Citation Nr: 1621796 Decision Date: 06/01/16 Archive Date: 06/13/16 DOCKET NO. 13-13 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Evaluation of residuals of a right shoulder separation, currently rated as 10 percent disabling. 2. Evaluation of right lower extremity peripheral neuropathy, currently rated as noncompensable. 3. Evaluation of a shell fragment wound of the right foot, currently 10 percent disabling. 4. Entitlement to an effective date prior to September 28, 2010 for the grant of service connection for diabetes mellitus. 5. Entitlement to service connection for erectile dysfunction, including as secondary to service-connected diabetes mellitus. 6. Entitlement to service connection for cataracts. 7. Entitlement to service connection for residuals of a tracheotomy. 8. Entitlement to service connection for a left knee disorder, including as secondary to service-connected disabilities. 9. Entitlement to an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 10. Entitlement to a total rating for compensation on the basis of individual unemployability. 11. Entitlement to special monthly compensation based on loss of use of a creative organ. 12. Evaluation of diabetes mellitus, rated as 10 percent disabling prior to November 19, 2011. ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2010, September 2010, and July 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In the June 2010 rating decision, the RO denied entitlement to an increased rating for residuals of a shell fragment wound of the right foot and a separate disability evaluation for right lower extremity neuropathy, as well as denied entitlement to service connection for PTSD, erectile dysfunction, diabetes mellitus, and cataracts. In a September 2010 rating decision, the RO denied entitlement to an increased disability evaluation for residuals of a right shoulder separation, as well as denied entitlement to service connection for residuals of a tracheotomy and a left knee disorder. In a July 2012 rating decision, service connection was granted for the Veteran's right lower extremity neuropathy; a noncompensable disability rating was assigned, effective June 26, 2009. Service connection was also granted for diabetes mellitus; a 10 percent disability evaluation was assigned, effective September 28, 2010 and a 20 percent disability evaluation was assigned effective November 19, 2010. Additionally, this rating decision denied the Veteran's claim of entitlement to special monthly compensation for loss of use of a creative organ. Additionally, this rating decision granted an earlier effective date of July 7, 2009 for the grant of a 30 percent disability evaluation for tension headaches. In his May 2013 VA Form 9, the Veteran indicated that he disagreed with the 10 percent disability rating for his diabetes mellitus for the rating period prior to November 19, 2010; he has not indicated that he disagreed with the 20 percent disability rating from November 19, 2010. See AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to an initial disability rating in excess of 10 percent for diabetes mellitus and entitlement to special monthly compensation based on loss of use of a creative organ, as well as the issues of entitlement to service connection for PTSD and cataracts are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran was awarded a Purple Heart and is presumed to have engaged in combat. 2. On June 26, 2009, the RO received a claim of entitlement to service connection for diabetes mellitus from the Veteran. 3. Residuals of a right shoulder separation most closely approximate nonunion without loose motion, with pain. He retains functional use of the arm above shoulder level. 4. The Veteran's residuals of a shell fragment wound of the right foot most closely approximate a moderate foot injury. 5. The Veteran's right lower extremity neuropathy has been manifested by mild numbness, sensory deficit, and pain of the plantar foot. 6. A left knee disorder was not manifest in service and is not attributable to service. 7. There are no residuals of a tracheotomy. CONCLUSIONS OF LAW 1. The criteria for an effective date of June 26, 2009 for the grant of service connection for diabetes mellitus are met. 38 U.S.C.A. §§ 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.400 (2015). 2. The criteria for a disability rating in excess of 10 percent for residuals of a right shoulder separation are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5203 (2015). 3. The criteria for a disability rating in excess of 10 percent for residuals of a shell fragment wound of the right foot have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2015). 4. The criteria for an initial compensable rating for a right lower extremity neuropathy have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8627 (2015). 5. A left knee disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). 6. Residuals of a tracheotomy were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance. In this case, the agency of original jurisdiction (AOJ) issued notice letters to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for service connection and increased disability evaluations, as well the legal criteria for entitlement to such benefits; the claim for an earlier effective date is downstream from the initial claim for service connection. The letters also informed him of his and VA's respective duties for obtaining evidence. VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was also afforded a VA examination responsive to the claims for service connection of erectile dysfunction and residuals of a tracheotomy. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The opinions were conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The Veteran was also afforded VA examinations responsive to the claims for increased ratings for the service-connected residuals of a right shoulder separation, residuals of a shell fragment wound of the right foot, and right lower extremity neuropathy. The examination reports contain all the findings needed to rate the Veteran's service-connected disabilities on appeal, including history and clinical evaluation. An examination or nexus opinion is not required regarding the claim for service connection of a left knee disorder, as the weight of the evidence demonstrates no related injury, disease, or event during service, and there is no current diagnosed disorder. Therefore, any opinion would be speculative. For these reasons, a remand to provide the Veteran with medical examinations and/or obtain medical opinions is not required with respect to this claim for service connection. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Earlier Effective Date Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increased, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C.A. § 5110(a). The effective date of an award of disability compensation to a veteran is the day following the date of discharge or release if the application therefor is received within one year from such date of discharge or release. 38 U.S.C.A. § 5110(b)(1). A claim is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1(p) (2015). The Veteran seeks an effective date earlier than September 28, 2010 for the grant of entitlement to service connection for diabetes mellitus. Effective dates are based upon a variety of factors, to include when a claim is received, whether the claim was received within one year of separation from service and whether the issue is impacted by a liberalizing law of VA issue. Based on a careful review of the record, the Board finds that a claim for service connection for diabetes mellitus was received by VA on June 26, 2009. The Veteran was discharged from service in November 1970. He did not file a claim for compensation until decades after separation from service. On June 26, 2009, the RO received a statement, wherein the Veteran claimed entitlement to service connection for diabetes mellitus. Stated differently, the original claim for compensation for any benefit was received on June 26, 2009. 38 C.F.R. § 3.160(b) (2015). The Board acknowledges that there was confusion as to whether the Veteran met the diagnostic criteria for diabetes mellitus prior to September 28, 2010, which is the first date of record reflecting a confirmed diagnosis of diabetes mellitus. Nevertheless, a review of medical records from Westmoreland Regional Hospital indicates that the Veteran had been treated with chronic kidney disease in April 2009 and that a July 2006 laboratory finding indicates that the Veteran had fasting glucose of 128mg/dL, which is greater than 125mg/DL and is thus diagnostic for diabetes mellitus. As such, the Board finds that the effective date is the date of claim, June 26, 2009. However, the Board must also consider whether the Veteran is entitled to an effective date prior to June 26, 2009. In this case, the Veteran separated from service in 1970. Because he did not file a claim until more than one year after 1970, the exception found at 38 U.S.C.A. § 5110(b) is not applicable. As there was no communication from the Veteran evincing intent to apply for entitlement to service connection for diabetes mellitus prior to June 26, 2009, that is the earliest effective date available for the grant of service connection for diabetes mellitus; an effective date prior to June 26, 2009 is not warranted. The Board points out that there are no earlier communications pertaining to the service-connected diabetes mellitus. Thus, an effective date of June 26, 2009 is appropriate, but an earlier effective date based on a prior, pending, unadjudicated claim is unavailable. Id. In addition, entitlement to service connection for diabetes mellitus was not based on any act or administrative issue, see 38 U.S.C.A. § 5110(g), 38 C.F.R. § 3.114, and an earlier effective date is therefore not warranted on this basis. Here, the inclusion of diabetes mellitus in the list of diseases entitled to presumptive service connection for those exposed to Agent Orange is considered a liberalizing law. However, in order to establish an effective date based on 38 U.S.C.A. § 5110(g), it must be established that the Veteran had diabetes mellitus prior to the liberalizing law. A review of the entire record does not demonstrate that the Veteran had diabetes mellitus prior to the addition of diabetes mellitus to the list of diseases associated with Agent Orange exposure in 2001. The grant, in this case, is not based upon a liberalizing law or VA issue. Therefore, under the laws and regulations pertaining to effective dates, June 26, 2009, but no earlier, is the appropriate effective date for the grant of entitlement to entitlement to service connection for diabetes mellitus. Stated differently, in this case, the effective date of the grant of compensation is based upon the date of the receipt of the original claim. 38 U.S.C.A. § 5110(a). Disability Evaluations Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Board observes that the Veteran's 10 percent disability ratings for his residuals of a right shoulder separation and residuals of a shell fragment wound of the right foot are protected; his 10 percent rating was in effect for 20 years effective November 28, 1990. See 38 C.F.R. § 3.951(b) (""A disability which has been continuously rated at or above any evaluation of disability for 20 or more years for compensation purposes under laws administered by the Department of Veterans Affairs will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud."). In Murray v. Shinseki, 24 Vet. App. 420 (2011), the Court found that, if a veteran has a protected rating under a specific diagnostic code, VA cannot reclassify the disability by assigning the same evaluation under a different diagnostic code if the effect is to reduce the protected rating, even while maintaining the same evaluation based on different manifestations of the disability. Right Shoulder The Veteran's residuals of a right shoulder separation are rated as 10 percent disabling pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5299-5203. See 38 C.F.R. § 4.20. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2015). Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I (2015). Diagnostic Code 5203 provides ratings for impairment of the clavicle or scapula. Malunion of the clavicle or scapula is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder. Nonunion of the clavicle or scapula without loose movement is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder; nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of a contiguous joint. 38 C.F.R. § 4.71a. In this case, documents of record establish that the Veteran is right handed; the Veteran reported that his dominant hand is his right hand at the August 2009 and September 2013 VA examinations. See 38 C.F.R. § 4.69 (2015). After a review of the lay and medical evidence, the Board finds that the Veteran's disability picture more nearly approximates his current 10 percent disability rating. The evidence shows that, throughout the rating period on appeal, the Veteran does not have nonunion of the clavicle with loose movement or dislocation of the clavicle. The August 2009, June 2010, and September 2013 VA examination reports indicate that x-rays of the right shoulder do not show an acute fracture or dislocation; according to the June 2010 report, upon x-ray there were mild degenerative changes and radiopaque areas likely representing shrapnel over the right shoulder area. According to the August 2009 VA examination report, the Veteran had range of motion to at least 140 degrees abduction; in June 2010, the Veteran had abduction to 140 degrees, with forward elevation to 140 degrees. Likewise, at the September 2013 VA examination, the Veteran had range of motion to 180 degrees flexion and abduction, with internal and external rotation to 90 degrees. There was no weakness, fatigue, deformity, or incoordination. The Veteran reported pain and there was tenderness of glenohumeral and acromioclavicular joints, but there was no guarding or decreased muscle strength. Furthermore, the available VA treatment records for the period on appeal do not show any treatment for the right shoulder, other than complaints of pain. Here, the lay and medical evidence are very similar. However, there is no lay or medical evidence of loose movement. We find credible his reports of pain and limitation of motion. However, even the credible lay evidence establishes that he retains functional use above shoulder level. Furthermore, Diagnostic Code 5203 establishes that a separate evaluation may not be assigned for impairment of function of the contiguous joint. In sum, if alternatively rated on the basis of limited function or limited motion, he would remain 10 percent disabled. The fact that he has pain or increasing pain does not warrant a higher evaluation unless that pain actually limits motion or functional use. The evidence also shows the Veteran did not have ankylosis of the scapulohumeral articulation or nonunion, fibrous union, or loss of the head of the humerus. Likewise, as previously discussed, there is no limitation of motion of the left arm to shoulder level. As such, the Board is precluded from assigning a disability rating in excess of 10 percent for residuals of a right shoulder separation under Diagnostic Codes 5200, 5201, or 5202. Moreover, although the Veteran has a surgical scar, the Board notes that the August 2012 VA examiner found that the scar was not painful or unstable, and was not greater 39 square centimeters. As such, the Veteran is not entitled to a separate, compensable disability evaluation for a scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7804-7805. The Board has also considered whether he has additional functional loss - beyond that objectively shown - due to his pain, or because of weakness, premature or excess fatigability, incoordination, etc. See DeLuca v. Brown, 8 Vet. App. 202 (1995), citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. However, the fact that the Veteran experienced pain, even if experienced throughout the range of motion, does not by itself warrant a higher rating under the diagnostic codes providing ratings for limitation of motion. The August 2009, June 2010, and September 2013 VA examiners noted that joint function of the right shoulder was not additionally limited, after repetitive use, by fatigue, weakness, lack of endurance, or incoordination, despite complaints of pain. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current, 10 percent disability rating. Shell Fragment Wound of the Right Foot The Veteran's residuals of a shell fragment wound of the right foot are rated as 10 percent disabling pursuant to the provisions of 38 C.F.R. § 4.71a, DC 5284. Under Diagnostic Code 5284, a 10 percent rating is assigned for moderate foot injury. A moderately severe foot injury warrants a 20 percent rating. A severe foot injury warrants a 30 percent rating. A Note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2015). After a review of the lay and medical evidence, the Board finds that the Veteran's disability picture more nearly approximates his current 10 percent disability rating. The evidence of record reflects that, throughout the rating period on appeal, the Veteran does not have moderately severe residuals of a shell fragment wound of the right foot. According to the August 2009 and September 2013 VA examination reports, the Veteran experienced pain on palpation, but did not experience erythema, inflammation, or limitation of motion; he had dorsiflexion to 20 degrees and plantar flexion to 45 degrees. There was also no evidence of marked deformity, redness, or callosities. Muscle strength was 5 out of 5 and deep tendon reflexes were 2+; there was no evidence of atrophy. His gait was normal. The Board acknowledges that the Veteran complained of hallux valgus and hammertoes at the August 2009 VA examination, but points out that the Vetera has hallux valgus and hammertoes of the left foot as well, and that the VA examiner found that his hallux valgus and hammertoes were unrelated to his residuals of a shell fragment wound of the right foot. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion. The VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability, beyond which was reflected in the examination reports. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. See also Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). While the Veteran identified flare-ups upon prolonged standing at his August 2009 VA examination, he did not report that the flare-ups resulted in any additional decrease in motion of the foot. Even with consideration of these reported flare-ups, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current, 10 percent disability rating for residuals of a shell fragment wound of the right foot. The Board also considered whether the Veteran may be entitled to a higher rating under other potentially applicable Diagnostic Codes for the rating period. However, there is no evidence that the Veteran's residuals of a shell fragment wound of the right foot resulted in ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5272. In addition, there is no evidence that the Veteran has unilateral acquired claw foot with toes tending to dorsiflexion, limitation of dorsiflexion at the ankle to a right angle, shortened plantar fascia, and marked tenderness under the metatarsal heads. See 38 C.F.R. § 4.71a, Diagnostic Code 5278. With regard to the criteria for severe malunion or nonunion of the tarsal or metatarsal bones, there is no evidence that the Veteran's residuals of a shell fragment wound of the right foot resulted in a deformity of the tarsal or metatarsal bones. As such, the Board does not believe that an evaluation in excess of 10 percent under Diagnostic Codes 5272, 5278, or 5283 is warranted. The Board also has considered whether the Veteran is entitled to a separate rating due to scars resulting in functional loss due to pain pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). See also 38 C.F.R. §§ 4.40, 4.45, and 4.59. He reports experiencing pain. But as already mentioned, there is no evidence of tenderness, limitation of motion, or other abnormality. And even flare-ups of his pain and repetitive activity do not result in a decrease in his range of motion in his right foot. Thus, there is no objective clinical indication he has other symptoms causing additional functional limitation (motion, etc.) to a degree that would support a higher disability rating. Right Lower Extremity Neuropathy The Veteran's right lower extremity neuropathy is currently evaluated as noncompensable pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8627. Under Diagnostic Code 8627, a 0 percent rating is warranted for mild to moderate neuritis of the internal saphenous nerve. A 10 percent rating is warranted for severe to complete neuritis of the internal saphenous nerve. A 10 percent rating is the maximum schedular rating available under Diagnostic Code 8627. 38 C.F.R. § 4.124a, Diagnostic Code 8627. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given 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. Id. After a review of all the evidence, the Board finds that the Veteran's service-connected right lower extremity neuropathy more nearly approximates the criteria for the current noncompensable disability evaluation. The Board finds that the Veteran's right lower extremity neuropathy is not productive of symptomatology consistent with severe to complete neuritis of the internal saphenous nerve. A review of VA treatment records, the August 2009, August 2012, and September 2013 VA examination reports, and the Veteran's statements reflect that the Veteran did not have any objective manifestations indicative of severe or complete neuritis. In this regard, the VA examiners conducted the appropriate tests and provided an assessment of the current severity of the Veteran's symptoms. Aside from mild numbness of the right lower extremity and decreased sensation of the foot and toes, the Veteran did not have any other objective manifestations; testing of strength and reflexes was normal, and there was no muscle atrophy. Moreover, although the September 2013 VA examination report found that testing revealed mild in complete paralysis of the right anterior tibial nerve, the August 2012 VA examiner found that testing of all of the lower extremity nerves was normal. The Board acknowledges the Veteran's contentions that he is entitled to a higher rating, and that he believes his right lower extremity neuropathy is severe. However, although the Veteran is competent to report symptoms such as pain and numbness, and the Board finds the Veteran to be credible in his report of symptomatology, his statements are outweighed by the findings of the VA examiners. The VA examiners found no evidence of a deficit with respect to reflexes or muscle weakness upon testing to determine the extent of functional loss and paralysis. These findings are entitled to greater probative weight, as they are based on objective manifestations of the Veteran's neurological impairment. In this case, the Board finds that the manifestations of the Veteran's right lower extremity neuropathy cannot be considered severe, since motor and reflex examinations were normal and only a sensory deficit to touch is shown. In reaching this determination, the Board has considered the guidance established in 38 C.F.R. §§ 4.120, 4.123, 4.124, and 4.124a. There is no evidence that the Veteran's right lower extremity neuropathy causes severe to complete neuritis of the internal saphenous nerve. In the absence of manifestations of severe to complete paralysis to the internal saphenous nerve, the preponderance of the evidence weighs against a higher rating for right lower extremity neuropathy. 38 C.F.R. §§ 4.1, 4.10, 4.124a, Diagnostic Code 8627. Scars The Board has also considered whether a separate compensable rating is warranted for the scars associated with the Veteran's residuals of a shell fragment wound of the right foot. Here, although the Veteran has 2 scars of the right foot, the Board notes that the August 2009 and August 2012 VA examiners found that the Veteran did not have a painful or unstable scars, and that no scar was greater 39 square centimeters. As such, the Veteran is not entitled to a separate, compensable disability evaluation for a scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7804-7805. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's right shoulder, right leg, and right foot disorders are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examination reports and which provided the basis for the disability rating that was assigned. The Veteran primarily complained of pain, which was clearly contemplated in the currently assigned disability evaluations. In any event, the evidence does not reflect that there has been frequent hospitalization or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Additionally, there is no indication that the Veteran's service-connected disabilities on appeal, standing alone, had an impact on his employment beyond that which is contemplated by the rating criteria. Therefore, referral for consideration of extraschedular ratings for the Veteran's service-connected disabilities on appeal is not warranted. 38 C.F.R. § 3.321(b)(1). Finally, the Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In the absence of exceptional factors associated with the service-connected disabilities on appeal, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2015). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran does not have a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply to the claim for service connection. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. The Board notes that the Veteran had active service during a period of war. Likewise, the Veteran's service personnel records reflect that he had service in Vietnam and that the Veteran was awarded a Purple Heart. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2014) are applicable. Residuals of a Tracheostomy and a Left Knee Disorder The Veteran claims that he has a left knee disorder related to his active duty and residuals of a tracheostomy that was performed in 1968. The Board notes that the Veteran's entrance reports of history and physical examination indicate that he reported having his tonsils removed at age 5 and a history of a dislocation of the right knee. The Board observes that the Veteran's service treatment records reflect that the Veteran was hospitalized on August 26, 1968 for treatment of shell fragment wounds of the neck, lower extremities, and right upper extremity; treatment records reflect that there was perforation of the larynx. He underwent debridement of his wounds, ligation of the right external carotid artery, and tracheostomy while hospitalized; the trachea deviated to the left. The tracheostomy tube was removed on September 2, 1968, and upon discharge on September 17, 1968, the sutures from the removal of the tube were noted as healing well and that an indirect laryngoscopy was normal. His November 1970 separation examination was normal. No left knee disorder was noted during service. The Board points out that the Veteran's service treatment records indicate that he requested a knee brace for use while playing football. However, there is no indication as to what knee, nor was a diagnosis rendered. At his November 1970 separation examination, physical evaluations of the lower extremities and musculoskeletal system were normal. Significantly, the Veteran has not provided any medical evidence of treatment, complaints, or diagnoses related to any residuals of a tracheostomy or to a left knee disorder in the years since service. In the absence of disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). In this regard, the Board notes that the Veteran's post-service VA and private treatment records do not show that any relevant pathology was reported. His silence as to pathology of the left knee and throat, when otherwise reporting a complete medical history, constitutes negative evidence. Forshey v. Principi, 284 F.3d 1335 (2002). As such, the Board finds that the Veteran's report of on-going problems to be inconsistent with the record and not credible. The Veteran is competent to report that he experiences pain in his left knee and throat. The Veteran is also is competent to report whether he has received diagnoses, including when he was first treated or diagnosed. No such diagnoses were confirmed by the record, however. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011) (noting impropriety of the Board categorically discounting lay testimony and requiring the Board to determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence is competent). Here, the Veteran's statements must be balanced against the other evidence of record, which does not show a current left knee or throat disorder. In addition, the evidence of record fails to show that any claimed disorder is related to service. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has noted that in order for a veteran to qualify for entitlement to compensation under those statutes, he or she must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To the extent that there are lay statements asserting that the Veteran has a left knee and/or throat disorder, related to an in-service injury or illness, the Board finds that the probative value of the general lay assertions are outweighed by the medical evidence of record which does not show any left knee pathology, disease, or residuals of injury. Likewise, the June 2010 VA respiratory examination report indicates that there is no evidence of any residuals of a tracheostomy; the Veteran denied any dysphagia and did not have any swallowing difficulties secondary to the previous shrapnel injury of the neck, and the VA examiner indicated that a review of the medical evidence of record does not show any current residuals of a tracheotomy other than the scar from the shrapnel. Moreover, nothing suggests that he has a disorder as a result of the tracheostomy or that there is a relationship between his service and the claimed left knee disorder. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). For the foregoing reasons, the preponderance of the evidence is against the claims for service connection of residuals of a tracheotomy and a left knee disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER An evaluation in excess of 10 percent for residuals of a right shoulder separation is denied. A compensable evaluation for right lower extremity neuropathy is denied. An evaluation in excess of 10 percent for residuals of a shell fragment wound of the right foot is denied. Service connection for a left knee disorder is denied. Service connection for residuals of a tracheotomy is denied. An earlier effective date of June 26, 2009, for the grant of service connection for diabetes mellitus is granted. REMAND The Board reiterates that the Veteran had service in Vietnam and that the Veteran was awarded a Purple Heart. The combat provisions of 38 U.S.C.A. § 1154 (West 2014) are applicable. The Board acknowledges that the Veteran was provided with VA examinations as to the claims for service connection of cataracts and erectile dysfunction. Nonetheless, these VA examinations are insufficient. In this regard, the Board points out that the February 2010 VA eye examination found that the Veteran did not have diabetic eye disease, but that he had very early nuclear sclerotic cataracts which were at least as likely as not caused by or the result of diabetes mellitus; however, no rationale was provided, and in September 2013, the VA examination did not show that the Veteran had cataracts. Instead, the VA examiner found that the Veteran had chronic open angle glaucoma that was not related to the Veteran's military service, including his service-connected diabetes mellitus. As such, it is unclear whether the Veteran has an eye disorder related to his service, including his service-connected diabetes mellitus. Moreover, as to the claim for erectile dysfunction, the Board observes that a February 2010 medical opinion found that the Veteran's erectile dysfunction could not be related to his diabetes mellitus because the onset of his erectile dysfunction preceded the onset of his hyperglycemia and diabetes mellitus; however, a review of the medical evidence (specifically, records from Westmoreland Regional Hospital) reflect that the onset of the erectile dysfunction was in 2006, as was the onset of hypoglycemia. As such, clarification of the opinion is required. Additionally, the Board observes that the Veteran underwent a VA PTSD examination in August 2009. The Board finds this examination to be inadequate. The VA examiner found that the Veteran met some, but not all of the criteria for a diagnosis of PTSD; however, no explanation as to which criteria were met, and which criteria were not met was provided. To this point, none of the DSM-IV criteria were discussed. Moreover, the VA examiner diagnosed the Veteran with major depressive disorder and VA found that his major depressive disorder was unrelated to service; however, the VA examiner failed to provide a rationale for his opinion. Accordingly, the Board finds that the Veteran should be afforded new VA examinations regarding the claims for service connection of erectile dysfunction, cataracts, and acquired psychiatric disorder, including PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As noted in the Introduction above, in a July 2012 rating decision, the Veteran's claim for service connection of diabetes mellitus was granted and a 10 percent disability evaluation was assigned for the rating period prior to November 19, 2010. Also, at that time, the Veteran's claim for special monthly compensation based on loss of use of a creative organ was denied. In August 2012, the Veteran indicated that he disagreed with the grant of a 10 percent disability evaluation for his diabetes mellitus for the rating period on appeal. In December 2012, the Veteran indicated that he did not agree with the denial of the claim for special monthly compensation. The Board construes the August 2012 and December 2012 statements as notices of disagreement (NOD). Because the Veteran filed a NOD as to these issues, the Veteran is entitled to a statement of the case (SOC) addressing the issues of entitlement to an increased disability rating for diabetes mellitus prior to November 19, 2010 and entitlement to special monthly compensation based on loss of use of a creative organ. When a claimant has filed a NOD and there is no SOC on file for that issue, the Board must remand, not refer, the issue to the RO for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238 (1999). As such, this claim must be remanded to the RO for issuance of a statement of the case (SOC). Given that the claims of entitlement to service connection for erectile dysfunction, an acquired psychiatric disorder including PTSD, and cataracts are being remanded for additional development, the Board finds that a decision on the TDIU issue must be deferred to allow the RO the opportunity to develop and readjudicate these claims. Furthermore, VA must make all necessary efforts to obtain relevant records in the possession of a Federal agency. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; Bell v. Derwinski, 2 Vet. App. 611 (1992). Any remaining, available VA treatment records related to the claims on appeal should be associated with the Veteran's claims file. Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file the Veteran's VA treatment records related to the claims on appeal from any VA facility identified by a review of the record. 2. The Veteran should be afforded a VA psychiatric examination to obtain an opinion as to the nature and etiology of any acquired psychiatric disorder, including PTSD, which may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any current acquired psychiatric disorder, including PTSD and/or a depressive disorder, was caused or aggravated by his service. 3. The Veteran should be afforded a VA examination to obtain an opinion as to the nature and etiology of any erectile dysfunction that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any current erectile dysfunction is proximately due to or the result of (caused or aggravated by) service-connected diabetes mellitus. A complete rationale should accompany each opinion provided. 4. The Veteran should be afforded a VA examination to determine the nature and etiology of any eye disorder, including cataracts, which may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any current eye disorder is proximately due to or the result of service-connected diabetes mellitus. The VA examiner is to specifically address the diagnoses rendered. A complete rationale should accompany each opinion provided. 5. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected disabilities as pertains to TDIU. The VA examiner should provide an opinion as to whether the Veteran, in light of his service-connected disabilities, when considered in combination, is capable of performing the physical and mental acts required by employment; whether he can find employment is irrelevant. The claims file should be made available to the examiner for review in connection with the examination. Any indications that the Veteran's complaints or other symptomatology are not in accord with the objective findings on examination should be directly addressed and discussed in the examination report. A complete rationale should accompany each opinion provided. 6. After completing all indicated development, the RO should readjudicate the claims for service connection of erectile dysfunction, cataracts, and an acquired psychiatric disorder including PTSD, and the claim for TDIU, in light of all the evidence of record. If any of the benefits sought remain denied, the case should be returned to the Board after compliance with requisite appellate procedures. 7. The AOJ should issue a statement of the case regarding the issue of entitlement to an increased disability rating for diabetes mellitus prior to November 19, 2010 and entitlement to special monthly compensation and special monthly compensation based on loss of use of a creative organ. Thereafter, if indicated, the claims should be returned to the Board for the purpose of appellate disposition. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs