Citation Nr: 1603870 Decision Date: 02/03/16 Archive Date: 02/11/16 DOCKET NO. 09-25 268 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for bladder cancer. 2. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) on and before March 17, 2015, and to a disability rating in excess of 70 percent thereafter. 3. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type 2 (diabetes). 4. Entitlement to a disability rating in excess of 10 percent for a neck scar. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Virginia Girard-Brady, Attorney at Law ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to January 1969, including service in the Republic of Vietnam (Vietnam) from April 1968 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the VA RO. A March 2008 rating decision granted service connection for a neck scar and assigned an initial 10 percent disability evaluation, and it granted service connection for PTSD and assigned an initial 50 percent disability evaluation. An October 2009 rating decision granted service connection for diabetes and assigned an initial 20 percent evaluation and denied service connection for bladder cancer. This case was previously before the Board in July 2012, when it remanded the Veteran's claims in order to further develop the medical evidence of record. As is discussed in greater detail below, the Board finds that its remand instructions have been substantially complied with, and the Board will proceed in adjudicating the Veteran's claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that when the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). A May 2015 rating decision increased the rating of the Veteran's PTSD to 70 percent effective March 18, 2015. The issue of entitlement to a greater disability rating remains on appeal because the May 2015 rating decision does not represent a full grant of the benefit sought. AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to service connection for bladder cancer and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. On and before March 17, 2015, the Veteran's PTSD was manifested by symptoms producing no more than occupational and social impairment with reduced reliability and productivity; it did not cause either occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or total occupational and social impairment. 2. On and after March 18, 2015, the Veteran's PTSD is manifested by symptoms producing no more than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; it has not caused total occupational and social impairment. 3. The Veteran's diabetes requires the use of insulin and the restriction of diet, but it does not require restriction of activities. 4. The Veteran's neck scar is not manifested by any of the characteristics of disfigurement, the scarring does not result in visible or palpable tissue loss, gross distortion, asymmetry, or nerve impairment approximating severe incomplete paralysis of the facial nerve or worse. CONCLUSIONS OF LAW 1. On and before March 17, 2015, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. On and after March 18, 2015, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 3. The criteria for a rating in excess of 20 percent for diabetes have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2015). 4. The criteria for a rating in excess of 10 percent for a neck scar have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008); 38 C.F.R. § 4.124a, Diagnostic Code 8207 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The VCAA also defines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A (West 2014). The Veteran received all appropriate notice in February 2008 and July 2009. Neither the Veteran nor his representative has alleged that prejudice resulted from any notice error either on appeal or otherwise. Shinseki v. Sanders, 129 S.Ct. 1696, 1704, 1705, 1706 (noting that "the party that seeks to have a judgment set aside because of an erroneous ruling carries the burden of showing that prejudice resulted"). In sum, the notice provisions of the VCAA have been fulfilled, and that no further notice is necessary. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's post-service medical treatment records, including VA treatment records and treatment records from the Social Security Administration (SSA), have been obtained to the extent they were both identified and available. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2015). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In the instant case, the Veteran was provided with psychiatric examinations in March 2008, November 2012, and March 2015. The Veteran was provided with examinations addressing his diabetes in October 2009, January 2013, and March 2015. The Veteran was provided with examinations addressing his neck scar in January 2013 and March 2015. The examination reports indicate that the examiners reviewed the Veteran's claims file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. These examination reports are adequate for the purpose of rendering a decision in the instant appeal. 38 C.F.R. § 4.2 (2015); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Moreover, neither the Veteran nor his representative has objected to the adequacy of any of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). The Veteran was also offered the opportunity to testify at a hearing before the Board, but he declined. The Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Increased Ratings Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2015). When 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 (2015). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2015); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability or the same manifestations of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2015). Increased Rating for PTSD The Veteran is currently in receipt of a 50 percent rating for PTSD on and before March 17, 2015 and a rating of 70 percent thereafter. The Veteran argues that he is entitled to greater ratings. Under the General Rating Formula for Mental Disorders, in pertinent part, a 50 percent rating is assigned when a veteran's PTSD causes 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-term 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is assigned when a veteran's PTSD causes 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 an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when a veteran's PTSD causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of the veteran's psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating 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. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2015). Furthermore, the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the symptoms listed under § 4.130 are not intended to serve as an exhaustive list of the symptoms that VA may consider but as examples of the type of degree of symptoms, or the effects, that would warrant a particular rating. Mauerhan, 16 Vet. App. at 442 (2002). The Veteran's actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that indicates the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV); 38 C.F.R. § 4.130 (2015). While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning the appropriate disability rating for the veteran. VAOPGCPREC 10-95 (1995), 60 Fed. Reg. 43186 (1995). GAF scores ranging from 51 to 60 indicate 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 ranging from 61 to 70 indicate 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. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.130 (2015). Turning to the facts in this case, the Board observes that the SSA concluded in 2006 that the Veteran was not disabled based on his PTSD, but it ultimately concluded that the Veteran was disabled as the result of disabilities for which the Veteran is not service connected, including an atherosclerotic left carotid artery, chronic obstructive pulmonary disease, and degenerative disc disease. SSA records indicate that the Veteran worked in 2006 as a tire-repairer for a service station and as a dishwasher. The Veteran underwent an examination in March 2008, at which time the examiner noted that the Veteran retired in 2006. Before this time, the Veteran reported that he held odd jobs. The Veteran reported that he isolated himself and avoided interacting with others. The Veteran did not otherwise believe that he had emotional issues that would interfere with his productivity, efficiency, or reliability at work, nor would such issues interfere with his ability to gain or maintain gainful employment. The Veteran was engaged to be married to his fiancée with whom he had lived for five years. The Veteran reported that they spent time together, enjoyed cooking together, and both managed household duties. The Veteran had four children, and he described his relationship with them as "great." The Veteran reported having one friend. The Veteran reported that he became nervous in crowds. The Veteran enjoyed fishing and camping, but he could not participate in these activities due to his health problems. The Veteran indicated that he loved his grandchildren, but he did not let anyone "get close". The Veteran indicated that he wanted to cry all the time. The Veteran reported that he experienced panic attacks occasionally. The Veteran did not have problems with his activities of daily living. The Veteran's remote and recent memory was mildly impaired. The examiner assigned the Veteran a GAF score of 50. In October 2008, February 2009, April 2009 and October 2009 treatment records, the Veteran was noted not to be depressed, and he did not have suicidal or homicidal ideation. These records indicate that the Veteran was alert, pleasant, cooperative, and in no acute distress. In December 2010, the Veteran complained to a clinician of symptoms of "sleep paralysis." The clinician assigned the Veteran a GAF score of 65. The Veteran had "resolved most concerns" associated with difficulties in his life, and he considered himself to be a "better person." The Veteran denied experiencing suicidal or homicidal ideation. The Veteran indicated that his mood was good, and he denied feelings of worthlessness or hopelessness. The Veteran was oriented, his thoughts were logical, and he denied hallucinations. The Veteran's memory was intact, his judgment and speech were normal, and his mood and affect were appropriate. The clinician noted that the Veteran was married and had a strong social support network. In a July 2011 treatment record, the Veteran was noted not to be depressed, and he did not have suicidal or homicidal ideation. The Veteran was alert, pleasant, cooperative, and in no acute distress. In December 2011, the Veteran's representative argued that there was "sufficient evidence in the record to entitle [the Veteran] to a 70 percent rating for his PTSD". The Veteran underwent a VA examination in November 2012, at which time the examiner indicated that the Veteran's PTSD resulted in 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 normal routine behavior, self-care, and conversation. The Veteran had been involved in his current long-term relationship for 10 years. The Veteran indicated that though he and his partner argued "some," their relationship was "pretty good." The Veteran indicated that he got more aggravated with his partner the longer he was with her. The Veteran indicated that he became irritable and worried. The Veteran saw his two adult children "maybe twice a year," and he did not speak with them on the phone. The Veteran indicated that he watched television and had no interest in doing anything else. The Veteran had a few friends whom he spoke with several times weekly, but he rarely participated in activities with friends. The Veteran indicated that he retired from working in 2006. The Veteran reported that he could not get along with people and would "just snap." The Veteran attributed the majority of his inability to work on his physical health problems, with the Veteran's irritability and inability to get along with others playing a secondary role. The Veteran denied having any long-lasting, formal mental health treatment. The Veteran denied experiencing suicidal or homicidal thoughts. The Veteran indicated that he was depressed, had nightmares, and had problems with memory. The Veteran had intrusive thoughts a few times each month, but no flashbacks. The Veteran had some mild exaggerated startle response and hypervigilance. The Veteran had emotional numbness, apathy, emotional withdrawal, and mild problems concentrating. The Veteran avoided people. The Veteran's irritability and anger posed a significant problem. The Veteran indicated that his depression began approximately one and a half years before the examination. The examiner indicated that the Veteran had the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment (specifically noting that when the Veteran was angry, he could be very irrational and disrespectful), disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran's activities of daily living were not impaired, and the examiner found the Veteran to be competent to manage his financial affairs. The examiner found that there was no evidence that mental health issues resulted in total occupational impairment. In a January 2013 treatment record, the Veteran denied feeling depressed or sad much of the time, feeling down or hopeless, having little pleasure or interest in doing things, or having through thoughts of not wanting to live. The Veteran was not being seen by a mental health clinician, and he had no desire to be seen. In an April 2013 treatment record, the Veteran was noted not to be depressed, and he did not have suicidal or homicidal ideation. The Veteran was alert and oriented. In a July 2013 treatment record, the Veteran denied feeling depressed or having suicidal or homicidal ideation. The Veteran was not observed to be in distress, and the Veteran was alert, pleasant, and cooperative. In a July 2013 depression screen, the Veteran denied having little interest or pleasure in doing things, or feeling down, depressed, or hopeless. In a March 2014 treatment record, the Veteran denied feeling depressed or having suicidal or homicidal ideation. The Veteran was not observed to be in distress, and the Veteran was alert, pleasant, and cooperative. The Veteran's PTSD was noted to be stable. In an October 2014 treatment record, the Veteran denied feeling depressed or having suicidal or homicidal ideation. The Veteran denied having little interest or pleasure in doing things, or feeling down, depressed, or hopeless. In a March 2015 Disability Benefit Questionnaire (DBQ), an examiner assigned the Veteran a GAF score of 55 and checked that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The examiner noted that the Veteran had been married and divorced three times, and the Veteran was currently involved in a common-law relationship that had lasted for approximately 14 years. The Veteran indicated that he had not had any contact with his family for over 20 years. The Veteran indicated that he felt sad, hateful, generally nervous and depressed most days. The Veteran reported that he had no regular friends. Instead, the Veteran preferred to sleep and keep to himself. The Veteran reported that he had been unemployed since the time of his last examination, with his poor health and negative attitude significantly interfering with his ability to maintain employment. The Veteran had not participated in mental health counseling. The Veteran denied experiencing any legal issues since his last examination. The examiner indicated that the Veteran had the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and an inability to establish and maintain effective relationships. The examiner found the Veteran to be competent to manage his financial affairs. Turning now to an analysis of the evidence of record, the Board notes again that the Veteran is in receipt of a 50 percent disability rating on and before March 17, 2015, and a 70 percent disability rating on and after March 18, 2015. Upon review of the evidence of record, the Board finds that the Veteran has not shown the total occupational and social impairment that is associated with a 100 percent disability rating at any time during the appeal, nor did he show the occupational and social impairment with deficiencies in most areas that is associated with a 70 percent disability rating at any time on and before March 17, 2015. The Board notes initially that the Veteran himself appears not to believe that his PTSD warrants a 100 percent evaluation at any time. Indeed, in December 2011, the Veteran's representative argued only that the Veteran was entitled to a 70 percent disability evaluation. With regard to the Veteran's occupational impairment, the evidence shows that the Veteran has not worked since 2006, and before that time, the Veteran worked for employers such as service stations and restaurants. The Board notes that the SSA was unable to find that the Veteran was disabled as a result of his PTSD. In March 2008, the Veteran indicated that while he isolated himself, he did not otherwise believe that he had emotional issues that would interfere with his productivity, efficiency, or reliability at work, nor would such issues interfere with his ability to gain or maintain gainful employment. In November 2012, it was noted that the Veteran's irritability and inability to get along with others played only a secondary role in his occupational impairment, with his other physical disabilities playing a primary role. Clinicians consistently found the Veteran to be competent to manage his financial affairs. The Board further notes that no clinician has found the Veteran to be occupationally impaired to a greater degree than is reflected by his current disability evaluations. Upon review of this evidence, the Board notes that the Veteran's PTSD symptoms doubtlessly have an impact on his occupational functioning, and it is because of these symptoms that the Veteran has been awarded a 50 percent and 70 percent staged disability rating throughout the appeal. The Board cannot find, however, that the evidence shows that the Veteran's PTSD symptoms result in a greater level of impairment. The weight of the evidence shows that while the Veteran has not worked, this failure to work is largely the result of disabilities other than his PTSD. In sum, the Board finds that the weight of the evidence does not support a finding that the Veteran has shown the total occupational impairment that is associated with a 100 percent disability rating at any time during the appeal, nor did he show occupational impairment with deficiencies in most areas that is associated with a 70 percent disability rating at any time on and before March 17, 2015. With regard to the Veteran's social impairment, the Board acknowledges that the Veteran has complained of symptoms such as social isolation and having few friends. The Board must also observe, however, that the Veteran has been in a serious relationship with his partner for many years. In February 2008, the Veteran reported that he had a "great" relationship with his children. In December 2010, the Veteran reported that he had a "strong social support network." In November 2012, the Veteran reported that he spoke with a few friends several times weekly. The Board notes that by March 2015, the Veteran remained in a relationship with his partner but otherwise denied having friends, instead reporting that he preferred to keep to himself. Upon review of this evidence, the Board notes that the Veteran's PTSD symptoms doubtlessly have an impact on his social functioning, and it is because of these symptoms that the Veteran has been awarded a 50 percent and 70 percent staged disability rating throughout the appeal. The Board cannot find, however, that the evidence shows that the Veteran's PTSD symptoms result in a greater level of impairment. While the Veteran experiences social withdrawal, maintaining a years-long relationship with his current partner is inconsistent with a finding that the Veteran suffered from social impairment of a severity associated with greater ratings. In sum, the Board finds that the weight of the evidence does not support a finding that the Veteran has shown the total social impairment that is associated with a 100 percent disability rating at any time during the appeal, nor did he show social impairment with deficiencies in most areas that is associated with a 70 percent disability rating at any time on and before March 17, 2015. In making this determination, the Board has considered the argument that the Veteran's representative advanced in December 2015 regarding the Veteran's 70 percent rating. The Veteran's representative has asserted that a 70 percent rating should be assigned in accordance with the facts found, not simply on the date of the Veteran's psychiatric examination. As discussed above, the facts in this case are inconsistent with a finding that the Veteran manifested greater symptoms before March 17, 2015. The Veteran's treatment records from at least a year before his March 2015 examination until the time of that examination consistently show that the Veteran denied experiencing symptoms such as depression. His decline in social interaction, wherein he relates reduced contact with his children and friends, is not documented until the March 2015 examination. For example, when he was examined in 2012, the Veteran related to speaking with several friends on a weekly basis, having a good relationship with his partner, and maintaining contact with his children. The treatment records for the period between that exam and the March 2015 examination do not directly address his social relationships but do note that the Veteran related that he retained pleasure and interest in doing things. He denied depression and was alert, pleasant, and cooperative during this period. Indeed, the Board must note that outside of the examinations that the Veteran was provided in association with the Veteran's claim for greater compensation, the Veteran consistently denied experiencing symptoms such as depression. The Veteran otherwise failed to seek mental health treatment or even complain to clinicians of his symptoms. While these factors are not on their own dispositive of the Veteran's claim for an increased rating, the Board finds that the Veteran's consistent denial of the symptom of depression in a clinical setting is inconsistent with an award of disability ratings in excess of those currently assigned. In making this determination, the Veteran's GAF scores, ranging from 50 to 65, have been considered. The Board finds that these scores, which are reflective of mild to moderate symptoms, and particularly when considered along with the symptoms contained in the associated clinical reports, are, if anything, consistent with ratings contemplating only mild to moderate symptomatology. The Veteran's existing 50 percent and 70 percent disability ratings contemplate symptomatology that is more severe than the Veteran's GAF scores. Accordingly, greater ratings based on the Veteran's GAF scores are not available. It is important for the Veteran to understand that the Board has carefully considered the Veteran's accounts of the psychiatric symptoms that he has experienced. If the problems he has cited were not considered, there would be no basis for the currently-assigned 50 percent and 70 percent disability ratings. Upon careful consideration of the evidence of record, however, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than those that have been currently assigned for his PTSD. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating for Diabetes The Veteran contends that he is entitled to a disability rating in excess of 20 percent for diabetes. Under the Diagnostic Code applicable to diabetes, a 20 percent disability rating applies to diabetes requiring insulin and restricted diet, or use of an oral hypoglycemic agent and a restricted diet. A 40 percent disability rating applies to diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent disability rating applies to diabetes requiring insulin, 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. A 100 percent rating applies to diabetes requiring more than one daily injection of insulin, 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 rated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2015). The phrase "regulation of activities" means that a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2015). The rating criteria contained in Diagnostic Code 7913 are conjunctive. In other words, the criteria for each higher disability rating include the criteria of each lower disability rating. If any criterion is not met at any particular level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152 (2009). Each higher rating requires the elements of the lower rating. Turning to the facts in this case, the Veteran filed his claim of entitlement to service connection for diabetes in April 2009. Since that time, the evidence of record, including VA examination reports and VA outpatient treatment records, shows that the Veteran has been prescribed insulin to maintain a satisfactory blood sugar level and that he has been placed on a restricted diet. At issue in this case, then, is whether the Veteran's diabetes requires the regulation of activities that is associated with greater disability ratings for diabetes. In an April 2009 nutrition consultation, the Veteran stated that he could not exercise as the result of chronic obstructive pulmonary disease, coronary artery disease, and problems with his legs. The Veteran underwent VA examinations in October 2009 and January 2013, at which time the examiners opined that the Veteran's diabetes did not require the regulation or restriction of activities. In a March 2015 DBQ, an examiner noted that the Veteran's treatment for diabetes consisted of insulin as needed based on blood test results. The examiner indicated that the Veteran's diabetes did not require the regulation of activities. The Board observes that the medical evidence contains numerous examples of medical providers encouraging the Veteran to exercise regularly. For example, in April 2009, in a nutritionist consultation, the Veteran was encouraged to engage in strengthening exercises and walking. In a separate April 2009 record, the Veteran was encouraged to walk for exercise. In October 2014 and December 2014, the Veteran was advised to increase his exercise, with the October 2014 clinician advising the Veteran to walk one to two miles daily. The Board acknowledges the lay contentions of the Veteran that his activities have been restricted as a result of his diabetes. However, the most probative medical evidence of record does not support the contention that the Veteran's diabetes requires the restriction of activities. Laypersons can attest to factual matters of which they have first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). While the Veteran is competent to report what he perceives through his senses, such as difficulty engaging in activities, he does not have medical training or expertise. Layno v. Brown, 6 Vet. App. 465 (1994). The Board assigns the Veteran's contentions little probative weight, because the weight of the evidence of record indicates that the Veteran has not been prescribed or advised to avoid strenuous occupational and recreational activities due to diabetes mellitus. The Board finds that whether the management of diabetes requires the restriction of activities or the avoidance of strenuous occupational and recreational activities is a decision that is medical in nature. The weight of the competent evidence of record shows that restriction of activities is not required due to diabetes. Therefore, the Board finds that a rating in excess of 20 percent for diabetes is not warranted. The Board acknowledges that compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2015). The evidence of record in the instant case indicates that the Veteran has only peripheral neuropathy due to his diabetes. A May 2015 rating decision granted the Veteran service connection for peripheral neuropathy, and the Veteran did not disagree with the decision. The Board thus will not further discuss the Veteran's peripheral neuropathy. It is important for the Veteran to understand that the Board has carefully considered the Veteran's accounts of the diabetic symptoms that he has experienced. If the problems he has cited were not considered, there would be no basis for the currently-assigned 20 percent disability rating. Upon careful consideration of the evidence of record, however, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 20 percent for diabetes. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating for a Neck Scar VA received the Veteran's claim for compensation for a neck scar in February 2008. Effective October 23, 2008, VA revised the regulations for evaluating skin disabilities. However, the new criteria only apply to claims filed on or after October 23, 2008, or if a request is made by a veteran for review under these clarified criteria who was previously rated under 38 C.F.R. § 4.118, Diagnostic Codes 7800 7805. Inasmuch as the Veteran's claim was received before October 23, 2008 and he has not requested review under the new criteria, the Board will only consider the criteria in effect before October 23, 2008. Diagnostic Code 7800 applies to disfigurement of the head, face, or neck, and it is rated as follows: 10 percent: With one characteristic of disfigurement 30 percent: Visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with two or three characteristics of disfigurement. 50 percent: Visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. 80 percent: Visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The eight characteristics of disfigurement are as follows: (1) Scar 5 or more inches (13 or more cm.) in length; (2) Scar at least one-quarter inch (0.6 cm.) wide at its widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo- or hyperpigmented in an area exceeding six square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. In evaluating whether any other Diagnostic Codes are potentially applicable, the Board notes that Diagnostic Code 7801 does not apply because the Veteran's scar is not deep, nor does it cause limited motion. Diagnostic Code 7802 does not apply because the Veteran's scar is on his neck, and this code applies to scarring elsewhere on the body. Diagnostic Code 7803 does not apply because the Veteran's scar is not unstable, and Diagnostic Code 7804 does not apply because the Veteran's scar is not painful on examination. Diagnostic Code 7805, applicable to "other" scars, does not apply, because the Veteran's scar is a superficial scar of the neck, and this type of scar is contemplated by Diagnostic Code 7800. With that said, the Veteran's scar is currently evaluated by analogy to incomplete moderate paralysis of the cranial nerve. A disability rating of 10 percent applies to moderate incomplete paralysis of the cranial nerve, a rating of 20 percent applies to severe incomplete paralysis of the cranial nerve, and a rating of 30 percent applies to complete paralysis of the cranial nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8207 (2015). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The rating schedule does not define terms such as "mild" or "severe," as such terms are used in the diagnostic codes. Instead, adjudicators must evaluate all of the evidence and make a decision that is equitable and just. 38 C.F.R. § 4.6 (2015). The Veteran underwent a VA examination in January 2013, at which time the examiner noted that the Veteran had a longitudinal linear scar on the throat below the left ear. The scar was 6cm in length. There was no pain or skin breakdown over the scar. The Veteran reported numbness from the left edge of the lip to the jawline and along the scar that did not interfere with the Veteran's ability to chew or swallow. The scar was not disfiguring. The scar was superficial, and it had no inflammation, edema, or keloid formation. The scar had no abnormal texture, abnormal pigmentation, or underlying soft tissue loss. The skin was not indurated or inflexible, and the contour was not elevated or depressed. The scar was not adherent to underlying tissue. The examiner found that the scar had no other disabling effects. No feature or set of paired features showed gross distortion or asymmetry. Nerve examination in January 2013 revealed that the Veteran had impairment of the facial cranial nerve in the form of mild numbness on the left side of the mouth and throat. The Veteran had normal muscle strength and sensory examination was normal. The examiner noted that the Veteran had incomplete, moderate impairment of the cranial nerve. In a March 2015 DBQ, an examiner noted that the Veteran had one scar of the head, face, or neck. The scar was not painful or unstable. The scar appeared on the left side of the Veteran's neck and was 9cm long by 0.15cm wide at its widest point. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scar did not result in a limitation of function. The Veteran reported decreased sensation in the area surrounding the scar. A March 2015 DBQ addressing the Veteran's cranial nerve impairment indicated that the Veteran reported decreased sensation in the left cheek, chin, and neck. The examiner noted that the Veteran's facial nerve was affected, and the Veteran did not have any symptoms attributable to his facial nerve condition. Muscle strength testing and sensory examination were normal. The examiner found that the Veteran suffered from incomplete, moderate impairment of the left facial nerve. Applying the pertinent rating criteria to the facts in the instant case, the Veteran's scar has shown no characteristics of disfigurement. The Veteran's scar is less than 13cm in length and 0.6cm in width. The surface contour of scar is not elevated or depressed on palpation, nor is it adherent to underlying tissue. The skin is not hypo- or hyperpigmented. The skin texture is not abnormal, underlying soft tissue is not missing, and the skin is not indurated and inflexible. With no characteristics of disfigurement, a rating in excess of the currently-assigned 10 percent evaluation is unavailable to the Veteran under the Diagnostic Code applicable to neck scarring. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). There is also no basis to assign a separate compensable rating based on disfigurement. With regard to a greater rating based on impairment of the cranial nerve, a greater evaluation would require a finding that the Veteran suffers from nerve impairment approximating severe incomplete paralysis or worse. The Veteran's nerve symptoms focus solely on numbness. No diminishment of strength has been shown, no functional impairment has been demonstrated, and sensory testing has been consistently normal. With only the Veteran's subjective complaint of numbness, the Board cannot find that the Veteran's symptoms rise to the level of severe incomplete paralysis of the facial nerve. Indeed, VA examiners have explicitly described the neurological dysfunction related to the scar as being "moderate." A disability rating in excess of 10 percent is thus unwarranted. It is important for the Veteran to understand that the Board has carefully considered the Veteran's accounts of the symptoms that he has experienced in association with his neck scar. If the problems he has cited were not considered, there would be no basis for the currently-assigned 10 percent disability rating. Upon careful consideration of the evidence of record, however, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent for a neck scar. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321(b) (2015); Fisher v. Principi, 4 Vet. App. 57 (1993). To determine whether to refer a claim for consideration of assignment of an extraschedular rating, first, the Board must determine whether the evidence presents such an exceptional disability picture that the schedular ratings for that service connected disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran'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 attendant thereto related factors such as marked interference with his 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 extra schedular rating. 38 C.F.R. § 3.321(b) (2015); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the schedular rating criteria are not inadequate, and it does not appear that the Veteran had exceptional or unusual psychiatric symptomatology. Instead, the Veteran merely disagrees with the assigned ratings for the levels of impairment associated with his PTSD, diabetes, and neck scar. The Veteran does not have any symptoms from his service connected PTSD, diabetes, or neck scar that are unusual or are different from those contemplated by the schedular rating criteria. Moreover, as noted, with respect to the Veteran's PTSD, Vazquez-Claudio directs the Board to consider all of the Veteran's PTSD symptomatology and to determine how these symptoms impacted his occupational and social functioning. As such, the schedular rating that is assigned has considered all of the PTSD related symptomatology within the confines of the schedular rating criteria. Therefore, the available schedular evaluations are adequate. The Board finds that referral for extraschedular consideration is not warranted. (ORDER ON NEXT PAGE) ORDER A disability rating in excess of 50 percent for PTSD on and before March 17, 2015, and a disability rating in excess of 70 percent thereafter is denied. A disability rating in excess of 20 percent for diabetes is denied. A disability rating in excess of 10 percent for a neck scar is denied. REMAND In January 2013, the Veteran was afforded an examination addressing the nature and etiology of his bladder cancer. The examiner opined that it was less likely than not that the Veteran's bladder cancer was related to his active duty service, to include as a result of his in-service exposure to herbicides while serving in Vietnam. The examiner's rationale for this opinion, which consisted solely of noting that the Veterans Benefit Administration has not adequately studied the relationship between bladder cancer and herbicide exposure, is inadequate. Accordingly, a supplemental opinion from an oncologist or other physician of sufficient expertise should be solicited. The Court of Appeals for Veterans Claims (Court) has also held that a request for a TDIU is not a separate claim for benefits, but rather, can be part of any claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009). If the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this case, the Veteran has claimed that he is prevented from working as a result of, in pertinent part, his psychiatric disability. As such, the question of TDIU based solely on the Veteran's psychiatric disability is raised by the record. Accordingly, the case is REMANDED for the following actions: 1. Forward the Veteran's claims file to an oncologist or other physician of expertise sufficient to render the requested opinion. Following review of the Veteran's claims file, and examination of the Veteran, if the examiner deems such physical examination to be necessary, the examiner should opine as to whether it is at least as likely as not (that is, a 50 percent probability or greater) that the Veteran's bladder cancer either began during or was otherwise caused by the Veteran's military service, to include as a result of his in-service exposure to herbicides. Citation to clinical research supporting the finding would be helpful in adjudicating the claim and avoiding further Remand. 2. Following completion of the above, and any other necessary development, adjudicate the issue of entitlement to a TDIU and readjudicate the issue of entitlement to service connection for bladder cancer. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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 2014). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs