as 0 and right knee as 1+. Left and right ankle reflexes both 0. There was no muscle atrophy, abnormal muscle tone or build, tremors, tics, or other abnormal movements. No function of any joint was affected by a nerve disorder. The Veteran's gait was antalgic, and the Veteran used a cane for balance. The diagnosis was PN of the right and left lower extremities due to the presence of neuritis and neuralgia. In the examiner's opinion, it was at least as likely as not that PN of the lower extremities was related to his service-connected DM because diabetes directly damaged the nerves in the extremities leading to neuropathy symptoms. (No electromyography (EMG) or nerve conduction studies (NCS) were conducted.) Additional VA examination was scheduled pursuant to the Veteran's complaints of balance problems. This evaluation (ear disease) was also conducted in September 2009. The report noted PN symptoms on the toes and plantar forefoot of both feet, described as paresthesias, impaired coordination, and tingling. On physical exam, there was normal sensory function of the left and right lower extremities to vibration, pain, light touch, and position sense. Left and right knees and ankles showed reflexes of 1+ (hypoactive). There was no muscle atrophy and gait and balance were normal, although the Veteran's gait was slightly widened and antalgic without ataxia. The examiner stated that PN of the lower extremities showed subjective symptoms only. He also stated that the Veteran had a normal neurological exam. He noted that these findings were inconsistent with the previous exam, so he ordered NCS for clarification. No balance disorder was diagnosed and etiology was unknown. In his opinion, the Veteran's balance complaints were less likely than not caused by PN because he had no physical findings of PN at this time. He also showed normal neurological exam without signs of a balance disorder. He added that NCS were pending to decipher whether there was any difficulty that existed in the lower extremities. Upon additional EMG and NCS in March 2010, the results were normal. There was no evidence of diabetic neuropathy or denervation and reinnervation of muscle belong to the L3-4 myotomes as well as spontaneous activity of the lumbar paraspinal muscles. Following review of the EMG and NCS reports, the VA examiner who had conducted the September 2009 exam reversed his diagnosis commenting that EMG and NCS showed no evidence of diabetic neuropathy. See the March 2010 addendum to the September 2009 report. The Veteran underwent VA exam regarding his DM in December 2011 but no complications associated with his PN were noted. Additional treatment records dated through 2013 (to include virtual documents) do not show PN of the bilateral lower extremities. Upon careful and thorough review of the evidence of record, the Board finds that the Veteran is not entitled to service connection for PN of the lower extremities, or a balance disorder, either on a direct basis or under the theory that such may be secondary to his DM. In this regard, there is no evidence in the claims file that the Veteran ever received a PN diagnosis or a balance disorder during service, and the only diagnosis of such post service was retracted by the examiner after additional EMG and NCS studies showed that there was no current neurological disorder of the lower extremities. The evidence of record simply does not reflect a competent diagnosis of PN, as generally claimed by the Veteran. Rather, to the extent that the evidence indicates the presence of neurological symptoms in recent years, medical tests have ruled out diabetic neuropathy. The Board emphasized that Congress specifically limits entitlement for service- connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131; and see Brammer v. Derwinski, 3 Vet. App. 223 (1992). In Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997), it was observed that 38 U.S.C.A § 1131, as well as other relevant statutes, only permitted payment for disabilities existing on and after the date of application for such disorders. The Federal Circuit observed that the structure of these statutes "provided strong evidence of congressional intent to restrict compensation to only presently existing conditions," and VA's interpretation of the law requiring a present disability for a grant of service connection was consistent with the statutory scheme. Degmetich, 104 F.3d at 1332; and see Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA's interpretation of the provisions of 38 U.S.C.A § 1110 to require evidence of a present disability to be consistent with congressional intent); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (the law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a disability). Simply put, in the absence of proof of present disability there can be no valid claim. As there is no competent medical evidence of PN of the lower extremities, (or a balance disorder), the claim must be denied. The Veteran's contentions as to etiology of this condition have been considered. It is noted that he is competent as a lay person to report on that which he has personal knowledge. See Layno, Jandreau, Charles, Falzone, supra. However, there is no evidence of record that he has specialized medical knowledge to be competent to offer medical opinion as to cause or etiology of the claimed disability. See Jones, Routen, supra. For the reasons stated above, the Board finds that the preponderance of the evidence is against the claim of service connection for PN of the lower extremities (and a balance disorder), and the claim must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert, supra. Increased Ratings - In General Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). 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). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be appropriate when the factual findings show distinct time periods where the serviceconnected disability exhibits symptoms that would warrant different ratings. See e.g. Hart v. Mansfield, 21 Vet. App. 505 (2007). Initial Rating in Excess of 70 Percent for PTSD with Conversion Disorder (Also Diagnosed as Anxiety Disorder, not Otherwise Specified, and Undifferentiated Somatoform Disorder). In cases such as this one, in which a claim for a higher evaluation arises out of the initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the claim and appellate process. See generally, Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran contends that his service-connected psychiatric is more disabling than contemplated by the initial 70 percent disability evaluation. His disability has been evaluated pursuant to DC 9411 for PTSD and has been in effect since May 2006. Under the relevant rating criteria, a 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411 (2012). A 100 percent evaluation is warranted where there is evidence of total occupational and social impairment due to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. 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). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126(2012); VAOPGCPREC10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more 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]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. The Veteran's service-connected PTSD is currently rated 70 percent disabling. The Board has reviewed the evidence in order to determine whether the criteria for the assignment of a higher disability rating have been met. In March 2006, he was seen by VA for psychiatric complaints. Depression was noted. When examined by VA in February 2008, the Veteran reported complaints of crying and anger. He sometimes hollered at others and was suspicious of them. He had difficulty sleeping. On mental status evaluation, he was alert, made good eye contact, had no gross impairment of thought processes or communication, no delusions, maintained personal hygiene, was oriented, denied ritualistic behaviors, and had normal rate of speech, but had nightmares, panic attacks, flashbacks, impaired impulse control, and a low mood. His GAF score was 57 and PTSD was diagnosed. In July 2009, VA records show continued depression. When examined by VA in August 2009, his psychiatric complaints continued. PTSD was diagnosed and his GAF score was 58. The Veteran provided testimony at a 2010 personal hearing. At that time, he said that he no longer worked due to a work injury to the shoulders. His SSA records show that he was awarded benefits in August 2006, effective May 2005, due to osteoarthrosis and allied disorders. The decision was partially based on his age and education, as well as past work history that included being a machinist. Additional VA examination was conducted in November 2011. At that time, the examiner did not find that the Veteran's symptoms warranted a diagnosis of PTSD pursuant to DSM-IV criteria. He noted that the Veteran had previously been diagnosed with conversion disorder in 2008 and PTSD in 2009. He explained that the Veteran's anxiety disorder and his PTSD symptoms all fell under his psychiatric diagnosis which also included a somatoform disorder. The Veteran's GAF score at this time was 60. The examiner stated that the Veteran psychiatric symptoms had no impact on his ability to work because he worked for 28 years as a machinist and quit after an unrelated injury to the shoulder. His social function impairment was primarily due to his anxiety disorder. In a December 2011 addendum, the examiner opined that the Veteran's psychiatric symptoms were service-related. Subsequently dated records show that the Veteran continues to be seen for psychiatric symptoms. Virtual records reflect that he was seen by VA in May 2012. At that time, he felt depressed, especially when he got nervous or felt down. He was offered mental health service, but declined and stated that he had been through the clinic before and did not want to return. The Veteran expressed no suicidal ideation, and the examiner felt that he was low risk to hurt himself. When seen for follow-up in November 2012, he was in good spirits. After reviewing evidence of record as a whole, to include the Veteran's ongoing VA treatment reports, his VA examination reports, and his lay statements, the Board finds that the assignment of an initial disability rating greater than 70 percent for the Veteran's service-connected PTSD is not warranted. At no point in the record does an examiner or any other medical personnel find that the Veteran's psychiatric disorder causes total occupational and social impairment, as is required for the assignment of a 100 percent rating. In not granting a 100 percent schedular rating for PTSD, the Board is not minimizing the severity of the Veteran's symptoms. The Board notes that the evidence demonstrates that the Veteran experiences significant social impairment as a result of his anxiety. However, the evidence of record does not reflect that the Veteran's service-connected psychiatric disorder manifests with gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As noted above, the Veteran does not have suicidal ideation, and the medical evidence of record does not reflect that he is in persistent danger of hurting himself. While the Board has considered the Veteran's complaints and assertions that his PTSD warrants a 100 percent rating, the Board ultimately finds that the criteria for a 100 percent evaluation have not been met. For these reasons, the Board concludes that an initial schedular evaluation in excess of 70 percent for PTSD is not warranted. In rendering this decision, the Board has taken into account that the Veteran's GAF scores since his effective date of service connection have been recorded as ranging from 57-60. As noted above, according to the GAF scale, scores ranging from 51 to 60 can reflect moderate symptoms OR moderate difficulty in social, occupational, or school functioning. See DSM-IV at 47. The Board has considered the Veteran's GAF scores and finds that the symptoms associated with the Veteran's PTSD do not warrant more than a 70 percent rating. Thus, the evidence of record, to include the Veteran's ongoing VA treatment records and his credible lay descriptions of symptoms, simply does not demonstrate that his PTSD has caused total occupational and social impairment at any time during the appeal. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (2012); Gilbert, supra. Rating in Excess of 30 Percent for Acne Vulgarus The Veteran contends that his service-connected acne vulgarus is more disabling than contemplated by the current 30 percent disability evaluation. Service connection for this skin condition has been in effect since 1969, and the 30 percent rating has been in effect since 1979. When the 30 percent rating was assigned in 1979, the Veteran's condition was rated by analogy to eczema. The 30 percent rating was based on manifestations that included constant exudation or itching, extensive lesions, or marked disfigurement. (It is noted that this DC is no longer in effect as explained below.) In a June 2009 statement, the Veteran's attorney representative raised the issue of an increased rating for all of the Veteran's service-connected disabilities when he asserted that a TDIU was warranted. This appeal ensued at that time. The Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of "staged ratings" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson, supra. Pursuant to current and appropriate DCs, which were amended in 2002 and 2008, prior to when the Veteran's claim was filed, the Veteran's acne vulgarus is rated pursuant to DCs 7828 and/or 7806, and only the revised criteria will be considered. DC 7828 provides for a 30 percent evaluation for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. 38 C.F.R. § 4.118. No higher disability evaluation is available under DC 7828. DC 7828 also states that acne may also be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. DC 7806 provides a 30 percent evaluation for dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, warrants a 60 percent evaluation. 38 C.F.R. § 4.118. DC 7806 also provides that the condition may be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. The applicable DC for scars, DC 7804, provides for compensable ratings for "scar(s), unstable or painful." When the Veteran underwent VA skin examination in September 2009, he reported that he got acne on his fact and back on an intermittent basis about three times per year. On exam, the skin involvement was described as superficial and affecting less than 40 percent of his face and neck, although his entire back was affected. The total body surface affected was 35 percent. Additional VA skin examination was conducted in December 2011. The Veteran reported that his acne had not been treated with oral and/or topical medications in the past year. The examiner noted that the acne had caused mild insignificant scarring over the back but not on exposed areas. Acne was shown to be superficial and affected body parts other than the face and neck. The back was shown to be affected with numerous small scars (mild). Exam showed 2 cm of area due to acne or acne scars. There was no distortion of facial features and tissue loss was reported. The acne scars on the back were described as mild and nondebilitating. Photos were taken pursuant to the Veteran's skin disorder in November 2012 and are part of the record and have been considered. They primarily show the extent of the skin condition to the face and neck area (brown and red and splotchy discolorations on the Veteran's left forehead). Subsequently dated records primarily reflect treatment for other conditions. Under the current criteria, the higher evaluation of 60 percent is not warranted pursuant to DC 7806. Dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, warrants a 60 percent evaluation. That is simply not shown here. The maximum involvement was described as 35 percent of mostly nonexposed areas as summarized above. Moreover, constant or near constant systemic therapy is not indicated. A 30 percent evaluation is warranted pursuant to DC 7806 throughout the appeal period. The Board has considered whether the assignment of a separate disability evaluation is warranted under DC 7804 (superficial scars, painful on examination). See generally Esteban v. Brown, 6 Vet. App. 259 (1994). However, at no time has the Veteran complained of or sought treatment for painful scars, and VA treatment records do not reflect such symptomatology. Further, neither the Veteran nor his representative have alleged to the RO, the Board, or the Court, that any of his scars have been painful at any point during the appeal period. There is no probative evidence of record to support an evaluation in excess of 30 percent for acne vulgarus, or a separate compensable evaluation for scarring, at any point in the appeal period. See Hart, supra. The preponderance of the evidence is against the claim; there is no doubt to be resolved. An evaluation in excess of 30 percent for acne with cysts is not warranted. See 38 U.S.C.A. § 5107(b) (2012). Rating in Excess of 20 Percent for Diabetes Mellitus It is also asserted that a rating in excess of 20 percent is warranted for DM. The Veteran is currently assigned a 20 percent evaluation for his DM pursuant to 38 C.F.R. § 4.119, DC 7913. Under this DC, a 20 percent disability evaluation is assigned for DM requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet. A 40 percent evaluation is contemplated for DM requiring insulin, restricted diet, and regulation of activities. "Regulation of activities," is defined in DC 7913 as "avoidance of strenuous occupational and recreational activities." Id. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). A 60 percent evaluation applies if diabetes mellitus requires insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. A 100 percent disability evaluation is assigned if diabetes mellitus requires more than one daily injection of insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. The Court has held that with regard to DM, "the evaluation for each higher disability rating include[s] the criteria of each lower disability rating, such that if a component [is] not met at any one level, the veteran [can] only be rated at the level that [does] not require the missing component." See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009) (citing Camacho, 21 Vet. App. at 366-67). In order words, all the criteria for a given lower rating must be met before a higher rating can be assigned for DM, even if some of the criteria associated with the higher rating, such as a restricted diet, are present. Review of the record reflects a diagnosis of DM upon private record in 1998. Additional diagnosis of such was made in 2004 based on lab findings. When examined by VA in September 2009, the Veteran's treatment regimen included insulin twice per day and oral medication (Metformin). His medical history included episodes of hypoglycemia reactions or ketoacidosis, but hospitalization had not been required. The Veteran visited a diabetic care provider one per month. He had been instructed to follow a restricted or special diet, although he was not restricted in physician activities. Additional VA evaluation for DM was conducted in December 2011. At that time, treatment included injection of insulin more than once per day. Regulation of activities was not required. He visited his diabetic care provider less than two times per month for episodes of ketoacidosis and/or hypoglycemic reactions. He had not been hospitalized for DM symptoms in the last year. Related blood pressure readings were 134/78, 128/76, and 124/72. Subsequently dated treatment records show no alteration of the Veteran's DM treatment regimen. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an increased evaluation for his DM at any point during the appeal period. The record demonstrates that his DM requires injection of insulin twice per day and a restricted diet, but his activities are not medically restricted. And, as reported above, his activities must be medically restricted for an increased rating. DC 7319. Moreover, his associated impotence has been awarded a separate disability evaluation. See the April 2013 rating decision. As for associated hypertension, that condition warrants a noncompensable rating pursuant to DC 7101. Thus, a separate rating for this condition is not warranted. Under DC 7101, HTN or isolated systolic hypertension must be confirmed by blood pressure readings taken two or more times on at least three different days and is rated according to a range of diastolic pressure levels. The minimum compensable rating of 10 percent disabling is available where diastolic pressure is predominantly 100 or more, or where systolic pressure is predominately 160 or more, or where an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control of HTN. A 20 percent disability rating is available under this DC where diastolic pressure is predominantly 110 or more, or where systolic pressure is predominantly 200 or more. A 40 percent rating is available under this DC where diastolic pressure is predominantly 120 or more. Finally, the maximum rating of 60 percent disabling is available under this DC where diastolic pressure is predominantly 130 or more. See 38 C.F.R. § 4.104, DC 7101 (2012). There is no probative evidence of record to support an evaluation in excess of 20 percent for DM, or a separate compensable evaluation for hypertension, at any point in the appeal period. See Hart, supra. The preponderance of the evidence is against the claim; there is no doubt to be resolved. An evaluation in excess of 30 percent for acne with cysts is not warranted. See 38 U.S.C.A. § 5107(b) (2012). Final Considerations as to the Increased Ratings Claims Discussed Above The potential application of various provisions of Title 38 of the Code of Federal Regulations have been considered, whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). However, the evidence does not suggest that his service-connected disabilities produce such an exceptional or unusual disability picture as to render impractical the applicability of the regular schedular standard and thereby warrant the assignment of an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1) (1996). These claims do not present factors such as marked interference with employment or frequent periods of hospitalization. VA and private examination records reveal that the Veteran has often reported symptoms associated with his psychiatric, skin and DM disabilities; however, the veteran has not been hospitalized for his service connected disabilities. Due regard has been given to the Veteran's symptoms due to these condition and the treatment required for their control. The functional loss, if any, has been noted. Neither the veteran's statements nor the medical records indicate that these conditions markedly interfere with the Veteran's employment as to warrant the assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) (2012). Entitlement to a TDIU for the Period from February 8, 2005, to May 5, 2008. As already discussed in the "Introduction" portion of this decision, the discussion below will be limited to the period from February 8, 2005, to May 5, 2008. It is argued that a TDIU is warranted from February 8, 2005, to May 5, 2008, in that his service-connected disabilities precluded his employment during this period. Review of the record reflects that for the period in question, the Veteran was service-connected for a psychiatric disorder, rated as 70 percent disabling; acne vulgarus, rated as 30 percent; and DM, rated as 20 percent disabling. While SSA records and other documents of record do not reflect that the Veteran quit working in 2005 due to service-connected disabilities, it is reasonable to conclude that the Veteran's service-connected conditions at the time were of significant severity, in total, to make the Veteran unemployable. The severity of the Veteran's psychiatric disorder is clearly contemplated in the 70 percent rating assigned. While that condition alone does not preclude employment, the additional symptoms associated with his skin disorder, and his DM, would arguably make him unemployable. The Board notes that a September 2009 document reflects that the Veteran actually was employed until June 5, 2005. Thus, the grant of a TDIU is limited to the dates of June 5, 2005, through May 5, 2008. All reasonable doubt was resolved in the Veteran's favor in making this determination. 38 C.F.R. § 3.102 (2012). ORDER Entitlement to service connection for a kidney condition, (claimed as kidney stones), to include as secondary to service-connected DM, is denied. Entitlement to service connection for peripheral neuropathy (PN) of the bilateral lower extremities (also claimed as a balance disorder), to include as secondary to DM, is denied. Entitlement to an initial rating in excess of 70 percent for PTSD with conversion disorder (also diagnosed as anxiety disorder, not otherwise specified, and undifferentiated somatoform disorder), is denied. Entitlement to a rating in excess of 30 percent for acne vulgarus, is denied. Entitlement to a rating in excess of 20 percent for DM with early diabetic nephropathy, hypertension, and impotence, is denied. Entitlement to a TDIU for the period from June 6, 2005, to May 5, 2008, is warranted. ____________________________________________ C. KAMMEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs