Citation Nr: 18142104 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 15-13 941 DATE: October 12, 2018 ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to a compensable initial rating for service-connected status-post repair of ventral umbilical hernia is denied. Entitlement to an initial rating in excess of 10 percent for service-connected painful residual scar, status-post repair of ventral umbilical hernia, is denied. Entitlement to a compensable initial rating for service-connected residual scar, status-post repair of ventral umbilical hernia is denied. Entitlement to an initial rating for service-connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) and attention deficit hyperactivity disorder (ADHD) of 70 percent, but no higher, from August 26, 2011 is granted. REMANDED Entitlement to a compensable initial rating for service-connected left ear hearing loss is remanded. FINDINGS OF FACT 1. The Veteran does not have a right shoulder disability that had its clinical onset in service or is otherwise related to active duty. 2. The Veteran does not have a bilateral foot disability, to include tinea pedis, that had its onset during active service, or is otherwise causally related to active service. 3. From the date of service connection, the Veteran’s service-connected status-post ventral umbilical hernia repair has been well-healed with intermittent abdominal pain and has not been manifested by a small postoperative ventral hernia, not well supported by a belt under ordinary conditions, or a healed ventral hernia or postoperative wounds with weakening of the abdominal wall and indication for a supporting belt. 4. The service-connected painful residual scar, status-post ventral umbilical hernia repair, is linear and measures 4 cm., and is tender upon examination. 5. The service-connected residual scar, status-post ventral umbilical hernia repair is superficial and with no resulting limitation of function. 6. From the date of service connection, August 26, 2011, the Veteran’s service-connected PTSD with MDD and ADHD has been manifested by occupational and social impairment, with deficiencies in most areas, but has not more nearly approximated total occupational and social impairment. CONCLUSIONS OF LAW 1. A right shoulder disability was not incurred in or aggravated by the Veteran’s active military service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 2. A bilateral foot disability was not incurred in or aggravated by the Veteran’s active military service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for a compensable disability rating for status-post repair of ventral umbilical hernia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.114, Diagnostic Code (DC) 7339 (2017). 4. The criteria for an initial rating in excess of 10 percent for painful residual scar, status-post ventral umbilical hernia repair, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, DC 7804 (2017). 5. The criteria for an initial compensable rating for residual scar, status-post ventral umbilical hernia repair, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7805 (2017). 6. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial disability rating of 70 percent, but no higher, for PTSD with MDD and ADHD are met from the date of service connection, August 26, 2011. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2007 to August 2011. Service in Southwest Asia is indicated by the record. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In October 2017, the Veteran presented sworn testimony during a personal hearing in Washington D.C., which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s VA claims file In a June 2018 Board decision, the claims were remanded for further evidentiary development. In an August 2018 rating decision, the Agency of Original Jurisdiction (AOJ) granted increased ratings of 30 percent prior to August 6, 2018 and 70 percent thereafter for service-connected PTSD with MDD and ADHD. The Veteran has not expressed satisfaction with the increased disability ratings; this issue thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The VA Appeals Management Center (AMC) issued a supplemental statement of the case (SSOC) in August 2018. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. The June 2018 Board decision also remanded the issue of entitlement to service connection for alopecia. In an August 2018 rating decision, service connection was granted for alopecia and a noncompensable (zero percent) disability rating was assigned. To the Board’s knowledge, the Veteran has not disagreed with that decision; that matter has accordingly been resolved. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of “downstream” issues such as the compensation level assigned for the disability or the effective date of service connection). Service Connection 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; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection on a direct basis, the record must contain competent evidence of (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 in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of observable symptoms that are in his or her personal knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 1. Entitlement to service connection for a right shoulder disability. Here, the Veteran contends that he developed a right shoulder disability during his active duty service. See, e.g., the October 2017 Board hearing transcript. For the reasons set forth below, the Board finds that service connection is not warranted. As indicated above, the Veteran served on active duty from August 2007 to August 2011. Service treatment records (STRs) dated in June 2010 indicated that the Veteran complained of right shoulder and pectoral pain after he had fallen on the stairs two weeks prior. STRs dated in September 2010 noted that the Veteran continued to experience right shoulder pain. A notation of right shoulder arthralgia was documented in December 2010. The Veteran was afforded a VA examination in August 2011 at which time the examiner reported that the Veteran’s right shoulder condition had resolved. At the October 2017 Board hearing, the Veteran presented personal testimony indicating that he continues to suffer from a right shoulder disability, for which he receives VA treatment. See, e.g., the October 2017 Board hearing transcript. Pursuant to the June 2018 Board decision, the Veteran was afforded a VA examination in August 2018 at which time the examiner indicated that the Veteran had a history of right rotator cuff strain in 2010. The examiner noted that the Veteran continues to experience intermittent right shoulder pain and weakness with overuse. Physical examination, including range of motion testing, was normal. The examiner determined, “[t]he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner explained, “[w]hile Veteran did sustain an injury to his right shoulder during service there is no documentation of record that there has been continued case and treatment of initial right shoulder injury.” The examiner continued, “[t]oday, Veteran reports pain on right shoulder when overuse of the joint accompanied by stiffness. No pain is noted on the shoulder today.” The examiner concluded, “[t]here is no evidence of chronic condition of the right shoulder. Today the right shoulder is normal. Symptoms are subjective only. A nexus has not been established.” When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The United States Court of Appeals for Veterans Claims (Court) has held that claims file review, as it pertains to obtaining an overview of a claimant’s medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the findings of the August 2018 VA examiner, in particular, were thoroughly explained and fully supported by the evidence of record. To this end, the Board notes that the VA examiner’s nexus opinion was based on a complete review of the record, including the lay statements and medical evidence submitted by the Veteran, and the reviewer explained the reasons for his conclusion based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the August 2018 VA examiner. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed disability and the Veteran’s active duty service outweighs any medical evidence suggestive of nexus. The Board has carefully considered the contentions of the Veteran that he suffers from a continuing right shoulder disability, which was incurred during his military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana, 24 Vet. App. at 433, n. 4. In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theory regarding the diagnosis and etiology of his disability are contradicted by the conclusion of the August 2018 VA examiner who specifically considered the Veteran’s lay statements in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted provided the August 2018 medical opinion to be of greater probative weight than the more general lay assertions of the Veteran. Considering the overall evidence, including the post-service medical evidence, the uncontradicted VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran’s claim that he suffers from right shoulder disability, which is related to his military service. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 2. Entitlement to service connection for a bilateral foot disability. Here, the Veteran contends that he developed a bilateral foot disability, which was incurred during his military service. For the reasons set forth below, the Board concludes that service connection is not warranted. The Veteran’s STRs, including his July 2011 pre-discharge examination, are pertinently absent any documentation of a bilateral foot disability or related complaints. Pursuant to the June 2018 Board Remand, the Veteran was afforded a VA examination in August 2018 at which time the examiner confirmed a diagnosis of bilateral tinea pedis. With respect to the diagnosed disability, the examiner concluded that “[t]he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner explained, “STR[s] reviewed found no diagnosis of bilateral feet condition during service. No complain[t] or diagnosis of skin condition of the feet. No documentation of continuous and chronic care of skin condition of the feet.” The examiner continued, “[a]lthough today Veteran is found to have condition of the fungal inspection of the feet. Unable to confirm that current condition of the feet was caused by any event in service without resorting to mere speculation. A nexus has not been established.” In this matter, the medical evidence of record shows that the currently diagnosed tinea pedis of the bilateral feet is less likely than not due to the Veteran’s military service. The Board finds the August 2018 VA examiner’s opinion particularly probative as to the question of etiology, as the opinion was based upon a thorough review of the record and thoughtful analysis of the Veteran’s entire history. See Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Significantly, after reviewing the Veteran’s medical history, the August 2018 VA examiner concluded that the Veteran’s diagnosed bilateral tinea pedis is not etiologically related to his military service. The Board has carefully considered the contentions of the Veteran that the currently diagnosed bilateral foot disability was incurred during his military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v, 581 F.3d at 1316; Kahana, 24 Vet. App. at 433, n. 4. In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-9; Falzone, 8 Vet. App. at 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons, 23 Vet. App. at 6 (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio, 606 F.3d at 1382 (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theory regarding the etiology of his bilateral foot disability is contradicted by the conclusion of the August 2018 VA examiner who considered the Veteran’s lay statements and in-service symptoms in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the August 2018 VA medical opinion to be of greater probative weight than the more general lay assertions of the Veteran. The Board is charged with weighing the positive and negative evidence; resolving reasonable doubt in the Veteran’s favor when the evidence is in equipoise. Considering the record, including the post-service medical evidence, the August 2018 VA examiner’s opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater evidentiary weight. In conclusion, the preponderance of the evidence is against the claim. Thus, the benefit-of-the-doubt rule does not avail the Veteran. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (2012) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. 3. Entitlement to a compensable initial rating for service-connected status-post repair of ventral umbilical hernia. The Veteran was service-connected for status-post repair of ventral umbilical hernia in a June 2012 rating decision. He disagreed with the assigned rating and this appeal followed. For the reasons set forth below, the Board finds that a compensable initial rating for service-connected status-post repair of ventral umbilical hernia is not warranted. The Veteran’s status-post repair of ventral umbilical hernia is assigned a noncompensable rating pursuant to 38 C.F.R. § 4.114, Diagnostic Code (DC) 7339. Under DC 7339 (ventral hernia, post-operative), a noncompensable rated is assigned for healed postoperative wounds with no disability and when the use of a belt is not indicated. A 20 percent rating is assigned when the hernia is small and not well supported by a belt under ordinary conditions or when there is a healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. The Veteran’s STRs demonstrate that he underwent surgical repair of a ventral hernia in June 2010. The Veteran was afforded a VA examination in August 2011 at which time the examiner noted the Veteran’s report that his course since surgery “has been okay. He has experienced some pain and sensitivity at the scar site.” He denied problems with eating or bowel movements. He does not have current treatment for status-post repair of ventral umbilical hernia. Physical examination revealed tenderness at the ventral umbilical scar site. His bowel sounds were positive. There was no weakness at the hernia site. The Veteran denied any other impairment of activities of daily living due to his surgically repaired ventral umbilical hernia. Pursuant to the June 2018 Board Remand, the Veteran was afforded a VA examination in August 2018 at which time he reported discomfort in his abdomen any time he does strenuous activities. A computerized tomography (CT) scan of the abdomen/pelvis, performed in August 2017, was normal. The Veteran reported that he works as a delivery associate and, when carrying heavy furniture, he has at times experienced pain in his abdomen. The Veteran stated that he is on light duty at work as a result of this abdominal pain. The examiner stated that the level of the Veteran’s impairment was mild; specifically, “sharp pain at the site of the abdomen at the umbilical area with strenuous activities.” The examiner explained that the Veteran is able to perform medium work in a normal eight hour work day: “[e]xerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects.” The evidence of record shows that, while the Veteran may experience intermittent abdominal pain, there is nothing in the record to indicate that his status-post ventral hernia repair requires a supporting belt. Under Diagnostic Code 7339, a 20 percent rating is also warranted with weakening of abdominal wall and an indication for a supporting belt. Significantly, the Veteran’s VA examiners and treatment providers have not suggested that a support belt is indicated. Moreover, the Veteran no longer has a hernia of any size, as detailed by the above VA examiners and reported by the Veteran. Thus, a compensable rating is not warranted. The medical evidence of record also indicates that the Veteran does not have massive, persistent, severe diastasis of recti muscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. As noted above, at most VA examiners have noted some residual tenderness. No impairment of muscle strength has been indicated by VA examiners or treatment providers. In light of the foregoing, the Board finds that the Veteran’s symptomatology continues to reflect the currently assigned criteria for a noncompensable evaluation. As noted above, the Veteran’s residual scar has been rated separately. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57; 38 C.F.R. § 4.3. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. 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). 4. Entitlement to an initial rating in excess of 10 percent for service-connected painful residual scar, status-post repair of ventral umbilical hernia. 5. Entitlement to a compensable initial rating for service-connected residual scar, status-post repair of ventral umbilical hernia. In the June 2012 rating decision, the Veteran was awarded service connection for residual scar, status-post repair of ventral umbilical hernia; he was assigned a 10 percent rating under DC 7804 (scar, unstable or painful) and a separate noncompensable rating under DC 7805 (scars, other and other effects of scars). He disagreed with the assigned ratings and this appeal follows. For the reasons set forth below, the Board finds that higher initial ratings are not warranted for the service-connected residual scar, status-post repair of ventral umbilical hernia. The rating criteria for scars are provided generally under 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, and 7804. The Board notes that the criteria under Diagnostic Code 7800 contemplate scars that are specifically of the head, face, or neck. Hence, Diagnostic Code 7800 is not for application in this case. Diagnostic Code 7801 concerns scars not of the head, face, or neck, but which are deep and nonlinear. A 10 percent evaluation is assigned for such scars encompassing an area or areas of at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.). A 20 percent evaluation is assigned for such scars encompassing an area or areas of at least 12 square inches (77 sq. cm.), but less than 72 square inches (465 sq. cm.). A 30 percent evaluation is assigned for such scars encompassing an area or areas of at least 72 square inches (465 sq. cm.), but less than 144 square inches (929 sq. cm.). A 40 percent evaluation is assigned for such scars encompassing an area or areas of 144 square inches (929 sq. cm.) or greater. Notes accompanying Diagnostic Code 7801 define deep scars as those associated with underlying tissue damage. Diagnostic Code 7802 contemplates scars that are superficial and nonlinear, and which do not involve the head, face, or neck. Under that rating code, a maximum schedular 10 percent disability rating may be assigned for scars encompassing an area of 144 square inches (929 square centimeters) or greater. Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent evaluation; three or four scars that are unstable or painful warrant a 20 percent evaluation; five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. Under Diagnostic Code 7805, any disabling effects that are not considered in the aforementioned scar rating criteria may also be rated under a diagnostic code that is appropriate for the disabling effect. In conjunction with his service connection claim, the Veteran was afforded a VA examination in August 2011 at which time the examiner noted that the Veteran has a surgical scar resulting from a ventral hernia repair in June 2010. The Veteran reported some irritation of the scar with occasional sharp pain. Upon physical examination, there was no skin breakdown, disfigurement, or limitation of motion. The examiner reported that the scar was u-shaped and located just below the umbilicus. The scar was linear and approximately two inches in length and less than ½ inch wide. The scar was painful to palpation. The scar was superficial, not deep. There was no underlying soft tissue damage or involvement. The examiner stated there was no inflammation, edema, or keloid formation. Pursuant to the June 2018 Board Remand, the Veteran was afforded a VA examination in August 2018. The examiner reported that the Veteran had one scar below the umbilical area, status-post umbilical hernia repair. The scar is stable, and not painful. The examiner stated that the scar is linear and measures 4 cm. The examiner indicated that there was no limitation of motion or other function due to the residual scar of the status-post ventral umbilical hernia repair. The examiner explained, “Veteran reports the scar site is sensitive on palpation. Scar is well-healed and stable. Symptoms are subjective only.” The examiner continued, “[p]alpation of abdomen does not elicit pain today. Scar is superficial, linear, well-healed, and stable.” The examiner stated that the Veteran’s scar has no impact on his ability to work. Upon careful review of the record, the Board finds that the preponderance of the evidence is against awarding higher ratings for the Veteran’s residual scar, status-post ventral umbilical hernia repair. First, the evidence of record shows that the Veteran has a scar under the umbilical area measuring approximately 4 cm. in length, which is less than 144 square inches. The scar is linear, well-healed, superficial, with no underlying tissue damage or skin breakdown. Critically, the scar does not cover an area exceeding 12 square inches, as such a 10 percent rating is not warranted under DC 7801. Moreover, the evidence of record does not support a finding that the Veteran has three to four scars that are unstable or painful, which would warrant a higher rating under DC 7804. In considering DC 7805, the evidence does not show any significant functional impairment associated with the Veteran’s hernia scar. The VA examiners have specifically found that although he experiences some intermittent pain and tenderness associated with his hernia scar, there is no functional impairment or limitation of motion. Accordingly, the Board finds that higher initial ratings for service-connected residual scar, status-post ventral umbilical hernia repair are not warranted. See 38 C.F.R. § 4.118. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. 6. Entitlement to an initial rating in excess of 30 percent prior to August 6, 2018 and 70 percent thereafter for service-connected PTSD with MDD and ADHD. The Veteran’s PTSD with MDD and ADHD is evaluated under 38 C.F.R. § 4.130, DC 9411. Under this diagnostic code, a 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is for assignment when there is 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 establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 55 to 80 as determined by VA and private treatment providers, as well as VA and private examiners. These scores are indicative of mild to moderate impairment. GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). GAF scores ranging between 61 to 70 reflect 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. A GAF score ranging from 51 to 60 reflect more moderate symptoms, e.g., flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, e.g., few friends, conflicts with peers or co-workers. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a 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 this matter, the Veteran was granted service connection for PTSD with MDD and ADHD in a June 2012 rating decision, and a 10 percent initial rating was assigned from August 26, 2011. As indicated above, in an August 2018 rating decision, the RO granted a higher rating of 30 percent for the service-connected PTSD with MDD and ADHD from the date of service connection; a 70 percent rating was granted from August 6, 2018 (the date of the most recent VA examination). For the reasons set forth below, the Board finds that a 70 percent evaluation, but no higher, is warranted under the schedular criteria from the date of service connection. The Veteran was afforded a VA psychological examination in August 2011 at which time he reported moderate issues with sleep disturbance and nightmares. He reported that he is close to his family including siblings. He also maintains friendships with high school and childhood friends. He reported that, in his leisure time, he likes to watch television and exercise. The examiner noted that the Veteran’s speech was unremarkable. His affect was flat, and his mood was anxious and dysphoric. He is well-oriented. His thought processes and content were unremarkable. He denied suicidal and homicidal ideation. His insight and judgment were intact; he denied hallucinations and delusions. The Veteran gets four to five hours of sleep per night due to falling asleep and nightmares. He is able to maintain personal hygiene. The Veteran reported fair impulse control; he reports that he would get into fights with fellow Marines while in service. He stated that he does not have any problems with activities of daily living. He denied memory impairment. The Veteran did endorse avoidance, irritability, difficulty concentrating, and hypervigilance. He was recently released from active duty service, and enrolled in online college courses in the Fall of 2011. The examiner confirmed a diagnosis of PTSD and assigned a GAF of 70. The examiner opined that the Veteran’s PTSD manifests as “signs and symptoms that are transient of mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.” VA treatment records dated in October 2011 noted that the Veteran was recently diagnosed with PTSD. The Veteran reported that his symptoms are mainly impaired sleep, irritability, and depression. He stated that he has difficulty concentrating and is fatigued because he does not sleep at night. He reported irritability with his parents. A GAF score of 80 was assigned. VA treatment records dated in February 2012 documented the Veteran’s continuing report of impaired concentration. His mood was euthymic and his affect was congruent. A GAF of 80 was again assigned. VA treatment records dated in January 2013 noted continuing symptoms of low motivation, low mood, low interest, low energy, poor concentration, and poor sleep with delayed sleep onset. The Veteran also described avoidance of thoughts of combat, hypervigilance, irritability, and exaggerated startle response. The treatment provider diagnosed the Veteran with attention deficit disorder (ADD) manifested by difficulty concentrating and procrastinating. A GAF of 55 was assigned. In October 2013, the Veteran told his VA treatment provider that his mood has been good most days. However, he reported experiencing three “bad days” per month, where he feels down and cannot get out of bed. A GAF of 60 was assigned. In December 2015, the Veteran reported attentional issues especially at work. He stated that he was bored with his former job. He stated that he felt depressed one morning, so he stayed in bed and did not call in sick; he never returned to that job. The VA treatment provider diagnosed the Veteran with a major depressive episode. See the VA treatment record dated December 2015. VA treatment records dated in January 2016 noted that the Veteran experiences social anxiety and difficulty interviewing. He is currently unemployed and is waiting to hear about a job. He denied suicidal and homicidal ideation. VA treatment records dated in August 2017 indicated that the Veteran works delivering furniture and his job has been very understanding of his PTSD symptoms. In July 2018, the Veteran told his VA treatment provider that “things have been ‘good’ overall. Still has some down days, but he has better control over things now.” The Veteran also reported that he started a commercial cleaning company. The VA treatment provider noted that the Veteran’s energy and focus are good, and his insight and judgment are fair. In a support of his claim, the Veteran submitted a September 2017 statement from his father, Mr. M.P., who described the Veteran’s irritability, as well as difficulty concentrating and sleeping. Mr. M.P. stated that the Veteran has difficulty maintaining a job and seems to experience bouts of depression. Mr. M.P. stated that the Veteran experiences flashbacks. In addition, Mr. M.P. stated that when the Veteran was terminated from a position as a police officer at the Navy Yard, “he went into a deep state of depression and left home without letting us know of his whereabouts for almost three and a half months.” The Veteran also submitted a September 2017 statement from his sister, Ms. L.D., who reported that some of the Veteran’s post-service work environments “triggered his disorder and caused him to shut down mentally. After he left the job, he isolated himself and we (the family) did not know where he was for about a month.” Ms. L.D. stated that the Veteran “continues to have nightmares, locks his door at night and has become more aggressive in tense situations.” At the October 2017 Board hearing, the Veteran testified that he experiences psychological symptoms including depression occurring at least five days per week, impaired sleep, mild memory loss, and irritability. He stated that he is short-tempered and gets into frequent arguments with his father. See the October 2017 Board hearing transcript. He additionally described three jobs, which he held in various intervals from 2012 through 2015; he stated that he was terminated from each of these three jobs for failing to show up during depressive episodes. Id. He is currently employed as a delivery man with a furniture company. Id. Pursuant to the July 2018 Board Remand, the Veteran was afforded a VA psychological examination in August 2018 at which time the examiner indicated that the Veteran’s diagnosed PTSD with MDD and ADHD causes occupational and social impairment with reduced reliability and productivity. The Veteran reported that his symptoms have worsened since his previous VA examination. The Veteran is not married and reported that he has been in three relationships since the 2011 evaluation. However, he stated that his “short temper, mood and sleep disturbance contributed to the unsuccessful relationships.” He reported a good relationship with his parents, and strained relationships with his two sisters. He stated that his temper causes strain with his relationships, although he indicated that he has many friends. He stated that he enjoys motor sports, going to the gym, and doing outdoor activities. He has been employed as a delivery associate for two and a half years. He stated that he has received one ‘write-up’ and one ‘counseling’ due to absences and tardiness. He denied negative performance evaluations or negative relationships with co-workers. He manages his psychological symptoms with medication. He endorsed persistent symptoms of avoidance, negative emotional state, markedly diminished interest or participation in significant activities, and feelings of detachment or estrangement from others. He additionally reported irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, suspiciousness, and near-continuous panic or depression affecting ability to function independently, appropriately, and effectively. He further described chronic sleep impairment, mild memory loss, disturbance of motivation and mood, difficulty in adapting to stressful circumstances including work or a work-like setting, and impaired impulse control with periods of violence. The examiner opined that the Veteran has endorsed symptoms including irritability, anxiety, and suspiciousness, which cause functional limitations and interfere with his ability to work. The Board has thoroughly reviewed the record and has given full consideration to 38 C.F.R. § 4.7 (where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned) and 38 C.F.R. § 3.102 (when there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the veteran). In determining whether the Veteran meets the schedular criteria for an increased disability rating, the Board’s inquiry is not necessarily limited to the criteria found in the VA rating schedule. See Mauerhan, supra. Notably, while the Veteran’s GAF scores have generally reflected levels of mild to moderate impairment, neither GAF scores nor an examiner’s characterization of the degree of the disability are dispositive of the legal questions involved in determining the appropriate rating for PTSD with MDD and ADHD. Based on the above, the Board finds that the impact of the Veteran’s PTSD with MDD and ADHD symptoms on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 70 percent rating from the date of service connection. The symptomatology associated with the Veteran’s service connected PTSD with MDD and ADHD, to include that indicated by the lay statements and treatment records, supports the assignment of a 70 percent rating because this disability has been shown to result in occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, due to such symptoms as near-continuous depression; impaired impulse control, with periods of unprovoked irritability with outbursts of anger; and difficulty in adapting to stressful circumstances. 38 C.F.R. § 4.130, DC 9411. Specifically, these symptoms have been endorsed by the Veteran, his father, and his sister, as corroborated by VA examiners and treatment providers. The Veteran has described an, at times, difficult relationship with his parents and sisters. See, e.g., the VA treatment records dated October 2011 and January 2013, and the VA examination report dated August 2018. The evidence also shows that the Veteran’s experiences frequent episodes of depression, causing him to be unable to get out of bed at least three days per month. See, e.g., the VA treatment records dated October 2013. Moreover, the Veteran’s VA treatment records, as well as the statements of his father and sister show that he has experienced major depressive episodes which have significantly disrupted his social and occupational functioning. See, e.g., the VA treatment records dated December 2015 and the lay statements dated September 2017. However, the symptoms have not more nearly approximated total occupational and social impairment at any point from the date of service connection. 38 C.F.R. § 4.7 (2016). Symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time and place; memory loss for names of close relatives, own occupation or name, have not been shown. The evidence documents the Veteran’s recurrent problems in work settings, including irritability, anxiety, and suspiciousness. However, he is able to obtain and maintain employment; as the record shows, he has been employed with the same company for nearly three years. Moreover, the Veteran is able to maintain friendships and familial relationships. Critically, therefore, the evidence does not show total occupational and social impairment due to PTSD with MDD and ADHD. Thus, neither the symptoms nor overall level of impairment meet the criteria for a 100 percent rating under the Rating Schedule, and a rating in excess of the 70 percent assigned herein is therefore not warranted for the Veteran’s PTSD with MDD and ADHD. While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected PTSD with MDD and ADHD, the evidence shows no distinct periods of time during the appeal period, when his disability varied to such an extent that a rating greater or less than the assigned ratings would be warranted. Hart, supra. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. REASONS FOR REMAND 1. Entitlement to a compensable initial rating for service-connected left ear hearing loss is remanded. The issue of entitlement to a compensable initial rating for left ear hearing loss was remanded in the June 2018 Board decision to obtain outstanding VA treatment records and to afford the Veteran with a new VA examination. The Board has reviewed the VA treatment records, which were associated with the clams file pursuant to the June 2018 remand instructions. Notably, an April 2016 VA audiology progress note referenced an April 2016 audiogram, which has not been associated with the record. Accordingly, as this medical evidence is potentially pertinent to the initial rating claim, the Board finds that this matter must be remanded in order to obtain the outstanding April 2016 audiogram.   The matter is REMANDED for the following action: Obtain all outstanding records of VA evaluation and/or treatment of the Veteran; in particular, the April 2016 referenced above. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. K. CONNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. K. Buckley, Counsel