Citation Nr: 1805323 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 12-29 673 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for chloracne. 2. Entitlement to a disability rating in excess of 50 percent for a right wrist injury with carpal tunnel syndrome. 3. Entitlement to a disability rating in excess of 30 percent for social anxiety disorder with bipolar I disorder and alcohol use disorder. 4. Entitlement to a disability rating in excess of 10 percent for arthritis of the finger joints of the right hand. 5. Entitlement to an initial compensable disability rating for the surgical scar associated with the right wrist disability. 6. Entitlement to a total disability rating based upon individual unemployability (TDIU). 7. Entitlement to an effective date earlier than September 8, 2011 for the award of service connection for chloracne. REPRESENTATION Appellant represented by: Robert V. Chisholm ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to May 1972 in the United States Air Force. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2015 and November 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In January 2015, the Board remanded a claim for service connection for acne/chloracne. Thereafter, in the July 2015 rating decision on appeal, the RO granted this claim. As such, the matter of service connection is no longer in appellate status and will not be addressed below. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). The electronic filing system contains documents pertinent to the appeal that were associated with the record since the RO's last readjudication of the claims. In the absence of a specific, written request for initial agency of original jurisdiction (AOJ) review of any additional evidence, there is an automatic waiver of AOJ review. See 38 U.S.C. § 7105(e)(1), (2) (West 2012) (applicable in cases where the substantive appeal is filed on or after Feb. 2, 2013). FINDINGS OF FACT 1. Chloracne is not manifested by visible or palpable tissue loss, gross distortion or asymmetry of two features or paired sets of features or, or four or five characteristics of disfigurement. The condition does not affect an area of 144 square inches or greater and disabling effects are not shown. 2. The right wrist injury with carpal tunnel syndrome is not manifested by complete paralysis of the median nerve. 3. Social anxiety disorder with bipolar I disorder and alcohol use disorder are not manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as a flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, or disturbances of motivation and mood. 4. Arthritis of the finger joints of the right hand is not manifested by occasional incapacitating exacerbations, ankylosis of any digit of the right hand or the right thumb, or a gap of more than 2 inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 5. The surgical scar associated with the right wrist disability has no disabling effects. 6. The service-connected disabilities do not render the Veteran unable to secure or follow substantially gainful employment. 7. In May 1972, the Veteran separated from service; a claim for service connection for chloracne was not received within one year of date of discharge. 8. On September 8, 2011, VA received the Veteran's claim for service connection for chloracne. 9. In a July 2015 rating decision, the subject of this appeal, the RO awarded service connection for chloracne, effective September 8, 2011. 10. There were no informal or formal claims, or written intent to file a claim for service connection for chloracne dated prior to the September 8, 2011 claim. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial rating in excess of 30 percent for chloracne are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 4.118, Diagnostic Code (DC) 7829 (2017). 2. The criteria for a rating in excess of 50 percent for the right wrist injury with carpal tunnel syndrome are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 4.124a, DCs 8599-8515 (2017). 3. The criteria for a rating in excess of 30 percent for social anxiety disorder with bipolar I disorder and alcohol use disorder are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 4.130, DC 9403 (2017). 4. The criteria for a rating in excess of 10 percent for arthritis of the finger joints of the right hand are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 4.71a, DCs 5220-5010 (2017). 5. The criteria for the assignment of an initial compensable rating for the surgical scar associated with the right wrist disability are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 4.118, Diagnostic Code (DC) 7805 (2017). 6. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). 7. The criteria for the assignment of an effective date earlier than September 8, 2011 for the grant of service connection for chloracne are not met. 38 U.S.C. §§ 5107, 5110(a) (West 2012); 38 C.F.R. §§ 3.102, 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In reaching the decisions below, the Board considered the Veteran's claims and decided entitlement based on the evidence. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Higher Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disability specified is considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. The VA examination reports discussed below are adequate for adjudication. The examiners examined the Veteran and pertinent records, considered his history, and set forth objective findings necessary for adjudication. The Board has further considered the admissible and believable assertions of the Veteran. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the lay statements are not considered more persuasive than the objective medical findings which, as indicated below, do not support higher ratings than those assigned. Chloracne In the July 2015 rating decision on appeal, the RO granted service connection for chloracne, and assigned a noncompensable rating from September 8, 2011 as well as a 30 percent rating from April 9, 2015, pursuant to 38 C.F.R. §4.118, Diagnostic Code 7829. In a November 2015 rating decision, the staged rating was eliminated, and the 30 percent rating was assigned from September 8, 2011. Under DC 7829, a 30 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. A 30 percent disability rating is the maximum schedular disability rating available under DC 7829. DC 7829 also provides that chloracne may be rated as disfigurement of the head, face, or neck (under DC 7800) or scars (under DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Under DC 7800, a higher rating of 50 percent is assigned for a skin disorder of the head, face, or neck with 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. Note (1) to DC 7800 provides that the 8 characteristics of disfigurement are as follows: (1) scar is 5 or more inches (13 or more cm.) in length; (2) scar is at least one-quarter inch (0.6 cm.) wide at the widest part; (3) surface contour of scar is elevated or depressed on palpation; (4) scar is adherent to underlying tissue; (5) skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.);(6) skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); and (8) skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). DC 7800 additionally directs the rater to separately evaluate associated disabling effects other than disfigurement, such as pain, instability, muscle, or nerve problems under the appropriate diagnostic code and apply 38 C.F.R. § 4.25 to combine the evaluations. Note (4). DC 7801 applies to scars not of the head, face, or neck, that are deep (with underlying soft tissue damage) and nonlinear. A rating of 40 percent is assigned if the area or areas exceeds 144 sq. inches (929 sq. cm.). DC 7802 applies to scars other than those on the head, face, or neck, that are superficial and nonlinear. This code provides a maximum rating of 10 percent rating if the area exceeds 144 square inches (929 sq. cm.). DC 7804 applies to unstable or painful scars. A maximum 30 percent rating is assigned for five or more unstable or painful scars. DC 7805 instructs the rater to evaluate any disabling effects und considered under DCs 7800-7804 under an appropriate diagnostic code. On VA examination in October 2011, the Veteran reported that he used to have acne on his face, neck and chest. He reported getting sores on his body that were deep and caused scarring. He previously skin cancer on his face, which had been treated and removed. On examination, the examiner found no current skin disorder. There was no scarring or disfigurement of the head, face, or neck. There were no skin neoplasms and there were no systemic manifestations due to any skin condition. The Veteran required no oral or topical medication for any skin condition. The examiner opined that the findings were insufficient to warrant any diagnosis. On VA examination in April 2013, the Veteran reiterated the medical history given on examination in October 2011. He also reported there were no debilitating episodes. On examination, the examiner found no scarring or disfigurement of the head, face, or neck. There were no skin neoplasms and there were no systemic manifestations due to any skin condition. He had used topical medication for rosacea in the past 12 months for a duration of 6 weeks or more, but not constantly. He required no other treatments. His acne was manifested by comedones, papules, pustules, or superficial cysts affecting body areas other than the face or neck. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The examiner opined "he has minimal prior acne vulgaris versus chloracne seen at best." On VA examination in May 2013, the examiner provided a discussion as to whether the Veteran had chloracne and whether it could be related to service. The examiner did not conduct an examination or render findings sufficient for rating the disability. On VA examination in April 2015, the Veteran reported a history of painful and deep cysts on the face and neck, which were not present on examination. The Veteran had used a topical medication, Metrogel, constantly or near-constantly in the past 12 months. He required no other treatments. On examination, symptoms consisted of typical chloracne residuals (white spots) on the upper chest and shoulders. He had very few lesions on the arms, and had some small pin-point lesions on the face. The condition affected 40 percent or more of the face and neck. Other body areas were also impacted. He did not have skin neoplasms. He did not have debilitating episodes. The Veteran was diagnosed with acne or chloracne, manifested by superficial acne as well as deep acne. On VA examination in November 2016, the Veteran reported recurrences of acne lesions, occasionally with yellow or green discharge. He reported occasional bumps on the arms and legs. He reported break-outs approximately every other month in various areas. On examination, the examiner found old chloracne lesions on the upper chest and a few on the upper arms. The condition was not painful or unstable, and did not cover an area of 6 inches or greater. He did not have skin neoplasms. He did not have debilitating episodes. The Veteran had used a topical medication, Metronidazole, for 6 weeks or more but not constantly in the past 12 months. He required no other treatments. His condition was manifested by superficial acne. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The exposed area affected included the face. The other lesions did not affect exposed areas but would encompass between 20 and 40 percent of the body surface area. VA treatment records and private medical records were reviewed, but do not contain information sufficient for rating the chloracne under the applicable diagnostic codes. The Board finds the preponderance of the evidence is against a rating in excess of 30 percent for chloracne. As noted above, a higher rating is not possible under DC 7829. DC 7800 does not apply because the record does not indicate visible or palpable tissue loss, gross distortion or asymmetry of two features or paired sets of features or, or four or five characteristics of disfigurement. The condition is not of the requisite size to warrant the application of DC 7801 or 7802. The condition is not unstable, and to the extent the Veteran has reported it is painful, DC 7804 does not afford a rating higher than 30 percent. Additionally, DC 7829 directs the rater to consider the predominant disability, and pain is not shown to be the predominant disability as it has been inconsistently documented and reported. DC 7805 does not apply as no disabling effects are indicated. The Board has considered that topical medication has been used to treat the condition. However, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit noted that DC 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code", and went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." As such, the Board does not find that the diagnostic codes contemplating systemic therapy apply here. Additionally, as it has not been shown that more than 40 percent of the entire body or more than 40 percent of the Veteran's entire exposed areas are affected, the diagnostic codes providing higher ratings in this regard also do not apply. Further, as there have been no debilitating episodes, the diagnostic codes providing higher ratings in this regard do not apply. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Right Wrist Disability In an October 1989 Board decision, service connection for the Veteran's right wrist disability was granted. In the implementing November 1989 rating decision, the RO assigned a staged rating, consisting of noncompensable and 10 percent evaluations. In a December 1994 rating decision, a higher rating of 30 percent was granted. In March 1999, a rating of 40 percent was granted. In June 2004, a rating in excess of 40 percent was denied. In a June 2007 Board decision, a 50 percent rating was granted. The RO implemented this award in a July 2007 rating decision, effective March 19, 2004. In August 2012, a rating in excess of 50 percent was denied. In July 2016, the Veteran filed a VA Form 21-8940, Application for Increased Compensation based on Unemployability. The RO construed this as a claim for higher ratings for his service-connected disabilities, and scheduled VA examinations to assess the current severity of his disabilities and their impact on employability. In the November 2016 rating decision on appeal, a rating in excess of 50 percent was again denied. The Veteran's right wrist disability has been rated under DC 8599-8515. Hyphenated diagnostic codes are used when a rating requires the use of additional rating criteria to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.71a. Under DC 8515, ratings are assigned dependent upon which extremity is involved, the dominant or "major" side, or the "minor" side. The Veteran is right-hand dominant, so the criteria pertinent to the "major" side apply. Under DC 8515, a rating of 50 percent is warranted for severe incomplete paralysis. A maximum rating of 70 percent is warranted when there is complete paralysis with hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. On VA examination in August 2016, the examiner noted the Veteran had undergone a right carpal tunnel release procedure, and no longer had objective evidence of carpal tunnel syndrome. The Veteran reported paresthesias and hypesthesia of the right hand and fingers, and stiffness. There was no constant pain or intermittent pain. There was mild paresthesias and numbness. Muscle strength was 5/5 in right wrist flexion and extension. There was no muscle atrophy. Reflex and sensory assessments were normal. Testing was conducted on the median nerve. The right median nerve was found to be normal, without either incomplete or complete paralysis. Abnormalities in other nerves affecting the right upper extremity were not found. The Veteran did not require assistive devices. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. VA treatment records and private medical records were reviewed, but do not contain information sufficient for rating the right wrist disability under the applicable diagnostic codes. As discussed above, as this matter stems from a 2016 claim, the pertinent appeal period is limited. The Board finds the preponderance of the evidence is against a rating in excess of 50 percent for the right wrist disability. The August 2016 VA examiner explicitly found there was no complete paralysis of the median nerve. Abnormalities of other nerves were not found. The diagnostic codes pertaining to the wrist do not provide ratings higher than 50 percent, and the impairment contemplated by these codes has not been raised by the record. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Psychiatric Disability In a September 2013 rating decision, the RO granted service connection for the psychiatric disability and assigned a 30 percent rating. In July 2016, the Veteran's VA Form 21-8940 was construed as a claim for higher ratings for his service-connected disabilities. In the November 2016 rating decision on appeal, the 30 percent rating was continued. Once a veteran has been diagnosed with a service-connected psychiatric disability, VA reviews his medical history to determine how significantly the disorder has disrupted the veteran's social and occupational functioning. The level of disability is rated according to a General Rating Formula for Mental Disorders, codified at 38 C.F.R. § 4.130 ("General Rating Formula"), which provides for ratings of zero, 10, 30, 50, 70, or 100 percent. VA compensates Veterans beginning at 10 percent disability, and compensation increases at each level. Pursuant to 38 C.F.R. § 4.130, a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an 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). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In a January 2016 VA treatment record, the Veteran's mood was euthymic and appropriate. He was not unduly anxious. No psychiatric distress was evident. There were no obvious abnormalities in thought content. On VA examination in August 2016, the Veteran reported that he lived with his wife and father. His father was 87 years old and had dementia, requiring full-time care from the Veteran and his wife. As such, the Veteran did not have much time for personal hobbies. He stated he did not socialize and coped with his social anxiety through avoidance. However, he interacted regularly with his three children and his grandchildren. He remained employed part-time, working one week per month. He reported his social anxiety would interfere with his ability to work if the job required a lot of socialization, including meetings or group discussions. He took medication for his psychiatric disability and felt it was helpful. There was no history of relevant legal or behavioral problems. He was abstinent from the use of substances. On examination, his symptoms included anxiety, panic attacks occurring weekly or less often, and difficulty in establishing and maintaining effective work and social relationships. He had fair hygiene. There were no abnormalities in motor behavior, speech, or thought processes. His affect was appropriate and his mood was euthymic. He denied hallucinations and did not display delusional thinking or paranoid thoughts. Insight and judgement were good. He was oriented. He denied suicidal or homicidal ideation. He did not display any indication of cognitive impairment. He could manage his financial affairs. The Veteran was diagnosed with social anxiety disorder, as well as bipolar I disorder and alcohol use disorder, both in full remission. His current symptoms were attributable to the social anxiety disorder. The examiner opined that the psychiatric disability caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks although generally functioning satisfactorily, the "severity statement" corresponding to a 30 percent rating. In considering the evidence under the laws and regulations as set forth above, the Board finds the preponderance of the evidence is against the claim for a rating higher than 30 percent. The August 2016 VA examiner specifically selected the severity statement corresponding to a 30 percent rating at the exclusion of the severity statements corresponding to higher ratings. Moreover, the symptoms attributed to the Veteran's psychiatric disorder, including anxiety and panic attacks occurring weekly or less often, fall squarely under the requirements for a 30 percent rating. Additionally, nearly none of the criteria contemplated by a 50 percent rating have been shown. On examination, the Veteran did not have a flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, or disturbances of motivation and mood. The VA examiner found the Veteran had difficulty in establishing and maintaining effective social relationships, as contemplated by a 50 percent rating. However, in light of the overall disability picture and VA examiner's assessment of the condition's severity, the Board does not find that this symptom in isolation warrants a rating in excess of 30 percent. The Board thus finds the overall symptomatology attributable to his psychiatric disability most closely approximates the level of severity contemplated by a 30 percent rating. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Right Fingers In a March 1990 rating decision, service connection for arthritis of the finger joints of the right hand was granted, and a 10 percent rating was assigned. In a June 2004 rating decision, June 2007 Board decision, June 2010 rating decision, and August 2012 rating decision, a rating higher than 10 percent was denied. In July 2016, the Veteran's VA Form 21-8940 was construed as a claim for higher ratings for his service-connected disabilities. In the November 2016 rating decision on appeal, a rating in excess of 10 percent was again denied. The Veteran's arthritis of the right fingers has been rated under DC 5220-5010. Diagnostic Code 5010 is the code for traumatic arthritis, which rates under DC 5003, the code for degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned with x-ray evidence of the involvement of two or more major joints or two or more minor joint groups. A 20 percent rating is assigned with x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. These 10 and 20 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). There are numerous diagnostic codes pertaining to ankylosis or limitation of motion of the fingers and hand. DCs 5216 to 5219 provide ratings for unfavorable ankylosis of multiple digits. DCs 5220 to 5223 provide ratings for favorable ankylosis of multiple digits. DCs 5224 to 5227 provide ratings for ankylosis of individual digits. DCs 5228 to 5230 provide ratings for limitation of motion of individual digits. The preamble to these diagnostic codes provides the following: (1) For the index finger (digit II), zero degrees of flexion represents the finger fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the metacarpophalangeal (MCP) joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal (PIP) joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal (DIP) joint has a range of zero to 70 or 80 degrees of flexion. (2) When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. (5) If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluation. In all of the forearm and wrist injuries, multiple impaired finger movements due to tendon tie-up, or muscle or nerve injuries, are to be separately rated and combined not to exceed the rating for loss of use of the hand. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213, Note. On VA examination in August 2016, the Veteran reported occasional discomfort and stiffness in the right hand. Prior to retirement, the hand limitations caused him to occasionally have to ask for help. He took Naprosyn for his symptoms. There were no flare-ups of the hand, finger, or thumb joints. On examination, the range of motion of the right hand was normal in every parameter. The examiner found there was no ankylosis in any finger of the right hand or the thumb. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was no pain on examination. There was no localized tenderness or pain on palpation of the joint or the associated soft tissue. The Veteran could perform repetitive-use testing with at least three repetitions, with no additional loss of function or range or motion. There was no functional loss due to pain, fatigue, weakness, a lack of endurance, or incoordination. Muscle strength was normal and there was no muscle atrophy. The examiner found no additional, contributing factors of disability. The Veteran did not require assistive devices. He was diagnosed with arthritis in the finger joints of the right hand. VA treatment records and private medical records were reviewed, but do not contain information sufficient for rating the finger disability under the applicable diagnostic codes. The preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the Veteran's arthritis of the right hand. A higher rating is not warranted under DC 5010 as the record does not show occasional incapacitating exacerbations. The August 2016 VA examiner found no incapacitation and the Veteran denied having any flare-ups. The preponderance of the evidence is also against the assignment of a rating higher than 10 percent under the diagnostic codes pertaining to the hand and fingers. DCs 5216 to 5227 do not apply as the record does not show ankylosis, favorable or unfavorable, of any digit of the right hand, or the right thumb. The VA examiner found explicitly to the contrary. Ratings higher than 10 percent are not provided under either DC 5229 or DC 5230, and as the record does not show that the Veteran has a gap of more than 2 inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, a 20 percent rating cannot be assigned under DC 5228. The preponderance of the evidence shows no additional loss of motion on repetition. The Veteran's pain and functional loss have already been considered in awarding the current rating. The Board finds insufficient evidence to support a finding of pain so disabling as to actually or effectively limit motion to such an extent as to warrant the assignment of a higher rating under the applicable diagnostic codes. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Right Wrist Scar In the November 2016 rating decision on appeal, the RO granted service connection for a right wrist scar, and assigned a noncompensable rating from July 25, 2016, pursuant to 38 C.F.R. §4.118, Diagnostic Code 7805. There are several diagnostic codes pertaining to scars. DC 7800 pertains to scars and disfigurement of the head, face, or neck. Diagnostic Code 7801 applies to scars not of the head, face, or neck, that are deep and nonlinear; a compensable rating requires evidence of a scar of at least 6 inches. Diagnostic Code 7802 provides a compensable rating with evidence of a superficial, nonlinear scar not of the head, face, or neck, that is of an area 144 square inches or greater. DC 7804 provides a higher rating of 10 percent with evidence of one or two scars that are unstable or painful. Diagnostic Code 7805 rates based on the effects of the scar under Diagnostic Codes 7800-7804, or based on any disabling effect not considered in a rating provided under Diagnostic Codes 7800-7804. On VA examination of the right wrist in August 2016, the examiner found the scar was not painful, unstable, or of an area greater than 6 square inches. On VA examination of the right fingers in August 2016, the examiner found the scar was not painful, unstable, or of an area greater than 6 square inches. There was one scar, located on the volar aspect of the right wrist. It measured 3 centimeters x 0.5 centimeters. VA treatment records and private medical records were reviewed, but do not contain information sufficient for rating the scar under the applicable diagnostic codes. The preponderance of the evidence is against a compensable rating for the right wrist scar. As the scar is not shown to have disabling effects, a compensable rating cannot be assigned under DC 7805. DC 7800 does not apply because the scar does not affect the head, face, or neck. The scar is not of the requisite size to warrant a higher or separate rating under DC 7801 or 7802. DC 7804 does not apply because the scar is not shown to be unstable or painful. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. TDIU The Veteran reports he is no longer able to secure or follow a substantially gainful occupation because of his service-connected disabilities. When entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability, it is part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). The Board construes his TDIU claim in connection with his 2011 claim for a higher rating chloracne; construing the claim in this manner is of the greatest benefit to the Veteran. VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. The Veteran's service connected disabilities consist of the following: right wrist disability (50 percent disabling), chloracne (30 percent disabling), psychiatric disability (30 percent disabling), arthritis of the right fingers (10 percent disabling), tinnitus (10 percent disabling), hearing loss of the right ear (noncompensable), and right wrist scar (noncompensable). He has been in receipt of a combined disability rating of 70 percent or higher since September 8, 2011, throughout the entire appeal period, with at least one disability rated at 40 percent or higher. Thus, the combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) have been met for the entire appeal period. Consequently, the Board must determine whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage.") Moore v. Derwinski, 1 Vet. App. 356 (1991). The record shows the Veteran completed high school. Following military service, he worked as a steam fitter. He reports that he last worked on February 15, 2012. He has not had other education or training either before or after becoming too disabled to work. He reports that in his last 5 years of employment, he had to force himself to continue working. His right wrist disability placed him at risk of falling off of ladders and he had constant pain in the back and knees. See VA Forms 21-8940. On VA examination in June 2010, the examiner noted the Veteran was working full-time. He had lost less than one week of work in the past year because of a non-service connected back disorder. On VA chloracne examination in October 2011, the examiner opined that the disability did not impact his ability to work. In March 2012, the Social Security Administration (SSA) determined that the Veteran was disabled as of February 15, 2012, due to degenerative disc disease of the lumbar spine with radiculopathy, and degenerative joint disease of the bilateral knees, both non-service connected disorders. A review of the underlying medical records reveals a finding that while the Veteran also had arthritic fingers, the condition did not cause limitations. In April 2012, the Veteran's employer submitted a letter stating the Veteran had been on leave without pay since February 15, 2012, due to problems with his right hand, wrist, shoulder, and back. He had been on leave without pay for 11 weeks. On VA examination in April 2012, the examiner found that the hand and wrist disabilities impacted the Veteran's ability to work in that his arthritis decreased his dexterity. He had to use his left hand for finer movements. However, the examiner further opined that the service-connected disabilities did not render him unable to secure or maintain substantially gainful employment. He had moderate impairment of the right median nerve and mild arthritis in the hand. Those conditions caused a slight decrease in strength and grip. He had worked in a previous job as a steamfitter for years with the conditions, and left because of a non-service connected back disorder. The examiner noted the Veteran had been awarded disability benefits from the SSA due only to non-service connected back, knee, and shoulder disorders. On VA psychiatric examination in April 2013, the examiner determined that the psychiatric disability caused occupational and social impairment due to mild or transient symptoms, which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress, or, the symptoms were controlled by medication. On VA chloracne examination in April 2013, the examiner opined that the condition did not impact his ability to work. In March 2014, a VA audiological examination was conducted but the examiner did not provide findings regarding the impact of the Veteran's hearing loss and tinnitus on employment. On VA chloracne examination in April 2015, the examiner opined that the condition did not impact his ability to work. On VA psychiatric examination in August 2016, the examiner noted the Veteran reported having a lot of licenses (mechanical, electrical, etc.) and remained employed for one week per month to provide estimates, training, and the use of his name on permits. The examiner opined that the psychiatric disability caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks although generally functioning satisfactorily. He further explained that from a mental health perspective, the Veteran could function in an occupational environment with limitations on tasks requiring social involvement. He would be able to perform satisfactorily with respect to meeting individual customers when discussing work-related issues. However, he would greatly struggle if his work requirements entailed group meetings, public speeches, and unstructured social interaction. On VA hand and wrist examination in August 2016, the examiner found the disabilities impacted employment to the extent that prior to his 2012 retirement, he had to occasionally ask for help when attempting to perform various tasks requiring the use of his right hand. Pain and weakness limited his ability to perform tasks with the right hand. On VA chloracne examination in November 2016, the Veteran reported working one week per month in an office. He reported that at times, he might not go in because of an outbreak of skin lesions, but this was rare and due to the embarrassment of the lesions. The condition did not keep him from working. As such, the examiner opined it was not likely that the chloracne prevented employment. In a June 2017 private vocational report of E.G., she stated that she had reviewed the entire claims file and conducted an assessment of the Veteran. She noted that the Veteran stopped working in 2012. She provided a detailed summary of the medical history pertaining to each service connected disability. She provided a detailed summary of the Veteran's military, occupational, and personal histories. She opined that it was more likely than not that the service-connected disabilities prevented him from securing and following substantially gainful employment since 2012. In doing so, she described the Veteran's difficulties prior to his retirement, and the accommodations he required. She described a worsening of his service-connected disabilities over time. His psychiatric disability causes social isolation and debilitating panic attacks. His hearing loss and tinnitus posed both a safety risk and problems in communication. In order to maintain employment, he would require the opportunity to rest or disengage in any activity that caused strain or aggravation to the right hand, including lifting more than 5-10 pounds, gripping, grasping, pushing, pulling, climbing ladders, or engaging in repetitive use of the hand. She conducted a transferable skills analysis, and found there was no reasonable job matching the Veteran's skills set. There were no occupations within his functional status that did not require substantial and unreasonable accommodations. She found there were no options for gainful employment for the Veteran. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claim. Initially, the record indicates Veteran maintained a substantially gainful occupation for a portion of the appeal period until February 2012, despite his service-connected disabilities. While VA examiners found an impact of the disabilities on physical work, no VA examiner opined that he is unable to secure or follow all types of substantially gainful employment due to service-connected disabilities. VA examiners in October 2011, April 2012, April 2013, April 2015, August 2016, and November 2016 found to the contrary. The April 2012 hand and wrist examiner found that the disabilities caused only a slight decrease in strength and grip. Psychiatric examiners in April 2013 and August 2016 explicitly found his disability did not cause total occupational impairment. The SSA awarded benefits due only to non-service disabilities, and underlying records indicate that his finger disability did not cause limitations. Moreover, as the Veteran has multiple mechanical and electrical licenses, permitting him to perform office work to provide estimates, training, and the use of his name on permits, it does not appear that substantially gainful sedentary employment would be precluded. The Board has considered the June 2017 private medical report and finds it provides a contrasting, and well-reasoned viewpoint. The probative value of the report is diminished to the extent that E.G. did not conduct an actual physical examination of the Veteran, yet found his physical disabilities were more severe than did the VA examiners who performed in-person examinations. Further, in light of the numerous opinions to the contrary, rendered by VA examiners from 2010 to 2016, as well as the SSA, the Board cannot find the evidence is in equipoise; rather, the preponderance of the evidence is against the claim. The only other evidence to the contrary is the lay evidence. While the Veteran is competent to report on the nature and perceived impact of his symptoms to the extent that they are capable of lay observation, he has limited competence to opine on the occupational impact of such symptoms as this is beyond his lay competence. Layno v. Brown, 6 Vet. App. 465 (1994). Accordingly, his assertions carry little probative weight in substantiating his claim. Further, weighing against the Veteran's assertions are the highly competent, and thus probative, findings of the multiple VA medical providers described above. Thus, the Board is without substantially competent evidence that the Veteran's service-connected disabilities cause him to be unable to secure or follow a substantially gainful occupation. The above evidence reflects that the weight of the evidence is against a TDIU as it indicates that the Veteran's service- connected disabilities do not produce unemployability. On this record, the Board finds that no basis exists to award a TDIU. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Earlier Effective Date Generally, the effective date for the grant of service connection based upon an original claim, a claim reopened after final disallowance, or a claim for increase is either the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise it will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b). Additionally, in a claim for increase or to reopen, a report of examination or hospitalization may be accepted as an informal claim for benefits, but the provisions of the applicable regulation do not apply here. 38 C.F.R. § 3.157 (b). A claim is 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). VA amended its regulations on March 24, 2015 to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As this appeal was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015 will be applied. Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris, may be considered an informal claim. Such an informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year after the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155; Norris v. West, 12 Vet. App. 413 (1999). The Veteran seeks an effective date earlier than September 8, 2011, for the grant of service connection for chloracne. The exact date sought, and the reasons for seeking an earlier date, are unclear. The Veteran separated from service in May 1972. A claim for service connection for chloracne was not received within one year of date of discharge. Rather, in June 1972 he submitted a VA Form 21-526 for a nervous condition and a right wrist disorder. Correspondence to and from VA was received in the following months and years, but none makes any mention of chloracne. On September 8, 2011, VA received a VA Form 21-526b for service connection for chloracne. In an August 2012 rating decision, the claim was denied. The Veteran appealed the RO's August 2012 rating decision, and in January 2015 the Board remanded the claim for further development. Thereafter, in a July 2015 rating decision, the RO awarded service connection for chloracne, effective on September 8, 2011. The appellant perfected a timely appeal of the effective date assigned in the July 2015 rating decision. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). Because the current effective date of service connection was based upon the date his September 8, 2011 claim was received, the question before the Board is whether there are any earlier claims upon which an earlier effective date of service connection may be granted. On close review of the record, however, the Board can point to no communication prior to the September 8, 2011 claim that could be interpreted as an informal claim for service connection for chloracne. No mention of chloracne, acne, or any other skin condition was made prior to this date. It was not until his September 8, 2011 VA Form 21-526b that the Veteran stated his intent to file a claim for service connection for chloracne. Thus, the only date that could serve as a basis for the award of service connection is the date of receipt of the Veteran's September 8, 2011 claim for service connection. The exact date on which entitlement arose need not be ascertained in order to conclude that the September 8, 2011, date selected by the RO is the earliest possible effective date here. The reason for this is that, to the extent that entitlement arose prior to September 8, 2011, the date of claim would be the later of the two, and hence the correct effective date as provided by 38 C.F.R. § 3.400(b)(2). Any evidence showing that the entitlement occurred after September 8, 2011 would similarly not entitle the Veteran to an effective date earlier than that already assigned. There is simply no legal entitlement to an earlier effective date for the award of service connection for the Veteran's chloracne. As such, the claim must be denied. ORDER An initial disability rating in excess of 30 percent for chloracne is denied. A disability rating in excess of 50 percent for a right wrist injury with carpal tunnel syndrome is denied. A disability rating in excess of 30 percent for social anxiety disorder with bipolar I disorder and alcohol use disorder is denied. A disability rating in excess of 10 percent for arthritis of the finger joints of the right hand is denied. An initial compensable disability rating for the surgical scar associated with the right wrist disability is denied. A TDIU is denied. An effective date earlier than September 8, 2011 for the award of service connection for chloracne is denied. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs