Citation Nr: 1803153 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 12-17 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for residuals of a cerebrovascular accident, to include vertigo, prior to April 15, 2016. 2. Entitlement to an initial rating in excess of 10 percent for an acquired psychiatric disorder, characterized as an adjustment disorder, prior to April 15, 2016. 3. Entitlement to an initial rating in excess of 10 percent for a left upper extremity nerve disorder, prior to April 15, 2016. 4. Entitlement to an initial rating in excess of 10 percent for a left lower extremity nerve disorder, prior to April 15, 2016. 5. Entitlement to service connection for a bilateral shoulder disorder, claimed as radiculopathy. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Meyer, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1988 to February 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from two separate rating decisions issued in May 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran requested a hearing in his June 2012 substantive appeal. He was scheduled for a November 2017 hearing, but failed to appear. He has not asserted good cause for missing the hearing, and the hearing request is considered withdrawn. 38 C.F.R. § 20.702(d) (2017). The Board notes that the Veteran was granted a 100 percent combined schedular rating for his service-connected disabilities, effective April 15, 2016. In numerous correspondences, including from June 2009 and June 2012, the Veteran specifically requested the assignment of a 100 percent combined schedular rating. As such, this is considered to be a full grant of the benefits sought on appeal from April 15, 2016, and therefore the increased rating claims are no longer on appeal from that date forward. AB v. Brown, 6 Vet. App. 35 (1993). Additionally, the Board notes that the Veteran was initially assigned a 10 percent rating his vertigo status post cerebrovascular accident under DC 6204 and a separate noncompensable rating for his cerebrovascular accident under DC 8009. However, in a September 2017 rating decision, the RO determined that the assignment of two separate ratings was clear and unmistakable error, and as a result, the RO combined the separate ratings into a single evaluation under DC 8009. The Board agrees with the RO's determination as the assignment of two separate ratings for the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. Specifically, a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. Therefore, as reflected in the title page, these issues have been properly characterized as a single increased rating claim for residuals of a cerebrovascular accident, to include vertigo. FINDINGS OF FACT 1. For the period prior to April 15, 2016, the Veteran's psychiatric disorder has been characterized by mild and transient symptoms such as depression, anxiety, and sleep disturbances. Moreover, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events), have not been shown. 2. Prior to April 15, 2016, the neurological symptoms in Veteran's left upper extremity were characterized by no more than mild incomplete paralysis with numbness, abnormal sensory function, and pain. 3. Prior to April 15, 2016, the neurological symptoms in Veteran's left lower extremity were characterized by no more than mild incomplete paralysis with numbness, abnormal sensory function, and pain. 4. Prior to April 15, 2016, the Veteran's residuals of a cerebrovascular accident, including vertigo, manifests with occasional dizziness; however, occasional staggering has not been shown. 5. Throughout the period on appeal, the Veteran does not have a diagnosis of a bilateral shoulder disorder, to include radiculopathy. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for an acquired psychiatric disorder, characterized as an adjustment disorder, prior to April 15, 2016, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9440 (2017). 2. The criteria for an initial rating in excess of 10 percent for a left upper extremity nerve disorder, prior to April 15, 2016, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.6, 4.120, 4.123, 4.124, 4.124a, DC 8515 (2017). 3. The criteria for an initial rating in excess of 10 percent for a left lower extremity nerve disorder, prior to April 15, 2016, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.6, 4.120, 4.123, 4.124, 4.124a, DC 8621 (2017). 4. The criteria for an initial rating in excess of 10 percent for residuals of a cerebrovascular accident, to include vertigo, prior to April 15, 2016, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.87, DCs 8009, 6204 (2017). 5. The criteria for entitlement to service connection for a bilateral shoulder disorder, including radiculopathy, have not been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings The Veteran is seeking increased ratings for his service-connected psychiatric disorder, left upper and lower nerve disorders, and residuals of a cerebrovascular accident (stroke). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2017); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. In the case of an initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability. Fenderson v. West, 12 Vet. App. 119 (1999). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Acquired Psychiatric Disorder For the period prior to April 15, 2016, the Veteran's psychiatric disorder, diagnosed as an adjustment disorder, was assigned a disability rating of 10 percent rating under 38 C.F.R. § 4.130, DC 9440. In order to warrant the next-higher 30 percent rating, the evidence must show occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9440 (2017). After a review of the evidence of record, the Board determines that a rating in excess of 10 percent is not warranted prior to April 15, 2016. Indeed, while the Veteran has sporadic symptoms that could support a higher rating, the Veteran's symptoms do not otherwise cause an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Specifically, in a March 2009 VA examination, the Veteran was noted to be polite, cooperative, and "emotionally reticent." The Veteran reported "vague" symptoms mostly related to "a little anxiety" that was manifested by difficulty sleeping. He also indicated that he had some depression. The examiner did not find any evidence of impairment with the Veteran's thought process, communication skills, inappropriate behaviors, personal hygiene, memory loss, speech, and/or impulse control. Moreover, there was no evidence of panic attacks, delusions, and/or homicidal or suicidal ideations. As a result, the examiner determined that the Veteran had transient and mild psychiatric symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. Similarly, in a May 2009 VA examination, the Veteran's affect, mood, and judgment were all reported as normal. Further, the examiner did not find any evidence of obsessive behaviors, hallucinations, delusions, or a thought disorder. The objective medical evidence, including treatment records, does not indicate that the Veteran was actively being treated for his psychiatric disorder, to include medication and psychotherapy, prior to April 15, 2016, and/or experienced symptoms that would warranted a higher rating. Therefore, the Board finds that the Veteran does not exhibit objective symptoms that would be sufficient to warrant a rating in excess of 10 percent prior to April 15, 2016. While it is true that the Veteran had some anxiety, depression, and trouble sleeping, these symptoms alone are insufficient to warrant an increased rating given the otherwise relatively mild array of symptoms and impact on the Veteran - especially in light of the fact that the Veteran did not have any significant psychiatric symptoms that were more than mild or transient throughout this period on appeal. Indeed, many of the examples listed in the diagnostic code for a higher rating have not been shown at all. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational inadaptability. In this regard, it is clear that the Veteran's disorder reflects some mild and transient impact on his social and occupational functioning. Nevertheless, the evidence does not indicate that a rating in excess of 10 percent is warranted. Specifically, at his March 2009 VA examination, the Veteran reported that he has "normal" social functioning and adjustment and "generally had meaningful interpersonal relationships." Further, while he did not have a job (for reasons primarily related to his other service-connected disorders), he stated that he "tries to keep busy doing yardwork and not napping during the day." Moreover, he reported that he was in fact able to "take care of his family and home." The Board has also considered the Veteran's Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran's GAF score reported by his March 2009 VA examiner was 65. A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. In this case, the Board finds that the Veteran's symptoms are most consistent with the more "mild" and transient symptoms reflected in a GAF score of 61-70, considering that the Veteran only sporadic mild and transient symptoms, and was able to generally function pretty well with meaningful interpersonal relationships. However, such symptoms are not so severe as to warrant a rating in excess of 10 percent. Left Upper Extremity and Left Lower Extremity Nerve Disorders Prior to April 15, 2016, the Veteran's was in receipt of two separate 10 percent ratings for his left upper (non-dominant) and lower extremity nerve disorders under 38 C.F.R. § 4.124a ,DCs 8515 and 8621, respectively. In order to warrant the next higher 20 percent rating under DCs 8515 and 8621, the evidence must demonstrate incomplete paralysis at the "moderate" level of the median nerve (non-dominant) and external popliteal nerve, respectively. 38 C.F.R. § 4.124a. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture 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. 38 C.F.R. § 4.124a. The words "slight," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Based on these findings, the Board finds that ratings in excess of 10 percent for left upper and lower extremity nerve disorders, respectively, are not warranted prior to April 15, 2016. Specifically, at a VA examination in March 2009, the Veteran reported pain, numbness, and weakness in his left upper and lower extremities. His left upper extremity was reported as his non-dominant extremity. The Veteran had slightly decreased motor strength and reflexes with normal sensation in his left upper extremity. The Veteran had some "very slight left finger-to-nose dystaxia." The examiner did not find evidence of upper extremity radiculopathy. Similarly, the Veteran had slightly decreased motor strength and reflexes with normal sensation in his left lower extremity. He also had "some left heel-to-shin dystaxia" that caused "some" difficulty walking. There was no evidence of muscle atrophy or radiculopathy. In a May 2009 VA examination, the Veteran had normal motor and sensory findings in his left upper and lower extremities. There are no treatment records demonstrating evidence of worsening in symptoms to warrant a 20 percent rating, such as increased muscle weakness, muscle atrophy, or functional limitations due to radiculopathy of his upper and lower left extremities. Thus, while the Veteran had subjective complaints of moderate pain and numbness, the objective medical evidence demonstrates that the Veteran did not have moderate incomplete paralysis of his median nerve and external popliteal nerve, respectively, or symptoms related thereto. The Board has considered whether the Veteran could receive a higher rating under other applicable diagnostic coders, including under 38 C.F.R. § 4.123 or 4.124, for neuritis or neuralgia, respectively. Nevertheless, while the Veteran had pain, he did not demonstrate symptoms of loss of reflexes, muscle atrophy, or sensory disturbances that would warrant a higher rating. Moreover, he did not report intermittent dull pain. Therefore, a higher rating is not warranted under any these or any other relevant diagnostic code(s). Residuals of a Cerebrovascular Accident Prior to April 15, 2016, the Veteran's cerebrovascular accident residuals, including vertigo, have been assigned a 10 percent rating under 38 C.F.R. § 4.87, DC 6204. Under this diagnostic code, the next-higher 30 percent rating is warranted when the evidence shows dizziness and occasional staggering. However, based on the evidence of record, a rating in excess of 10 percent is not warranted for the period on appeal. Specifically, at his March 2009 VA examination, the Veteran indicated that his dizziness and vertigo first manifested after his stroke. He also stated that his episodes of vertigo are brief in nature and do not cause constant dizziness. Further, the Veteran denied balance and gait problems and there was no evidence that he experienced episodes of staggering. Similarly, in a May 2009 VA examination, the examiner did not find any evidence of a gait imbalance or staggering that was related to his vertigo. Additionally, the Board acknowledges the Veteran's assertions that he staggers from his vertigo. However, the objective medical evidence indicates that to the extent the Veteran has any gait or balance issues, these problems are related to his numerous service-connected disabilities, such as his back and lower extremity nerve disorders. Therefore, a rating in excess of 10 percent for the Veteran's vertigo is not for application. The Board has also considered whether a separate rating is warranted for any other disorder that is a residual of his stroke. However, it does not appear that any such disorders are present for which the Veteran is not already receiving compensation. In addition to the symptoms addressed above, the Veteran is also service-connected for a headache disorder with a 30 percent disability rating. However, the Veteran has not appealed this rating, and therefore this issue is not before the Board. C.f. Tyrues v. Shinseki, 23 Vet.App. 166, 176 (2009) (in situations where an issue is bifurcated, an appellant must then specifically appeal each bifurcated issue). Finally, the Board has considered whether the Veteran is entitled to a higher rating under any other potentially applicable diagnostic code, including DC 8009 (addressing brain hemorrhage). Nevertheless, the Veteran did not have a brain embolism, thrombosis, or hemorrhage within 6 months at any point during the period on appeal. As such, a higher rating under this or any other potentially applicable diagnostic code is not for application. In considering the appropriate disability rating, the Board has also considered the statements from the Veteran that his psychiatric disorder, left upper and lower extremity nerve disorders, and stroke residuals are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his psychiatric and hand disabilities according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Specifically, with respect to his psychiatric disorder, while the Veteran reported that he had depression, anxiety, and sleep impairments, these symptoms were discussed and addressed by the VA examiners and treating medical providers. Additionally, regarding the Veteran's nerve disorders and stroke residuals, the medical examiners and treating medical providers addressed and discussed the nature and severity of his pain, weakness, and gait problems. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, including limitations with activities of daily living, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board's analysis. As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Lastly, the Veteran was granted TDIU, effective March 10, 2016. As this aspect of his claim was separately adjudicated and the Veteran has not submitted a notice of disagreement to this decision, it is no longer on appeal. See Tyrues v. Shinseki, 23 Vet.App. 166, 176 (2009) (in situations where an issue is bifurcated, an appellant must then specifically appeal each bifurcated issue). Service Connection The Veteran is seeking entitlement to service connection for a bilateral shoulder disorder, claimed as radiculopathy. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, including radiculopathy, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Moreover, for such chronic diseases, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014). Moreover, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). Service connection may only be granted for a current disability; and therefore, if a claimed condition is not shown, there may be no grant of service connection. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Upon review of the evidence of record, the Board determines that service connection is not warranted. While the post-service medical evidence reflects that the Veteran had numerous complaints of pain, swelling, and tenderness to his bilateral shoulders, aside from his already service-connected upper left extremity disorder, there is no evidence of a diagnosed disorder, including radiculopathy to the shoulders. Specifically, the March and May 2009 VA examiners did not find any evidence of radiculopathy or any other bilateral shoulder disorder. Therefore, while the Veteran experienced bilateral shoulder symptoms, these symptoms alone without a diagnosed disorder are not a disorder for VA purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999. As such, service connection for a bilateral shoulder disability, is not for application because the evidence does not indicate that a disability exists. See 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Additionally, the Board notes that the Veteran is already in receipt of separate ratings for a left upper extremity nerve disorder which manifest with the aforementioned symptoms in his left shoulder. Thus, any additional compensation for these symptoms would be considered pyramiding. See 38 C.F.R. § 4.14. In arriving at this conclusion, the Board has also considered the statements made by the Veteran relating to his diagnosis of a bilateral shoulder disorder. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). In this case, however, the Veteran is not competent to provide testimony regarding a diagnosis and/or etiology of his bilateral shoulder disorder. See Jandreau, 492 F.3d at 1377, n.4. Because an extremity disability is not diagnosed by unique and readily identifiable features, it does not involve a simple identification that a layperson is competent to make. Therefore, the unsubstantiated statements regarding the claimed diagnosis and etiology of the Veteran's shoulder disorder and radiculopathy are found to lack competency As a result, the Board concludes that the preponderance of the evidence is against the claim for service connection for a bilateral shoulder disorder, and there is no doubt to be otherwise resolved. Therefore, the claim for service connection must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). VA Duty 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. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C. §§ 5103, 5103A. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided notice letters informing him of both his and VA's obligations. Moreover, there is no indication of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Therefore, additional notice is not required and any defect in notice is not prejudicial. With respect to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). The Board finds that all necessary assistance has been provided to the Veteran. Indeed, all VA treatment records and relevant private treatment records have been obtained. The Veteran has also been provided with VA examinations. The Board acknowledges the Veteran's assertions that his VA examinations were inadequate because the examiners failed to appropriately address and consider the severity of his reported symptoms, however, upon review of the examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2017); Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER An initial rating in excess of 10 percent for an acquired psychiatric disorder, characterized as an adjustment disorder, prior to April 15, 2016, is denied. An initial rating in excess of 10 percent for a left upper extremity nerve disorder, prior to April 15, 2016, is denied. An initial rating in excess of 10 percent for a left lower extremity nerve disorder, prior to April 15, 2016, is denied. An initial rating in excess of 10 percent for residuals of a cerebrovascular accident, to include vertigo, prior to April 15, 2016, is denied. Service connection for a bilateral shoulder disorder, claimed as radiculopathy, is denied. ____________________________________________ B.T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs