Citation Nr: 1416131 Decision Date: 04/11/14 Archive Date: 04/24/14 DOCKET NO. 08-19 125 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with major depressive disorder and substance disorder prior to August 6, 2004, from October 1, 2004 to June 21, 2005, from October 1, 2005 to January 15, 2006, and since April 1, 2006. 2. Entitlement to a rating in excess of 30 percent for left total knee replacement, to include a separate compensable rating for instability. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran had active service from April 1969 to April 1971. This matter comes before the Board of Veterans Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs Regional Office (RO) in Montgomery, Alabama. A review of the Veterans Benefits Management System paperless claims processing system reveals no records pertinent to the current appeal. A review of the Virtual VA electronic claims file reveals VA treatment records pertinent to the appeal. Temporary total ratings for periods of hospitalization have been assigned. There has been no disagreement with any of those determinations, and those periods are not part of this appeal. The issue of entitlement to a rating in excess of 30 percent for PTSD with major depressive disorder and substance disorder from October 1, 2004 to June 21, 2005, from October 1, 2005 to January 15, 2006, and since April 1, 2006 is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Prior to August 6, 2004, the Veteran's PTSD was manifested, primarily, by difficulty sleeping, nightmares, flashbacks, anxiety, depression, exaggerated startle response, and avoidance of crowds and social events; collectively, these symptoms are indicative of occupational and social impairment with reduced reliability and productivity. Symptoms of occupational and social impairment with deficiencies in most areas were not demonstrated. 2. The Veteran's left total knee replacement has not been manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. There is no evidence of limitation of flexion less than 93 degrees or of any limitation of extension, including due to pain or following repetitive motion. 3. The Veteran has slight lateral instability of the left knee. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the appellant's favor, prior to August 6, 2004, the criteria for a rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a rating in excess of 30 percent for left total knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262 (2013). 3. With resolution of reasonable doubt in the appellant's favor, the criteria for a separate 10 percent rating, but no more, for instability of the left knee have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in letters dated in May 2003, March 2006, and May 2008, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment and provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The issues were last adjudicated in August and September 2013, and any defect as to timing of notice is harmless, non-prejudicial error. Dingess/Hartman, 19 Vet. App. 473. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records, VA examination reports, private treatment records, and VA treatment records. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, the Veteran was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Laws and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability, but a claimant may likewise experience multiple distinct degrees of disability that result in different levels of compensation for the period on appeal. Hart, 21 Vet. App. 505; Francisco v. Brown, 7 Vet. App. 55 (1994). In the current case, the Veteran has been assigned "staged" rating periods for evaluation of PTSD; only the period prior to August 6, 2004 is addressed in the decision below. Where there is a question as to which of the 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. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's service-connected PTSD is currently rated as 30 percent disabling for the period prior to August 6, 2004, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under 38 C.F.R. § 4.130, Diagnostic Code 9411, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. Diagnostic Code 9411 provides that a 30 percent rating is warranted for occupational and social impairment with an 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, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A Veteran's assigned GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). A GAF score between 41 and 50 indicates that a Veteran has 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 51 to 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 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Veteran's left total knee replacement is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5055, as a knee replacement with prosthesis. Under Diagnostic Code 5055, a 100 percent rating is assigned for one year following implantation of a knee prosthesis for a service-connected knee disability. After this period has ended, a 60 percent rating is assigned when there are chronic residuals consisting of severe painful motion or weakness. With intermediate degrees of residual weakness, pain, or limitation of motion, a rating is made by analogy to Diagnostic Codes 5256, 5261, and 5262. The minimum rating for knee replacement with prosthesis is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Diagnostic Codes 5256, 5261, and 5262 pertain to functional limitation of the knee. VA regulations, set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59, provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The United States Court of Appeals for Veterans Claims has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of extension of the leg is evaluated as follows: extension limited to 15 degrees (20 percent); extension limited to 10 degrees (10 percent); and extension limited to 5 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5261. Limitation of flexion of the leg is evaluated as follows: flexion limited to 30 degrees (20 percent); flexion limited to 45 degrees (10 percent); and flexion limited to 60 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5260. Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04; 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. VA General Counsel has also held that a claimant who has both arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998). Slight recurrent subluxation or lateral instability of the knee warrants a 10 percent disability rating, and a 20 percent disability rating is in order for evidence of moderate recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA's Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). PTSD The Veteran contends that his PTSD warrants an initial rating in excess of 30 percent prior to August 6, 2004. The Veteran was granted entitlement to service connection for PTSD in November 2011, with an effective date of June 30, 1998, rated as 30 percent prior to August 6, 2004. The Veteran has indicated that he was treated and hospitalized for psychiatric disorders and/or drug and alcohol abuse several times prior to 1998. He has submitted statements describing the traumatic events he experienced in Vietnam and the problems he has had adjusting socially since service, including difficulty sleeping and social avoidance. Statements from the Veteran's mother, mother-in-law, wife, and two friends describe how he returned from Vietnam a changed man, the struggles he had with drugs and alcohol in the years since then, and the problems he has had with family and social relationships. A September 1999 letter from the Veteran's Vet Center therapist stated that the Veteran reported having nightmares, flashbacks, suspiciousness, frustration, anger, sleep disturbance, past alcohol abuse, and social isolation. He noted that the Veteran had memory impairment, concentration problems, exaggerated startle response, avoidance behavior, and intrusive distressing thoughts, and described his condition overall as "serious." The Veteran's VA treatment records show that he has been receiving psychiatric counselling at least since 1998. In March 1998 the Veteran reported that he had not had any alcohol for 2 months, but that he was having sleep problems and occasional flashbacks of Vietnam. In May 1998 the Veteran reported having problems, sleeping, nightmares, depression, exaggerated startle response, and flashbacks, and he also reported that he had entered a Substance Abuse Treatment Program for alcohol abuse treatment. After admittance to the Substance Abuse Treatment Program, the Veteran reported depression, nightmares, occasional paranoia, and feeling withdrawn. He reported a long history of drug and alcohol abuse. The Veteran was found to be oriented as to time, place, and person, cooperative, and with flat affect. He was diagnosed with alcohol dependence and assigned a GAF score of 65. At a May 1998 psychologist's assessment, the Veteran reported that he had entered eight treatment programs previously and that he had been receiving disability benefits from the Social Security Administration (SSA) due to a gunshot wound, arthritis, and back problems. In February 1999 the Veteran reported having nightmares, anxiousness, problems sleeping, and occasional depression, and denied any suicidal ideation. He was noted to have normal speech, logical thought processes, appropriate affect, and anxious mood. In April 1999 the Veteran reported similar symptoms as well as problems with anxiety. At a June 1999 evaluation, the Veteran denied any depressive, manic, or psychotic symptoms and was noted to be cooperative, with normal speech pattern, euthymic mood, appropriate affect, logical thoughts processes, and no suicidal ideation. He was diagnosed with PTSD and polysubstance abuse in remission. The Veteran reported similar symptoms at an August session. In October 1999 the Veteran reported sleep problems and anxious avoidance of crowds and noise. He was noted to be alert, oriented, and casually groomed and dressed, with normal speech, blunted affect, euthymic mood, coherent thoughts, fair insight and judgment, and no suicidal ideation. He was diagnosed with PTSD and assigned a GAF score of 55. In December 1999 the Veteran's psychiatrist noted the same observable symptoms, diagnosed the Veteran with generalized anxiety disorder and alcohol abuse in remission, and assigned him a GAF score of 65. In January 2000 the Veteran reported some anxiety and depression during the holidays, but stated that his medication had been helping him. In May 2000 he reported that he continued to have nightmares about Vietnam and was under stress related to his spouse. In July 2000 he reported symptoms of depression, nightmares, exaggerated startle response, and crowd avoidance. He was diagnosed with PTSD and assigned a GAF score of 55. In February 2002 the Veteran was evaluated by a clinical psychologist. The Veteran reported that he had a history of anxiety, depression, and substance abuse, but that he had not had a drink in about 5 years. The Veteran was noted to be alert, oriented, and cooperative, with slow psychomotor activity and knee pain, coherent and relevant speech, constricted affect, mildly anxious mood, intact memory, fair insight, adequate judgment, and no suicidal ideation. He was diagnosed with anxiety disorder and assigned a GAF score of 60. At a March 2004 mental health evaluation, the Veteran reported feeling at times unhappy, depressed, and anxious, having fair sleep with medicine, low energy, and no suicidal ideation. He admitted to a past history of suicide attempts, and stated that his last attempt had been in 1982. He reported having alcoholic drinks that morning. The Veteran was noted to be fairly cooperative, fairly dressed and groomed, alert, and oriented, with normal speech and fair judgment and insight. He was diagnosed with mood disorder, alcohol dependence, alcohol induced mood disorder, and PTSD, and assigned a GAF score of 60-65. Later in March 2004 the Veteran was evaluated by an addiction therapist. He reported that the Veteran was oriented, demonstrated good insight, denied suicidal ideation, had intact memory, poor computation skills, appropriate presentation and appearance, and was depressed with congruent affect. He diagnosed the Veteran with alcohol dependence, alcohol induced mood disorder, and depression, and assigned him a GAF score of 50. At a March 2004 group therapy session, the Veteran reported that he continued to drink as a means of pain relief, and was assigned a GAF score of 55. In April and May 2004 the Veteran reported continued problems with alcohol use and was assigned GAF scores of 50. Based on the evidence described above, the Board finds that prior to August 6, 2004, the evidence supports a rating of 50 percent, but no higher, for PTSD. The Veteran's treatment records and VA examinations show that he has frequently been shown to have a flattened affect, frequent anxiety, and significant disturbances in motivation and mood, which has led him to avoid social activities and interactions. Resolving all reasonable doubt in the Veteran's favor, the Board finds that these symptoms are most consistent with a 50 percent disability rating. At no time prior to August 6, 2004, however, did the Veteran show evidence of such symptoms as obsessional rituals, speech intermittently illogical, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal hygiene, or total inability to establish and maintain effective relationships. At all VA evaluations, the Veteran's judgment and thinking were always noted to be normal and logical. His mood, at times, was noted to be anxious or depressed, and he reported feelings of anxiety and depression, but never indicated that he had near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively. The Veteran has reported attempting suicide in the past, with the most recent attempt being in 1982, but there is no indication of any suicidal ideation during the period currently under consideration. The Veteran's speech was always noted to be normal, and his thinking and judgment were at all times found to be goal-oriented or fair. The Veteran was always described as having normal and appropriate appearance. There was no indication at any time that the Veteran had a neglect of personal appearance or hygiene. Socially, the Veteran has indicated nervousness in social situations and avoidance of crowds, but he has indicated that he has had a relationship with a girlfriend and cares for his grandchildren. The Board also notes that the Veteran was assigned GAF scores of 50 to 65 during this period. These GAF scores overall reflect moderate symptoms or moderate difficulty in social or occupational functioning, which, alone, do not provide a basis for assigning a rating in excess of 50 percent. The Board also notes that many of the Veteran's reported symptoms are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which the 50 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran's extent of occupational and social impairment. Accordingly, in this case, the Board finds that the existence and severity of the Veteran's psychiatric symptoms are adequately contemplated by the relevant rating criteria and are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. The majority of the evidence indicates that at no time prior to August 6, 2004 did the Veteran demonstrate deficiencies in most areas. The Veteran has had meaningful relationships and demonstrated appropriate behavior, normal thought processes, and was able to generally care for himself and others. Given these findings, the Board concludes that the weight of evidence shows that the Veteran's symptoms most closely approximate the criteria of a rating of 50 percent for PTSD, but do not meet the criteria required for a rating in excess of 50 percent prior to August 6, 2004. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. 38 U.S.C.A. § 5107(b). The Board has considered the application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Here, the rating criteria reasonably describe the Veteran's disability and his symptomatology. There are no exceptional or unusual factors with regard to the Veteran's PTSD. The rating criteria reasonably describe the Veteran's disability levels and symptomatology, and in fact provide for consideration of far greater disability and symptoms than currently shown by the evidence. The Veteran was not hospitalized at any time during the period currently being decided. While the Veteran was not employed during this time, he has clearly indicated that he was unemployed and receiving SSA disability benefits due to unrelated, nonservice-connected disabilities. There has been no indication that PTSD symptoms have been a factor affecting his ability to work. As such, the Veteran's disability picture is contemplated by the rating schedule and those criteria are adequate to address his symptoms and average impairment of earning capacity. As the disability picture is contemplated by the rating schedule, the assigned schedular ratings are, therefore, adequate. See Thun, 22 Vet. App. 111. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). Left Total Knee Replacement The Veteran also contends that his left total knee replacement warrants a rating in excess of 30 percent. The Veteran filed the current claim on appeal in February 2008, in which he stated that although he had been granted a temporary 100 percent rating for his left knee following left total knee replacement surgery, he now felt the current severity of his knee disability should be reevaluated. In April 2008 the Veteran submitted a statement indicating that his knee pain had become more severe and that he was having problems with the knee replacement prosthesis. In January 2007 the Veteran was diagnosed with moderately severe left knee osteoarthritis and underwent a left total knee replacement. Records from the USA Orthopedic Rehabilitation Center show that following his left total knee arthroplasty, the Veteran underwent inpatient rehabilitation, but did not complete the full course of physical therapy. In February 2008 the Veteran reported having left knee pain that made walking long distances and prolonged sitting and standing difficult. Range of motion testing found passive range of motion of 115 degrees of flexion, and active range of motion of 108 degrees of flexion and 0 degrees of extension. He was noted to have lateral tenderness, some swelling, decreased strength, and instability. The Veteran's VA treatment records show that the Veteran has reported continued knee pain following his 2007 surgery. In February 2008 the Veteran reported pain on the inside of his left knee. The treating orthopedic surgeon noted that it was approximately one year status post left total knee arthroplasty, and that the Veteran had been attending physical therapy, but that this increased his knee pain. On physical examination, the surgeon noted tenderness, but no effusion. Range of motion testing of the left knee showed flexion of 0 to 110 degrees with no pain, and from 110 to 125 degrees with tenderness. With the knee in full extension, there was some discomfort, and at 20-30 degrees there was slight opening and pain. The incision was noted to be well-healed and sensation down the leg was normal. At an April 2008 follow-up orthopedic surgery evaluation, the Veteran reported continued discomfort in his left knee. Physical examination revealed mild effusion and range of motion from 0 to 115 degrees with some discomfort at 115 degrees. There was no tenderness, no anterior pain, and slight increased opening with valgus stress. At a May 2012 orthopedic surgery consultation, the Veteran stated that his knee felt a little "loose," at times, and that he had more severe pain down his left leg. X-rays of the left knee were reviewed, and the examiner noted that the pain was likely radiculitis caused by his back, and not related to his knee. In March 2008 the Veteran underwent a VA knee examination. The Veteran denied any locking of the joint, subluxation, or dislocation, and reported some instability but no falls. He reported having pain while standing which lasted several hours and flare-ups three times a week. He reported that the pain became worse on activity and that he wore a knee brace. On examination, the examiner noted evidence of the previous surgery and a well-healed 23 centimeters long, 2-3 millimeters wide scar with no tenderness, adherence to underlying tissue, or depression. Range of motion testing revealed left knee flexion up to 93 degrees and full extension, with some pain associated with motion. Pain was increased after repetitive motion. The examiner stated that additional limitation of motion during flare-ups could not be determined without resorting to speculation, and stated that no effusion, edema, tenderness, deformities, or instability were found. The Veteran was diagnosed with left knee status post total knee replacement with instability. In December 2011 the Veteran was afforded another VA examination. He reported intermittent left knee pain, especially in the morning, and functional limitation only with prolonged walking or sitting. He did not report any flare-ups. Range of motion testing revealed left knee flexion of 110 degrees and extension of 0 degrees, with no objective evidence of painful motion and no change following three repetitive motions. Muscle strength and stability were found to be normal, and the examiner found no meniscal conditions. The functional impact was noted to be only mild functional limitation, with difficulty after prolonged walking or sitting. The examiner noted that loss of function due to flare-ups could not be determined without resort to speculation. The Veteran also underwent a VA examination in April 2012. He reported that the pain in his left knee was worse and that it frequently "clicks." He did not report any flare-ups. Range of motion testing revealed 110 degrees of flexion, with pain beginning at 110 degrees, and 0 degrees of extension, with no objective evidence of painful motion. There was no additional limitation in range of motion following three repetitive motions. The examiner diagnosed the Veteran with degenerative joint disease. The left knee had tenderness on palpation, normal strength and stability, no subluxation, and no meniscal conditions. The examiner found that the Veteran's left knee disorder did not affect his ability to work, and that he could undertake sedentary or light duty employment if he so chose. In light of the above described evidence, the Board finds that the residual pain, weakness, and minimal limitation of motion of the Veteran's left knee replacement are not severe and that such symptoms more closely approximate the criteria for a 30 percent rating under Diagnostic Code 5055. Thus, a rating in excess of 30 percent for a left total knee replacement under is not warranted at any time during the claim period. At no time has the Veteran's left knee flexion been shown to be any less than 93 degrees. There have been indications of some pain or tenderness during motion, but no clinical findings of further limitation of motion due to pain or weakness. The Veteran was shown to have slight pain at 20-30 degrees of flexion, but there has been no finding at any time of any limitation of either flexion or extension due to pain, including following repetitive motion, which would entitlement compensable evaluations under Diagnostic Codes 5260 or 6261. There has furthermore been no indication of any ankylosis of the knee at any time, and no clinical evidence of any painful motion or weakness in the lower extremity which could be classified as "severe." As these findings would not warrant a compensable rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5260, and 5261, the Veteran is assigned a minimum rating of 30 percent for prosthetic replacement of the knee joint under 38 C.F.R. § 4.71a, Diagnostic Code 5055. Regarding the DeLuca factors, the Board acknowledges the evidence of pain on motion and the Veteran's functional limitations caused by pain following prolonged sitting and walking, and has considered these factors in the assignment discussed above. DeLuca, 8 Vet. App. at 206. An increased rating, however, is not warranted based on these factors alone. In this regard, while VA examiners recorded that the Veteran had pain or tenderness on motion, they also indicated that there was no additional limitation of flexion and extension of the left knee caused by pain or weakness. Without clinical medical evidence indicating such additional functional limitation, the Board is unable to find that the Veteran's pain is so disabling as to actually or effectively limit flexion or extension of the left knee to such an extent as to warrant assignment of a higher rating. The Board has considered the clinical evidence indicating that the Veteran has lateral instability of the left knee, and found that a separate rating of 10 percent for left knee instability is warranted, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Veteran was noted in February and March 2008 to have some lateral instability of the left knee. Because the criteria for prosthetic replacement of the knee considers only the residuals relating to weakness, pain, or limitation of motion, application of a separate rating criteria for the Veteran's symptoms of instability does not violate the general rule against "pyramiding." See 38 C.F.R. § 4.14 (2013). The Veteran's knee instability has been described as only partial and not resulting in any falls, and thus is most accurately categorized as "slight" lateral instability, which warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board has also considered whether the Veteran has manifested any other symptoms that could warrant a higher or separate rating for his left total knee replacement. The Veteran is not entitled to a rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259, 5262, or 5263 (2013), as there is no evidence of cartilage removal or dislocation, tibia or fibula impairment, or genu recurvatum. There is evidence that the Veteran has a left knee scar associated with the total knee replacement. The rating criteria for scars were revised during the course of this appeal, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). These amendments, however, are only effective for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran has not requested such consideration. As his claim for an increased rating was received in February 2008, the 2008 amendments are not applicable in this appeal. To warrant a compensable rating under the applicable criteria, a scar would need to involve the head, face or neck and have at least one character of disfigurement (Diagnostic Code 7800); be deep or cause limited motion and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (Diagnostic Code 7801); be superficial and affect an area or areas of 144 square inches (929 square centimeters) or greater (Diagnostic Code 7802); be superficial and unstable (Diagnostic Code 7803); be superficial and painful on demonstration (Diagnostic Code 7804); or cause some limitation of the function of the part affected (Diagnostic Code 7805). 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2008). In this case, the left knee scar does not involve the head, face, or neck and there is no evidence that it is deep, causes any limitation of motion or function, affects an area exceeding at least 6 square inches, or is unstable or painful. Hence, a separate compensable rating for a left knee scar is not warranted at any time during the claim period. Id. In sum, there is no basis for assignment of a rating in excess of 30 percent for left total knee replacement and 10 percent for left knee lateral instability at any time during the current appeal. All other relevant Diagnostic Codes have been considered, and none have been found to be applicable in the current case. The Board has again considered the applicability of the benefit of the doubt doctrine, but, as the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply. 38 U.S.C.A. § 5107(b). The Board has also considered the application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. The rating criteria accurately describe the Veteran's disability and his symptomatology. There has been no showing of any exceptional or unusual factors pertaining to the Veteran's left knee disability, and the rating criteria describe the Veteran's disability levels and symptomatology and provide for of far greater limitation of motion than what is currently shown by the evidence. The Veteran was not hospitalized for a left knee disability at any time during appeal period, and his left knee disability has not been shown to affect his employment status or earning capacity. As the disability picture is contemplated by the rating schedule, the assigned schedular ratings are adequate. See Thun, 22 Vet. App. 111. Referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to an initial rating of 50 percent, but no more, for PTSD with major depressive disorder and substance disorder prior to August 6, 2004 is granted, subject to the controlling regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 30 percent for left total knee replacement is denied. Entitlement to a separate 10 percent rating for instability of the left knee is granted, subject to the controlling regulations governing the payment of monetary benefits. REMAND The Veteran contends that his PTSD warrants a rating in excess of 30 percent for the periods of October 1, 2004 to June 21, 2005, October 1, 2005 to January 15, 2006, and since April 1, 2006. Review of the record indicates that the Veteran has been receiving fairly frequent VA medical and psychiatric care throughout the appeal period, including several periods of in-patient treatment. Unfortunately, the current record does not contain the Veteran's complete VA treatment records. These must be obtained and associated with the claims file before the issue can be adjudicated. Additionally, the Veteran was last afforded a VA psychiatric examination in May 2012. Although the examiner noted that he had reviewed the claims file and VA treatment records, it is not clear from the examiner's description of the Veteran's history that he was aware of the Veteran's lengthy history of psychiatric treatment and hospitalizations, and his ultimate findings are that the severity of the Veteran's psychiatric disability is considerably less than the findings in the Veteran's prior VA evaluations for treatment. This inconsistency should be addressed in a new examination. Furthermore, it would be greatly helpful to the Board for the VA examiner to address the severity of the Veteran's disability and his general capacity for occupational and social functioning during the entire period on appeal. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC must obtain all outstanding, pertinent records of treatment of the Veteran from the Gulf Coast Veterans Health Care System in Biloxi, Mississippi and its affiliated facilities, including the Mobile Outpatient Clinic and the Pensacola Joint Ambulatory Care Center. The RO/AMC must follow the procedures set forth in 38 C.F.R. § 3.159(c) and associate all records with the claims file. 2. After any additional records are obtained and associated with the claims file, schedule the Veteran for a VA examination to determine the nature and severity of his PTSD with depressive disorder and substance disorder. The paper and electronic claims folder must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file has been reviewed. The examiner must provide a complete explanation for any opinion offered. The examiner should provide a full multi-axial diagnosis, to include a GAF score related to the Veteran's PTSD with depressive disorder and substance disorder. All signs and symptoms of psychiatric disability should be reported in detail. The examiner should describe the impact of the Veteran's psychiatric disability on his occupational and social functioning, and should discuss the impact it has on his activities of daily living, including his ability to obtain and maintain employment, and overall functional impact. The examiner is also asked to specifically review the evidence of record pertaining to the Veteran's psychiatric disability for the periods of: October 1, 2004 to June 21, 2005, October 1, 2005 to January 16, 2006, and April 1, 2006. Based on the evidence of record, what was the impact of the Veteran's psychiatric disorder on his occupational and social functioning during each of these periods? Do the Veteran's periods of hospitalization for in-patient psychiatric and substance abuse treatment between these periods indicate that the severity of the Veteran's disability was significantly worse than the current findings indicate? Please also discuss the Veteran's prior reports of suicide attempts and whether the Veteran has shown any suicidal ideation since August 2004. 3. The Veteran is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. The RO/AMC will then review the Veteran's claims file and ensure that the foregoing development actions have been completed in full, and that no other notification or development action, in addition to those directed above, is required. If further action is required, it should be undertaken prior to further adjudication. 5. After completing the requested actions, the RO/AMC should readjudicate the claim in light of all pertinent evidence. If the benefit sought on appeal remains denied, the Veteran and his representative shall be provided with a supplemental statement of the case, with appropriate time allowed for response. The Board intimates no opinion as to the outcome in this case by the action taken herein The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs