Citation Nr: 1527195 Decision Date: 06/25/15 Archive Date: 07/07/15 DOCKET NO. 09-11 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an initial compensable rating for a scar located at the right lateral epicondyle of the humerus, as residual from a motor vehicle accident. 2. Entitlement to an initial compensable rating for hemorrhoids. 3. Entitlement to an higher initial rating for chronic adjustment disorder with mixed anxiety and depressed mood, greater than 10 percent prior to June 1, 2009, and greater than 70 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1974 to July 1979 with the United States Coast Guard. He also had active service from April 1987 to January 1992, and from December 1994 to September 2004 with the United States Navy. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2008 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York which granted service connection for a right upper extremity scar as residual of a motor vehicle accident, hemorrhoids, and chronic adjustment disorder with mixed anxiety and depressed mood. The Veteran appealed from the initial ratings assigned for these disabilities and perfected his appeals to the Board. In June 2012 these matters were remanded for additional development and adjudication. The Board's orders having been complied with, these issues are now once again before the Board for adjudication. In an August 2009 Report of Contact, the Veteran appears to have raised the issues of entitlement to increased ratings for service-connected right ulnar fracture residuals, low back strain, left carpal tunnel syndrome, scar on the posterior aspect of the right elbow joint, scar on the posterior aspect of the right wrist and scar on the anteromedial aspect of the left forearm. In its June 2012 remand, the Board referred these issues to the Agency of Original Jurisdiction (AOJ) for appropriate action. Since June 2012 no actions have been taken on these matters, to include contacting the Veteran to clarify his intention. Therefore, the Board continues not to have jurisdiction over these issues, and they are again referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2014). FINDINGS OF FACT 1. Throughout the initial rating period, a scar located at the right lateral epicondyle of the humerus has been productive of occasional itching without any limitation of function of the affected extremity. 2. Throughout the initial rating period, hemorrhoids have been productive of mild symptoms, but have not been large or thrombotic, or irreducible with excessive redundant tissue, and there has been no evidence of frequent recurrences. 3. Prior to June 1, 2009 chronic adjustment disorder with mixed anxiety and depressed mood was been productive of occupational and social impairment with reduced reliability and productivity, pressured speech, angry outbursts, sleep disturbances, and labile mood. 4. Since June 1, 2009, chronic adjustment disorder with mixed anxiety and depressed mood has been productive of sleep disturbance, high levels of anger, and an extremely labile affect with only marginal judgement. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for a scar located at the right lateral epicondyle of the humerus have not been met or more nearly approximated at any time during the rating period on appeal. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Code 7805 (2007). 2. The criteria for an initial compensable rating for hemorrhoids have not been met or more nearly approximated at any time during the rating period on appeal. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.114, Diagnostic Code 7336 (2014). 3. The criteria for an initial rating of 50 percent, but no higher, prior to June 1, 2009 have been met for chronic adjustment disorder with mixed anxiety and depressed mood. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130 Diagnostic Code 9440 (2014). 4. The criteria for a rating of 100 percent for chronic adjustment disorder with mixed anxiety and depressed mood have been met since June 1, 2009. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130 Diagnostic Code 9440 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initial Ratings, Generally Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2014). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2014). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's appeals for higher initial ratings are appeals from the initial assignments of disability ratings following the establishment of service connection. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found; such separate disability ratings are known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Initial Rating for Upper Right Extremity Scar In the February 2008 decision on appeal, the Veteran was awarded service connection for a scar of the right upper extremity resulting from a motor vehicle accident, and granted an initial noncompensable (i.e., zero percent) evaluation under 38 C.F.R. § 4.118, Diagnostic Code (DC or Code) 7805. During the pendency of the Veteran's appeal, the criteria for rating the skin was amended, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118 , DCs 7800 to 7805). Where the rating criteria are amended during the course of an appeal for an increased evaluation, the Board considers both the former and current schedular criteria because, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See 38 U.S.C.A. § 5110(g) (West 2014); 38 C.F.R. § 3.114 (2014); VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (Apr. 10, 2000). However, the amended regulations with respect to scars are only applicable to claims received on or after October 23, 2008, and the Veteran's underlying claim for service connection was received in September 2005. While the Veteran's representative made mentioned of the existence of old and new rating criteria, this was done in the context of discussing an earlier 2002 regulatory change rather than the 2008 amendments. At no time has the Veteran or his representative requested review under the post-2008 rating criteria, and accordingly such the regulations as amended are not applicable. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Thus, under the applicable pre-2008 criteria, scars not otherwise described within the rating criteria were to be rated on limitation of function of the affected part - in this case the arm. 38 C.F.R. § 4.118, DC 7805 (2007). Scars that are deep or that cause limited motion are rated 10 percent disabling for area(s) exceeding 6 square inches (39 sq. cm.), and 20 percent for area(s) exceeding 12 square inches (77 sq. cm.) under DC 7801. Scars that are superficial, do not cause limited motion, and cover area or areas of 144 inches (929 sq. cm.) or greater are given a 10 percent rating under DC 7802. Unstable superficial scars are rated 10 percent disabling under DC 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Superficial scars that are painful on examination are rated 10 percent disabling under DC 7804. A deep scar is one associated with underlying soft tissue damage, and a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 , DCs 7801-7805 (2007). Ratings for widely separated areas, as on two or more extremities or anterior and posterior surfaces of extremities or trunk, are separately rated. 38 C.F.R. § 4.118, DCs 7801, 7802 (2008). Where the schedular criteria does not provide for a noncompensable evaluation, such an evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. After reviewing the entire claims file, the Board finds that the Veteran's right arm scar has not been compensably disabling at any time during the period on appeal. Specifically, the scar has been productive only of occasional itching without any limitation of function of the affected extremity. While the Veteran is competent to report on those symptoms which are capable of lay observation, such as pain, or limitation of motion, Layno v. Brown, 6 Vet. App. 465 (1994), at no time during the period on appeal has he complained of any specific disability symptoms with respect to his right arm scar. On VA examination in October 2006 - for instance - the Veteran reported that he had no pain and the only symptom present was "occasional itching over the scar." To the extent that pain in the right arm was present, it was associated entirely with surgical hardware used to repair the Veteran's right radial head. These symptoms are contemplated by the Veteran's service-connected fracture of his right ulnar shaft, the rating for which is not on appeal. The examiner described that the scar was "slightly tender on deep palpation," but presented no other symptoms and caused no limitation of motion or other limitation of function. On a physical examination in December 2011 a scar was noted over the lateral right elbow, but the only reported symptoms was slight tenderness. The Veteran had recently lacerated his elbow, but even with this post-service nonservice-connected injury, the scar was "healing well with only a line of erythema where the laceration had been." Throughout the record, which covers more than a decade of treatment, the Board finds that the Veteran's lack of complaints referable to the elbow are evidence of the lack of any limitation-causing symptoms. 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. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that (citing Fed. R. Evid. 803(7)). Here, it is reasonable to assume that the Veteran would have commented on any perceived pain or loss of use associated with his right elbow scar when seeking other treatment, particularly in 2011 when seeking treatment of an unrelated right elbow laceration. The Board has considered whether a compensable rating may be warranted under an alternative Code, but finds that one is not. In considering the rating on appeal, the Board has considered applying alternate Codes to evaluate the Veteran's service-connected disability where applicable. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this regard, the Board notes that the assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case," see Butts v. Brown, 5 Vet. App. 532, 538 (1993), and that one Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Simply put, however, without any symptoms other than superficial "occasional itching," a compensable rating cannot be granted. Accordingly, the Board concludes that the Veteran's right arm scar has been noncompensably disabling throughout the entire initial rating period on appeal. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Hemorrhoids In the February 2008 decision on appeal, the Veteran was awarded service connection for hemorrhoids and granted an initial noncompensable evaluation effective October 1, 2004. The Veteran's hemorrhoid disability is rated under 38 C.F.R. § 4.114, Diagnostic Code (DC or Code) 7336. Under this Code, a noncompensable rating is warranted where hemorrhoids are mild or moderate in degree. A 10 percent rating is warranted where they are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, and a maximum 20 percent rating is warranted where there is persistent bleeding with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336 (2014). Descriptive words such as "mild" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2014). The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a) (West 2014); 38 C.F.R. §§ 4.2, 4.6 (2014). After reviewing the entire claims file, the Board finds that the Veteran's hemorrhoids have not been compensably disabling at any time during the period on appeal. Specifically, hemorrhoids have been productive of only mild symptoms, has not been large or thrombotic, or irreducible with excessive redundant tissue, nor is there evidence of frequent recurrences. On VA examination in October 2006, the Veteran reported bleeding one to two times a week. When it occurs, the Veteran is able to manually resolve prolapse. He was offered surgical intervention but declined, and there was no pain at the hemorrhoid site. As with his service-connected scar, there are exceedingly few complaints referable to the Veteran's hemorrhoids in treatment record. On repeated physical evaluations, external hemorrhoids have been visible, but related-symptoms are not reported, including in April 2010 and February 2010. Without evidence of large or thrombotic hemorrhoids, irreducible hemorrhoids with excessive redundant tissue, or hemorrhoids evidencing frequent recurrences, a compensable rating is not warranted. To the extent that the Veteran reported bleeding one to two times a week, with manually resolvable prolapse, the Board finds this to be clear evidence that his hemorrhoids are mild in degree - thus warranting a noncompensable rating. Accordingly, the Board concludes that the Veteran's hemorrhoid disability has been noncompensably disabling throughout the entire initial rating period on appeal. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration Regarding the Right Arm Scar and Hemorrhoids In addition to schedular ratings based on the criteria described in the Diagnostic Codes, a veteran may be entitled to what is known as an "extraschedular" rating which may be based on criteria not specifically listed in a disabilities' specific Diagnostic Code. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate and no referral is required. Id. at 115. Here the schedular rating criteria used to rate the Veteran's service-connected disabilities above, reasonably describe and assess his disability level and symptomatology. The criteria rate the disabilities on the basis of pain and stability of a scar, and severity and frequency of hemorrhoid symptoms. Thus, the demonstrated manifestations - namely a nonpainful scar, and hemorrhoids with mild symptoms - are contemplated by the provisions of the rating schedule. Accordingly, the Board finds that the evidence fails to show unique or unusual symptomatology regarding the Veteran's disabilities that would render the schedular criteria inadequate. Additionally, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Nonetheless, the Board has fully considered the Veteran's additional service-connected disabilities - including chronic adjustment disorder, fractured right ulnar shaft, low back strain, essential hypertension, gastroesophageal reflux disease, a scar of the left arm, and left carpel tunnel syndrome - in concluding that referral for consideration of an extraschedular rating is not warranted. Based on the foregoing, the Board finds the schedular evaluations are adequate, and referral for consideration of extra-schedular evaluation is not required. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. Initial Rating for Chronic Adjustment disorder with mixed Anxiety and Depressed Mood In the February 2008 decision on appeal, the Veteran was awarded service connection for chronic adjustment disorder with mixed anxiety and depressed mood, and granted an initial 10 percent rating, effective October 1, 2004. In a subsequent, June 2009 decision, the Veteran was granted a 70 percent rating, effective June 1, 2009. The Veteran's chronic adjustment disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC or Code) 9440. Under this Code, a 10 percent rating is assigned for a showing of occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or if the veteran's symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, DC 941 (2014). A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned 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 circumstances (including work or a work like setting); or the inability to establish and maintain effective relationships. Id. Finally, a 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as 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 the names of close relatives, own occupation, or own name. Id. Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. The provisions of this rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit, even if such claims are subsequently remanded to the AOJ. Accordingly, as this matter was certified to the Board prior to August 4, 2014, the newly adopted regulations are not for application. In evaluating the Veteran's level of disability, the Board has considered the Global Assessment of Functioning (GAF) scores as one component of the overall disability picture. GAF is a scale used by mental health professional and reflects psychological, social, and occupational functioning on a hypothetical continuum of mental health illness and is relevant in evaluating mental disability. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. Here, the record reflects GAF scores during the period on appeal ranging from 32 to 60. GAF scores are between 60 and 51, indicates 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). GAF scores from 50 to 41 are evidence of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Where GAF scores are between 40 and 31, this reflects 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 younger children, is defiant at home, and is failing at school). DSM-IV. The VA Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501 (West 2014); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002) (holding that "the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment"). The Board finds that prior to June 1, 2009, the Veteran's service-connected chronic adjustment disorder has more nearly approximated the criteria for a 50 percent rating, but not higher. Specifically, chronic adjustment disorder was productive of occupational and social impairment with reduced reliability and productivity, pressured speech, angry outbursts, sleep disturbances, and labile mood. On VA examination in October 2006, the Veteran reported actively writing for three newspapers and volunteering with senior citizens on a weekly basis. Approximately once a week he and his girlfriend had a verbal altercation of some kind, but he denied any physical aggression. The Veteran had some friends with whom he maintains relations, but also described engaging in hostile arguments with them at times. He describe some social withdrawal, and in particular avoiding answering his phone due to fear of getting into confrontations with others. Mental status examination reflected rapid and pressured speech, and the Veteran required redirection many times throughout his examination due to his agitation. He was oriented as to person, place, time, and reason, but did show signs of difficulty with attention and concentration. There was no obvious impairment of short-term or long-term memory functioning, and the Veteran reported that he was anxious, depressed and angry on a daily basis. The Veteran acknowledged a history of suicidal ideation, but only in one instance when he became very angry in response to a review board telling him that he was deficient in his job. The Veteran denied suicidal ideation, but described sleep disturbances including insomnia, being easily disturbed by any noise, and difficulty falling back asleep. He also denied panic attacks. The examiner concluded that the Veteran's GAF score was 52, based on moderate symptoms of anxiety, depression, and accompanying social impairment. In February 2008, the Veteran came to a VA mental health clinic because he had not "been seen in a while." He reported that his mood was "down" and that he was depressed. Sleep was poor, and he had racing thoughts, distractibility, and poor concentration. The Veteran denied anxiety, hallucinations or delusions, as well as thoughts of harming himself or others. The Veteran's speech was "verbose and pressured at times," and his affect was "full and expansive." His mood was labile and congruent with affect, though his thought process was occasionally off-track, requiring frequent redirection back on-to topic. The evaluating physician noted evidence of persecutory, grandiose and obsessive thoughts, and although he appeared to have average intelligence and was able to think abstractly, his attention and concentration were impaired as was his insight. The Veteran's GAF score was 60. While the record contains additional treatment reports, the foregoing are an accurate representation of the Veteran's level of symptomatology prior to June 2009. As they show, the Veteran had symptoms resulting in the equivalent of occupational and social impairment consistent with a 50 percent, but not 70 percent, rating. Specifically, while there is evidence of impaired judgment and abstract thinking as well as disturbances in motivation and mood reflected by his ongoing complaints of anxious, depressed anger, symptoms simply did not more closely reach the level of a 70 percent rating. Of particular note in arriving at this conclusion, are the Veteran's GAF score during this period which did not fall below 50, indicating at worst only moderate symptoms and moderate difficulty in social and occupational settings. Though true that the Veteran's thoughts wandered, he had disturbed sleep, and was often depressed, anxious, and angry, he showed no symptoms equivalent to that more serious level of impairment associated with a 70 percent rating such as obsessional rituals, intermittently illogical, obscure, or irrelevant speech, or near-continuous panic or depression so severe as to limit his ability to function independently. However, given the severity of his symptoms, the 10 percent rating assigned by the RO prior to June 2009, plainly does not adequately reflect the Veteran's level of disability. Thus, the Board concludes that prior to June 1, 2009, the Veteran's chronic adjustment disorder with mixed anxiety and depressed mood was 50 percent disabling, but no higher. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Since June 1, 2009, the Veteran's service-connected chronic adjustment disorder has more nearly approximated the criteria for a 100 percent rating, and has been productive of sleep disturbance, high levels of anger, and an extremely labile affect with only marginally intact judgement. In June 2009, the Veteran underwent an exceptionally lengthy and thorough VA examination during which he denied having any close friends, saying that he does not trust others. He reported that he had "lost all sense of self-motivation and stays in his house for long periods of time. Sleep disturbances included waking in fits of rage, yelling at himself to get his life back on track. Mental status examination revealed that the Veteran was "extremely upset while talking to [the examiner] about his life." The Veteran was cooperative, alert, oriented to person, place, and time, and adequately groomed . He showed no obvious psychomotor retardation, although at times he was quite agitated to the point of having some psychomotor agitation. The Veteran's affect was "extremely labile" but not manic. The Veteran did not appear to have any auditory hallucinations, and his thought processes were coherent . The examiner described the Veteran as of above average intellectual endowment, but with only fair insight. The examiner reported that the Veteran had "shown almost total treatment resistance, despite the fact that he has been getting both medication and counseling all these years," and the Board notes that the Veteran's treatment records reflect a long history of noncompliance with mental health medication. Judgement was only marginal, but the Veteran was not actively dangerous to himself or others. The examiner diagnosed the Veteran's depression to be "recurrent" and "severe," and his GAF score was "around 32." As the VA examination indicates, the Veteran's symptoms are extremely severe, and the record shows that he is virtually consumed with anger. The GAF score of 32 is demonstrative of the Veteran's high degree of social impairment. Based on the foregoing, the Board concludes that the Veteran's service-connected chronic adjustment disorder has been 100 percent (i.e., totally) disabling since June 1, 2009. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Consideration for Chronic Adjustment Disorder with Mixed Anxiety and Depressed Mood The Board has also considered whether referral for an extraschedular ratings is warranted for the service-connected chronic adjustment disorder, but finds that the schedular rating criteria used to rate the Veteran's disability reasonably describe and assess the Veteran's disability level and symptomatology, if not all of the specific symptoms. The schedular rating criteria, Diagnostic Code 9440, expressly provides for disability ratings based on a combination of history and clinical findings. In this case, the evidence adequately reflects the symptoms of the Veteran's chronic adjustment disorder including sleep disturbances, pressured speech, anger, depression, changes in mood and motivation, and labile affect. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. The schedular rating criteria include occupational and social impairment, as indicated by reduced reliability and productivity, and as caused by specific psychiatric symptoms. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442 ; see also 38 C.F.R. § 4.21 (2014). For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's mental health disability, and referral for consideration of an extra-schedular evaluation is not warranted. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral for consideration of extra-schedular evaluation is not required. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. Finally, entitlement to a total disability rating based on individual unemployability has been raised and granted in a RO decision not on appeal. Thus, the question of whether such entitlement has been raised in this present appeal is not for consideration. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2014). The Veteran's appeals arises from the appeal of initial evaluations following the grants of service connection. Once service connection is granted the claim is substantiated, and additional notice is not required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). Based on the foregoing, adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and no further notice is needed under applicable VA laws and regulations. VA also has a duty to assist an appellant in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2014); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought - only those that are relevant to the veteran's claim"). Regrettably, the Veteran's claims folder has been "rebuilt," suggesting that original service treatment records and other potentially pertinent documents are unavailable for review. In cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule where applicable. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The unavailability of records, however, does not lower the legal standard for substantiating a claim, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). The Board finds that VA has satisfied its duty to assist by acquiring service records, to the extent possible, as well as records of VA treatment. These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The duty to assist was further satisfied by VA examinations in October 2006 and June 2009 during which examiners conducted physical examinations of the Veteran, took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. While the June 2009 VA examiner was not provided the Veteran's claims file for review, an accurate history was elicited from the Veteran regarding his mental health. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2014); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). Based on the foregoing, VA has fully met its duties to notify and assist the claimant with the development of the claims and no further notice or assistance is required. Finally, in June 2012 the Board remanded the immediate issues of for additional development, including sending the Veteran VA Form 21-8940, retrieval of VA treatment records, ordering of new VA examinations regarding the Veteran's current levels of severity, and readjudication of the claims on appeal. Since that time, all of the foregoing were accomplished except for the readjudication of the Veteran's previous claim of a total disability rating based on individual unemployability (TDIU). At the time that the Board had ordered the RO to readjudicated the Veteran's claim for a TDIU, the benefit sought had already been granted, though it appears that the decision effecting this grant simply had not yet be physically placed in to the file. As TDIU had been granted, there remained no issue on appeal and the RO correctly did not readjudicate the claim. Although new VA examinations were scheduled pursuant to the Board's orders on three separate occasions, the Veteran failed to appear for the scheduled examinations. Internal correspondence reflects that the RO attempted to repeatedly to contact the Veteran by mail and telephone, even going so far as to ask one of his VA treating physicians to suggest to the Veteran that he contact the Buffalo RO - all without success. VA's duty to assist a veteran is not a one-way street, and it is the responsibility of veterans to cooperate with VA with regard to development. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Given the RO's actions, and the Veteran's lack of response, the Board finds that VA has no additional duty with regard to scheduling new VA examinations. Based on the foregoing, , the Board finds that the RO substantially complied with the June 2012 remand directives, and the Board has properly proceed with the foregoing decisions. See Stegall v. West, 11Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). ORDER An initial compensable rating for a right arm scar, as residual of a motor vehicle accident is denied. An initial compensable rating hemorrhoids is denied. An initial of 50 percent, and no higher, for chronic adjustment disorder with mixed anxiety and depressed mood is granted prior to June 1, 2009. An initial rating of 100 percent for chronic adjustment disorder with mixed anxiety and depressed mood is granted, effective June 1, 2009. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs