Citation Nr: 18156021 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-38 376 DATE: December 6, 2018 ORDER Entitlement to an effective date prior to April 23, 2015 for the award of a 10 percent rating for tinnitus is denied. Entitlement to an increased initial 30 percent rating for a rectum sphincter control disability, prior to August 31, 2018, is granted. Entitlement to an increased initial rating in excess of 30 percent for a rectum sphincter control disability, for the entire period on appeal, is denied. Entitlement to an increased initial 10 percent rating for gastroesophageal reflux (GERD), prior to June 9, 2015, is granted. Entitlement to an increased initial rating in excess of 10 percent for gastroesophageal reflux (GERD), for the entire period on appeal, is denied. Entitlement to an initial compensable rating for hemorrhoids is denied. Entitlement to an increased initial 50 percent rating for posttraumatic stress disorder (PTSD) previously rated as generalized anxiety disorder (GAD), prior to July 11, 2018, is granted. Entitlement to an increased initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) previously rated as generalized anxiety disorder (GAD), prior to July 11, 2018, is denied. Entitlement to an increased initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) previously rated as generalized anxiety disorder (GAD), from July 11, 2018 forward, is denied. Entitlement to an increased initial 10 percent rating for residuals of right lower areola scar, prior to June 9, 2015, is granted. Entitlement to an increased initial rating in excess of 10 percent for residuals of right lower areola scar for the entire period on appeal is denied. Entitlement to an increased initial 10 percent rating for residuals of left lower areola scar is granted. Entitlement to an initial rating in excess of 10 percent for residuals of a left lower areola scar is denied. Entitlement to service connection for a right wrist disability is granted. Entitlement to service connection for a left wrist disability is denied. Entitlement to service connection for headaches is granted. REMANDED Entitlement to an initial compensable rating for lumbar spine muscle spasms is remanded. Entitlement to service connection for fatigue is remanded. Entitlement to an increased initial rating in excess of 10 percent for angina is remanded. Entitlement to an earlier effective date for the grant of service connection for angina is remanded. Entitlement to a total disability rating based upon individual unemployability due to service connected disabilities (TDIU), prior to July 11, 2018, is remanded. FINDINGS OF FACT 1. On April 29, 2015, the RO received a formal claim of entitlement to service connection for tinnitus. 2. Prior to April 23, 2015, there was no formal or informal claim pending for service connection for tinnitus, and the claim was received greater than 1 year after discharge from active duty on October 31, 2013. 3. During the entire period on appeal, the Veteran’s rectum sphincter control disability has been manifested by ongoing leakage and involuntary bowel movements necessitating wearing a pad. 4. During the entire period on appeal, the Veteran’s GERD has been manifested by pain, heartburn, nausea, vomiting and cramping and was not productive of considerable impairment of health. 5. The Veteran’s hemorrhoids have been manifested by pain and occasional rectal bleeding and have been mild or moderate. 6. Prior to July 11, 2018, the Veteran’s PTSD previously rated as GAD was manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impaired concentration and impulse control, nightmares, significant hypervigilance, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances, but not by occupational and social impairment with deficiencies in most areas. 7. From July 11, 2018 forward, the Veteran’s PTSD previously rated as GAD was manifested by occupational and social impairment with deficiencies in most areas due to symptoms such as depressed mood, intrusive thoughts, anxiety isolating behaviors, chronic sleep impairment, memory and concentration difficulty, panic attacks, difficulty getting along with others, suspiciousness, loss of interest in activities, passive and fleeting suicidal ideations, difficulty in establishing and maintaining relationships and adapting to stressful circumstances and intermittent inability to perform activities of daily living, but not by total occupational and social impairment. 8. During the entire period on appeal, the Veteran’s residuals of one right lower areola scar was shown to be painful but not unstable, and no characteristics of disfigurement. 9. During the entire period on appeal the Veteran’s residuals of one left lower areola scar was shown to be painful but not unstable, and no characteristics of disfigurement. 10. The Veteran’s right wrist disability began during active service. 11. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a left wrist disability. 12. Resolving reasonable doubt in the Veteran’s favor his headaches began during active service. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to April 23, 2015 for the grant of entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 2. Prior to August 31, 2018, the Veteran’s rectum sphincter control disability was 30 percent disabling. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7332. 3. The criteria for an initial evaluation in excess of 30 percent for a rectum sphincter control disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7332. 4. Prior to June 9, 2015, the Veteran’s GERD was 10 percent disabling. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7399-7346. 5. The criteria for an initial evaluation in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7399-7346. 6. The criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7336. 7. Prior to July 11, 2018, the Veteran’s PTSD previously rated as GAD was 50 percent disabling. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411. 8. From July 11, 2018 forward, the criteria for an initial evaluation in excess of 70 percent for the Veteran’s PTSD previously rated as GAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411. 9. Prior to June 9, 2015 the Veteran’s residuals of a right lower areola scar was 10 percent disabling. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7800-7804. 10. During the entire period on appeal, the criteria for an initial evaluation in excess of 10 percent for right lower areola scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7800-7804. 11. During the entire period on appeal the Veteran’s residuals of left lower areola scar was 10 percent disabling. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7800-7804. 12. The criteria for service connection for a right wrist disability are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 13. The criteria for service connection for a left wrist disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 14. The criteria for service connection for headaches are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army as a military policeman from February 2005 to October 2013 with service in Southwest Asia. Earlier effective date Generally, the effective date of an award shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. The effective date of an award of compensation for service connection will be the “[d]ay following separation from active service or date entitlement arose if claim is received within 1 year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later.” 38 C.F.R. § 3.400 (b)(2); see also 38 U.S.C. § 5110 (a); Sears v. Principi, 16 Vet. App. 244 (2002). The Board notes that effective on March 24, 2015, VA amended its rules as to what constitutes a claim for benefits; such now requires that claims be made on a specific claim form prescribed by the Secretary, which is available online or at the local Regional Office. These amendments, however, are only applicable with respect to claims filed on or after March 24, 2015, and thus are applicable in the present case. Prior to March 24, 2015, VA recognized formal and informal claims. A claim is defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1 (p). An informal claim is any communication or action indicating intent to apply for one or more benefits, and must identify the benefit sought. 38 C.F.R. § 3.155 (a). VA must look to all communications from a claimant that may be interpreted as applications or claims both formal and informal for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). Although a claimant need not identify the benefit sought “with specificity,” see Servello v. Derwinski, 3 Vet. App. 196, 199-200 (1992), some intent on the part of the Veteran to seek benefits must be demonstrated. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-7 (1995) (noting that while VA must interpret a claimant’s submissions broadly, VA is not required to conjure up issues not raised by claimant). The United States Court of Appeals for the Federal Circuit has emphasized VA has a duty to fully and sympathetically develop a Veteran's claim to its optimum. Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to “determine all potential claims raised by the evidence, applying all relevant laws and regulations,” Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001), and extends to giving a sympathetic reading to all pro se pleadings of record. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). The Veteran contends he is entitled to an effective date prior to April 23, 2015 for the grant of service connection for tinnitus. Specifically, the Veteran contends that an earlier effective date for the award of service connection of tinnitus is warranted. The Veteran was discharged from service on October 31, 2013. He submitted a formal claim for service connection for tinnitus which was received by VA on April 29, 2015. The Veteran’s Application for Disability Compensation and Related Compensation Benefits, VA Form 21-526EZ was signed and electronically submitted on April 29, 2015. An August 2015 rating decision granted service connection for tinnitus. This appeal followed. Effective dates for service connection are based on the date of receipt of the claim; the date of receipt of the Veteran’s claim was April 29, 2015. The Veteran has not provided additional evidence to show that VA received his application within one year of discharge from service, as to his claim for service connection for tinnitus. Effective dates for service connection based on an original claim generally are not based on the date the condition began and cannot be any earlier than date of receipt of claim. See, e.g., Lalonde v. West, 12 Vet. App. 377, 382 (1999) (holding that “the effective date of an award of service connection is not based on the date of the earliest medical evidence demonstrating a causal connection, but on the date that the application upon which service connection was eventually awarded was filed with VA”). The Board finds that there is no interpretation of the facts of this case which will support a legal basis for favorable action with regard to the Veteran’s claim. There was no communication or submission of evidence from the Veteran evidencing intent to apply for benefits from the time of separation from service in October 2013 until receipt of the Veteran’s formal claim in April 2015. Accordingly, the Board finds no basis in the law or facts in this case for an effective date for his service connected tinnitus, earlier than April 23, 2015. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. For these reasons, the claim is denied. The benefit of the doubt doctrine was considered; however, as the preponderance of the evidence is against this claim this doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, staged ratings will be considered and discussed, if warranted. Increased initial rating for rectum sphincter disability The Veteran contends that he is entitled to an increased rating for his rectum sphincter disability. Prior to August 31, 2018 the Veteran’s rectum sphincter disability was rated at 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7332. Then, from August 31, 2018 forward, the Veteran’s rectum sphincter disability is rated at 30 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7332. Herein, the Board finds that a 30 percent rating is warranted for the entire period on appeal under Diagnostic Code 7332. The Board finds that based on the evidence of record, the preponderance of the evidence is against finding that a rating in excess of 30 percent for the Veteran’s rectum sphincter disability, for the entire period on appeal is warranted. Under Diagnostic Code 7332, for the rectum and anus, impairment of sphincter control, a noncompensable evaluation is warranted for healed or slight impairment of sphincter control, without leakage. A 10 percent evaluation is warranted for constant, slight, or occasional moderate leakage. A 30 percent evaluation is warranted for occasional involuntary bowel movements, necessitating wearing of a pad. A 60 percent evaluation is warranted for extensive leakage and fairly frequent involuntary bowel movements. A 100 percent evaluation is warranted for complete loss of sphincter control. 38 C.F.R. § 4.114, Diagnostic Code 7332. As an initial matter, the Board notes that the Veteran is also service connected for hemorrhoids and gastroesophageal reflux and entitlement to an increased rating for these service connected disabilities is on appeal and will be discussed in greater detail below. The Veteran contends that his rectum sphincter disability is characterized by ongoing leakage necessitating wearing a pad. The Veteran reports this is extremely embarrassing when he experiences leakage which occurs twice a week and accidents while at school, occur several times a month and warrant him changing clothes. Based on the evidence of record, the Board finds that the preponderance of the evidence is against finding that an increased rating in excess of 30 percent is warranted for the entire period on appeal. The Veteran was afforded a VA examination in August 2014. The examiner noted an in-service repair of a perirectal abcess and fistula with impairment of rectal sphincter control. The Veteran exhibited an anal/perianal fistula and impairment of rectal sphincter control. The examiner noted ongoing mild or moderate hemorrhoids and impairment of rectal sphincter control with leakage and losing stool approximately twice a week. The Veteran reported an increase in symptoms when he is nervous, and at times this leakage results in him needing to change his undergarments. Examination noted a slight decrease in rectal tone, with no scars. The examiner noted the Veteran’s rectal sphincter control impacts his ability to work and the examiner attributed such to service. Then, the Veteran was afforded a VA examination in October 2018. The examiner noted impairment of rectal sphincter control with anal/perianal fistula. The Veteran reported ongoing pain and increased urgency when needing to use the restroom. Symptoms included a slight impairment of sphincter control with difficulty holding a bowel movement, leakage necessitating wearing a pad and occasional moderate leakage. Examination noted no current hemorrhoids. The examiner noted the Veteran’s rectum sphincter control impacts his ability to work in that he experiences slight incontinence at least twice a week which requires the wearing of a pad. Further, mild reductions in strenuous activity are recommended due to bowel leakage, and sedentary tasks are impaired by the Veteran needing to change pads due to bowel leakage. VA treatment records have been associated with the claims file and note ongoing reports of pain, leakage and rectal bleeding and diarrhea at times. A September 2015 colon and rectal surgery consult noted ongoing loss of liquid stool with straining, accidents and increased symptoms while working out or experiencing gastrointestinal symptoms. The Veteran reported wearing a pad during instances of increased symptomology. Based on the lay and medical evidence of record the Board finds that the Veteran’s rectum sphincter disability does not more nearly approximate the level of severity contemplated by an increased 60 percent rating. The Board notes the Veteran’s contentions regarding his ongoing incontinence, leaking and needing to wear a pad at times. However, such lay evidence, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports that prior to August 31, 2018, the Veteran’s rectum sphincter disability was characterized by occasional incontinence, leaking and needing to wear a pad, warranting a 30 percent rating under Diagnostic Code 7332 for the entire period on appeal. A 60 percent rating is warranted under Diagnostic Code 7332 with extensive leakage and fairly frequent involuntary bowel movements. The VA examination in October 2018 noted symptoms including slight impairment of sphincter control with difficulty holding a bowel movement, leakage necessitating wearing a pad and occasional moderate leakage. The examiner noted the Veteran’s rectum sphincter control impacts his ability to work in that he experiences slight incontinence at least twice a week which requires the wearing of a pad. Further, mild reductions in strenuous activity were recommended due to bowel leakage, and sedentary tasks are impaired by the Veteran needing to change pads due to bowel leakage. VA treatment records note occasional accidents and incidents of leaking warranting wearing a pad, occurring on occasion typically several times a month. There was no indication of extensive leakage and fairly frequent involuntary bowel movements at any point during the appeal. As such the Boards finds that the Veteran is not entitled to an increased rating in excess of 30 percent for his rectum sphincter control. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 30 percent for the Veteran’s service connected rectum sphincter disability is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, an increased 30 percent rating, but no higher is granted. Initial increased rating for GERD The Veteran contends he is entitled to an increased rating for his service connected gastroesophageal reflux disease (GERD). Prior to June 9, 2015, the Veteran’s service connected GERD has been rated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. From June 9, 2015 forward, the Veteran’s GERD has been rated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. Herein, the Board finds that a 10 percent rating is warranted for the entire period on appeal under Diagnostic Code 7399-7346. The Board finds that based on the evidence of record, the preponderance of the evidence is against finding that an initial rating in excess of 10 percent for the Veteran’s GERD for the entire period on appeal is warranted. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. GERD is not specifically listed in the rating schedule, but is evaluated as analogous to hiatal hernia. 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous). Hiatal hernia is evaluated as follows: A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health; a 30 percent rating requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; a 10 percent rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity (10 percent). 38 C.F.R. § 4.114, Diagnostic Code 7346. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114. The Board notes that the Veteran is currently service connected for a rectum sphincter disability and hemorrhoids and entitlement to increased rating claims for these service connected disabilities are also on appeal and will be discussed in greater detail within this decision. Based on the evidence of record, the Board finds that the preponderance of the evidence is against finding that an increased 30 rating is warranted for the entire period on appeal. The evidence of record shows that the Veteran has had two or more symptoms including pain, heartburn, nausea and vomiting, cramping, but not symptoms of persistently recurrent epigastric distress productive of considerable impairment of health. The Veteran has reported ongoing restrictions on his diet and regular medication was required. The Veteran was afforded a VA examination in August 2014. The examiner noted GERD with pyrosis and reflux. The examiner noted the Veteran’s GERD does not impact his ability to work. In addition, the Veteran was afforded a VA examination in June 2015. The examiner noted GERD with infrequent episodes of epigastric distress, pyrosis (heartburn), reflux, and episodes of nausea and vomiting. The Veteran takes continuous Prilosec for control. The examiner noted the Veteran’s GERD does not impact his ability to work. VA treatment records have been associated with the claims file. Treatment records note ongoing occasional reports of epigastric pain and cramping, nausea, heartburn, diarrhea, gas, bloating and occasional blood in the stool. Treatment records note the Veteran continued to be prescribed medication as needed to reduce stomach acid. A May 2015 letter from the Veteran’s primary care provider noted increased heartburn and dyspepsia symptoms. Based on the lay and medical evidence of record the Board finds that the Veteran’s GERD does not more nearly approximate the level of severity contemplated by an increased 30 percent rating. The Board notes the Veteran’s contentions regarding his ongoing pain, nausea, heartburn, diarrhea, gas, bloating and occasional blood in his stool. However, such lay evidence, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports that prior to June 9, 2015 the Veteran’s GERD was characterized by two or more symptoms of recurrent epigastric distress, pyrosis and heartburn, warranting a 10 percent rating under Diagnostic Code 7346 for the entire period on appeal. The VA examiner in August 2014 noted GERD with infrequent episodes of epigastric distress, pyrosis (heartburn) and reflux. To warrant an increased 30 percent rating persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation accompanied by substernal arm or shoulder pain, productive of considerable impairment of health must be present. There is no indication that the Veteran’s symptoms including epigastric pain and pyrosis, or any dysphagia, or regurgitation have been persistently recurrent and productive of considerable impairment of health. The June 2015 examiner noted no impact on the Veteran’s ability to work. As such, the evidence of record is against a finding that the Veteran has demonstrated persistently recurrent epigastric distress with symptoms productive of considerable impairment of health. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 10 percent for the Veteran’s service connected GERD is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, an increased 10 percent rating, but no higher is granted. Increased initial compensable rating for hemorrhoids The Veteran contends that his hemorrhoids have worsened and an increased compensable rating is warranted. The Veteran contends ongoing pain and symptomology related to his hemorrhoids. The Veteran is competent to testify to such lay observable symptomatology, and there is no evidence that these statements are not credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, these statements are entitled to probative value as to the severity of his hemorrhoids during the period on appeal. The Veteran’s hemorrhoids are rated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7336. The Board finds that based on the evidence of record the preponderance of the evidence is against finding that a compensable rating for the Veteran’s hemorrhoids is warranted for the entire period on appeal. Under Diagnostic Code 7336, a noncompensable rating applies for mild or moderate hemorrhoids. Large or thrombotic irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences are rated 10 percent disabling. Hemorrhoids with persistent bleeding and with secondary anemia or with fissures are rated 20 percent disabling. A 20 percent is the highest scheduler rating for hemorrhoids. The Board notes that the Veteran is currently service connected for a rectum sphincter disability and gastroesophageal reflux and these increased rating claims are on appeal and will be discussed in greater detail within this decision. Based on the evidence of record, the Board finds that the preponderance of the evidence is against finding that an increased initial compensable rating is warranted for the entire period on appeal. The Veteran was afforded a VA examination in August 2014. The examiner noted internal or external hemorrhoids diagnosed in-service. The examiner noted the Veteran’s hemorrhoids are mild or moderate in severity. Then, the Veteran was afforded a VA examination in October 2018. The examiner noted internal or external hemorrhoids which are mild or moderate. The examiner noted moderate hemorrhoids with any straining such as running or large bowel movements. VA treatment records have been associated with the claims file and note occasional reports of hemorrhoid pain and rectal bleeding. Gastroenterology colonoscopy findings note small internal hemorrhoids. Based on the lay and medical evidence of record the Board finds that the Veteran’s hemorrhoids do not more nearly approximate the level of severity contemplated by an increased 10 percent rating. The Board notes the Veteran’s contentions regarding pain and bleeding at times. The Veteran is competent to testify to such lay observable symptomatology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, such lay evidence, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports a noncompensable rating is warranted for the entire period on appeal. A 10 percent rating is warranted under Diagnostic Code 7336 with internal or external hemorrhoids large or thrombotic, irreducible with excessive redundant tissue, evidencing frequent recurrences. The VA examinations in August 2014 and October 2018 and VA treatment records consistently note hemorrhoids that are mild or moderate in severity. The Board finds that the Veteran’s hemorrhoids do not more closely approximate an increased 10 percent rating. Hemorrhoids were noted to increase to moderate severity with any straining including running and large bowel movements. However, the Veteran’s hemorrhoids have not been large or thrombotic, irreducible with excessive redundant tissue, evidencing frequent recurrences, with peristent bleeding, secondary anemia or fissures. As such the Board finds that the Veteran is not entitled to an increased compensable rating for his hemorrhoids. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased compensable rating for the Veteran’s service connected hemorrhoids is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. Increased rating for PTSD previously rated as GAD The Veteran contends he is entitled to an increased rating for his service connected posttraumatic stress disorder (PTSD) previously rated as generalized anxiety disorder (GAD). The Veteran’s service connected PTSD has been rated as 30 percent disabling prior to July 11,2018. Then from July 11, 2018 forward, the Veteran’s GAD now rated as PTSD was rated as 70 percent disabling. Herein, the Board finds that a 50 percent rating is warranted prior to July 11, 2018. The Board will discuss the Veteran’s various periods on appeal The Veteran’s GAD now rated as PTSD is rated using the general formula for mental disorders (general formula). The Board notes that the Veteran’s PTSD was previously rated as GAD, throughout the period on appeal the Board will consider the entirety of the Veteran’s symptomology as discussed below. A 50 percent rating is assigned 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 assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Importantly in this case, effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). See 79 Fed. Reg. 149, 45094 (August 4, 2014). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. As the Veteran’s claim was pending before the AOJ on August 4, 2014, a diagnosis and analysis of the Veteran’s current severity of his PTSD must conform to DSM-V. See 38 C.F.R. § 4.125(a). However, as a portion of the period on appeal occurred prior to August 2014, the file contains VA mental health examinations performed prior to August 2014 when DSM-IV was the medical and regulatory standard and was appropriate for use by the examiners at those times. As there is no information to the contrary, the Board will presume that earlier VA examiners appropriately utilized the diagnostic standard in effect at the time of their examinations. Further, the symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013) the Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Prior to July 11, 2018 The Veteran contends that he is entitled to an increased initial rating for his service connected PTSD previously rated as GAD that has been rated as 30 percent disabling for this period on appeal. Herein, the Board finds that a 50 percent rating is warranted for this period on appeal. The Board finds that based on the evidence of record the preponderance of the evidence is against finding that a rating in excess of 50 percent for the Veteran’s PTSD previously rated as GAD is warranted for this period on appeal. The Board finds that during this period on appeal, the Veteran’s PTSD approximated a 50 percent rating. The evidence of record shows that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported symptoms including depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impaired concentration and impulse control, nightmares, significant hypervigilance, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. He reported increased difficulty concentrating at school and while doing school work. Additionally, the Veteran reported ongoing forgetfulness and inattention which impacting him timely paying bills and completing school work at times. The Veteran was afforded a VA mental disorder examination in August 2014. The examiner noted occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversations. Symptoms reported including anxiety, panic attacks more than once a week, chronic sleep impairment, impaired concentration and fatigue. The examiner noted ongoing anxiety that has continued since service. Then, the Veteran was afforded a VA mental disorders examination in June 2015. The examiner noted generalized anxiety disorder and unspecified bipolar disorder with occupational and social impairment with reduced reliability and productivity. Symptoms reported including depressed mood, anxiety, panic attacks once a week, chronic sleep impairment, mild memory loss, impaired impulse control, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. The examiner noted the Veteran was currently employed. VA treatment records have been associated with the claims file. Treatment records note ongoing complaints of anxiety attacks. The Veteran reported difficulty sleeping. On mental status examinations the Veteran was consistently oriented, appropriately dressed, with intact memory, attention and concentration, a fatigued mood, intact and safe insight and judgment and denied suicidal/homicidal ideations. Treatment records note ongoing panic attacks, and occasional depressed mood. Based on a review of the evidence of record the Board finds that a 50 percent rating, but no higher is warranted for this period on appeal. During this period on appeal, the Veteran experienced symptoms including depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impaired concentration and impulse control, nightmares, significant hypervigilance, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. These symptoms are contemplated by the 50 percent rating granted herein. The Board recognizes that some of the Veteran’s reported symptomology approximates the listed criteria for an evaluation in excess of 50 percent. The Board also notes that some of the Veteran’s symptoms have slightly worsened during the period on appeal. However, the overall nature, frequency, and severity of his symptoms have not risen to the level of an increased 70 percent evaluation. During this period on appeal, the Veteran experienced occupational and social impairment with reduced reliability and productivity due to symptoms such as depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impaired concentration and impulse control, nightmares, significant hypervigilance, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. The Veteran’s symptoms during this period are all typical and considered in the assignment of a 50 percent rating. The Veteran’s PTSD previously rated as GAD has not been characterized by occupational and social impairment with deficiencies in most areas such as work, school, family relationships, judgment, thinking or moods. During this period on appeal, the Veteran continued attending college working towards a bachelor’s degree in nursing, and working at different points during the period. The Veteran reported regularly exercising and going to the gym, maintaining a good relationship with his two older children, and seeing several friends regularly. While increased symptomatology was noted including panic attacks and increased difficulties at school at times there was no indication of suicidal ideations, obsessional rituals, illogical, obscure or irrelevant speech, impaired impulse control and/or spatial disorientation. Additionally, treatment records note that the Veteran largely maintained his personal appearance and hygiene and was able to function independently. The evidence of record shows that the Veteran was able to perform activities of daily living and his overall disability picture is not one of occupational and social impairment with deficiencies in most areas. The evidence of record supports a change in the severity of the Veteran’s symptomology prior to July 2018 supported by VA treatment records and the Veteran’s lay statements and such is reflected by the granting of a 50 percent rating herein. The Veteran’s overall impairment caused by his GAD and associated symptomology more nearly approximates occupational and social impairment with reduced reliability and productivity. As such, the evidence of record is against a finding that the Veteran has demonstrated occupational and social impairment with deficiencies in most areas, which would warrant a 70 percent rating for this period. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 50 percent for the Veteran’s service connected PTSD previously rated as GAD is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, an increased 50 percent rating, but no higher is granted. From July 11, 2018 forward From July 11, 2018 forward, the Veteran’s PTSD was rated as 70 percent disabling. The Board finds that during this period on appeal the Veteran’s PTSD approximated a 70 percent rating. The Board finds that based on the evidence of record the preponderance of the evidence is against finding that a rating in excess of 70 percent for the Veteran’s PTSD, previously rated as GAD is warranted. The Board finds that during this period on appeal the Veteran’s PTSD approximated a 70 percent rating. The evidence of record shows that the Veteran had occupational and social impairment with deficiencies in most areas. The Veteran reported symptoms including depressed mood, intrusive thoughts, anxiety isolating behaviors, chronic sleep impairment, memory and concentration difficulty, panic attacks, difficulty getting along with others, suspiciousness, loss of interest in activities, passive and fleeting suicidal ideations, difficulty in establishing and maintaining relationships and adapting to stressful circumstances and an intermittent inability to perform activities of daily living. The Veteran reported a recent worsening of his symptoms during this period. The Veteran was afforded a VA PTSD examination in August 2018. The examiner noted occupational and social impairment with reduced reliability and productivity. Symptoms reported including a depressed mood, anxiety, suspiciousness, panic attacks, impaired concentration, impaired sleep, anger, irritability, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. The Veteran reported struggling with his college classes and that he was currently on academic probation as he has difficulty staying organized and focused. Then, the Veteran was afforded a VA PTSD examination in October 2018. The examiner noted occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. Symptoms reported including flashbacks, depressed mood, intrusive thoughts, anxiety isolating behaviors, chronic sleep impairment, memory and concentration difficulty, panic attacks, difficulty getting along with others, suspiciousness, loss of interest in activities, passive and fleeting suicidal ideations, difficulty in establishing and maintaining relationships and adapting to stressful circumstances and intermittent inability to perform activities of daily living. On mental status exam, the Veteran was alert and well oriented, well groomed, speech and memory were within normal limits, with an anxious mood, thought process and content were linear and appropriate and insight/judgement were intact. The Veteran reported having a good relationship with his two older children and enjoys spending time with friends and exercising. The Veteran reported he was kicked out of school and is attempting to get back into the nursing program. The examiner noted that the Veteran’s psychological symptoms significantly interfere with his ability to get along with others, and his anger and impulse control has impacted his ability to successfully attend and graduate from college. Based on a review of the evidence of record the Board finds that a 70 percent rating, but no higher is warranted for the period on appeal. During this period the Veteran experienced symptoms including flashbacks, depressed mood, intrusive thoughts, anxiety isolating behaviors, chronic sleep impairment, memory and concentration difficulty, panic attacks, difficulty getting along with others, suspiciousness, loss of interest in activities, passive and fleeting suicidal ideations, difficulty in establishing and maintaining relationships and adapting to stressful circumstances and intermittent inability to perform activities of daily living. These symptoms are contemplated by the 70 percent rating. The Board recognizes that some of the Veteran’s reported symptomology approximates the listed criteria for an evaluation in excess of 70 percent. The Board also notes that some of the Veteran’s symptoms have slightly worsened during the period on appeal. However, the overall nature, frequency, and severity of his signs and symptoms have not risen to the level of an increased 100 percent evaluation. During this period on appeal, the Veteran experienced occupational and social impairment with deficiencies in most areas such as work, school, family relationships, judgment, thinking or moods due to symptoms such as flashbacks, depressed mood, intrusive thoughts, anxiety isolating behaviors, chronic sleep impairment, memory and concentration difficulty, panic attacks, difficulty getting along with others, suspiciousness, loss of interest in activities, passive and fleeting suicidal ideations, difficulty establishing and maintaining relationships and adapting to stressful circumstances and intermittent inability to perform activities of daily living. The Veteran’s symptoms during this period are all typical and considered in the assignment of a 70 percent rating. The Veteran’s PTSD has not been characterized by total occupational and social impairment. During this period, the Veteran reported continuing to maintain close contact with his two older children and his parents. He also reported continuing to exercise and spend time with several friends. During this period, the Veteran reported he was kicked out of college while working on completing a nursing degree due to his ongoing PTSD symptomology and difficulty with following directions. While increased symptomatology was noted including fleeting and passive suicidal ideation on occasion and increased depression and anxiety, such is contemplated by the increased 70 percent rating during this period. There is no indication the Veteran experienced gross impairment in thought processes or communication, persistent delusions, grossly inappropriate behaviors, or is in peristent danger of hurting himself or others. The Veteran did at times have difficulty performing activities of daily living, however, he did not have memory loss for names of close relationships, his own occupation or his name. The Board notes that the Veteran reported worsening and increased symptomology reporting he is now residing at his parents’ house, and is no longer attending the nursing program. However, the evidence of record shows that the Veteran was largely able to perform activities of daily living and his overall disability picture is not one of total occupational and social impairment. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 70 percent for the Veteran’s service connected GAD, for this period, is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. Scars The Veteran contends that he is entitled to an increased initial rating for his right and left lower areola scars. Prior to June 9. 2015, the Veteran’s right lower areola scar was rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. From June 9, 2015 forward, the Veteran’s right lower areola scar was rated at 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7804. The Veteran’s left lower areola scar is rated at noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7802. The Veteran’s right and left lower areola scars will be discussed separately below. As an initial matter, the Board notes that Diagnostic Code 7800 pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. The Veteran’s scars are located on his right and left chest, as such; Diagnostic Code 7800 is not applicable for rating purposes. Diagnostic Code 7801 applies to burn scars or scars due to other causes, not of the head, face, or neck that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801. A deep scar is one that is associated with underlying soft tissue damage. Id. at Note 1. Diagnostic Code 7802 pertains to burn scars or scars due to other causes, not of the head, face, or neck that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7802. A superficial scar is one that is not associated with underlying soft tissue damage. Id. at Note 1. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, and a 30 percent disability rating is assigned for five or more scars that are unstable or painful. Note (1) states “an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” Note (2) states “if one or more scars are both unstable and painful, add 10 percent to the rating that is based on the total number of unstable or painful scars.” 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7805 provides that other scars (including linear scars), and other effects of scars, require the rating of any disabling effects not considered in a rating provided under Diagnostic Codes 7800 to 7804 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. In this case, the record does not reveal disabling effects beyond the scope of Diagnostic Codes 7800 to 7804, so an additional rating under 7805 is not warranted. The 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118 are: (1) Scar is 5 or more inches (13 or more centimeters (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.); (8) Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Increased initial rating for residuals of right lower areola scar Prior to June 9, 2015, the Veteran’s right lower areola scar was rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. From June 9, 2015 forward, the Veteran’s right lower areola scar was rated at 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7804. Herein, the Board finds that a 10 percent rating is warranted for the entire period on appeal under Diagnostic Code 7804. The Board finds that based on the evidence of record the preponderance of the evidence is against finding that a rating in excess of 10 percent for the Veteran’s right lower areola scar is warranted, for the entire period on appeal. The Veteran contends that his right lower areola scar is characterized by pain and tenderness and as such an increased rating is warranted. The Veteran’s scar is a residual of an in-service breast lump excision. Based on the evidence of record the Board finds that the preponderance of the evidence is against finding that an increased rating in excess of 10 percent is warranted for the entire period on appeal. The Veteran was afforded a VA examination in August 2014. The examiner noted bilateral breast lump with gynecomastia status post excision in the left and right breast. The examiner noted that the Veteran’s scars are not painful and/or unstable, or covering a total area greater than 39 sq. cm. The Veteran’s scars were barely visible measuring 2 cm. by 0.20 cm., and liner along the bilateral inferior areola. The examiner noted the Veteran’s scars do not impact his ability to work, or result in functional impairment. The Veteran was afforded a VA examination in June 2015. The examiner noted scars on the trunk or extremities, which are not the result of burns. The examiner noted 1 painful scar of the right lower areolar that has sharp pain with palpation. No scars were unstable, with frequent loss of covering of the skin. No scars were both painful and unstable. The Veteran’s right lower areola scar measuring 4 cm. by 0.2 cm., was superficial, non-linear, well healed, stable and tender. The Veteran’s scar resulted in no disfigurement of the head, face or neck. The Veteran’s scars do not impact his ability to work. VA treatment records have been associated with the claims file. The Veteran reports ongoing complaints of pain and tenderness. Treatment records note ongoing chest tenderness to touch related to his scar. Based on the lay and medical evidence of record the Board finds that the Veteran’s right areola scar does not more nearly approximate the level of severity contemplated by an increased 20 percent rating. The Board notes the Veteran’s contentions regarding his ongoing pain and tenderness. However, such lay evidence, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports that prior to June 9, 2015, the Veteran’s right lower areola scar was painful warranting a 10 percent rating under Diagnostic Code 7804 for the entire period on appeal. A 20 percent disabling rating is warranted under Diagnostic Code 7804 when there are three or four scars that are unstable or painful. Note (1) states that “an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” Note (2) states 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.” The VA examinations in August 2014 and June 2015 and VA treatment records consistently note the Veteran’s right lower areola scar is painful. The VA examination in August 2014 and June 2015 reflects that the Veteran’s scar is not unstable, and there is not a frequent loss of covering of skin over the scar. In addition, the scar is not 13 cm. or more in length or 0.6 cm. wide, and there is no visible or palpable tissue loss or gross distortion, abnormal skin texture, abnormal pigmentation or missing underlying soft tissue or an inflexible area. As such the Board finds the Veteran is not entitled to an increased initial rating in excess of 10 percent for his right lower areola scar. The Board has considered whether a rating is warranted under any other Diagnostic Code. As to other potentially applicable diagnostic codes, Diagnostic Code 7800 is related to scars of the head, face or neck and thus is not for consideration. Diagnostic Code 7801 relates to burn scars due to other causes not of the head, face, or neck that are deep and non-linear. The Veteran’s scar was noted by the June 2015 VA examiner to be not due to burns and that it was superficial. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (holding that the use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met). Therefore, Diagnostic Code 7801 is not applicable to the Veteran’s scar. Diagnostic Code 7802 relates to scars not of the head, face or neck, which are superficial and nonlinear. Such scars in an area of 144 square inches (929 square cm) or greater warrant a 10 percent evaluation. A superficial scar is one not associated with underlying soft tissue damage. If multiple qualifying scars are present, a separate evaluation is assigned for each affected extremity based on the total area of the qualifying scars that affect that extremity. 38 C.F.R. § 4.118, Diagnostic Code 7802. While the Veteran’s scar is superficial and non-linear it did not cover 929 sq. cm. or greater. Diagnostic Code 7805 provides that other scars, and other effects of scars, require the rating of any disabling effects not considered in a rating provided under Diagnostic Codes 7800 to 7804 under an appropriate Diagnostic Code. In this case, the Veteran is in receipt of a noncompensable rating under 7805, and an increased rating is not warranted as the effects of the Veteran’s scars have been fully considered under the above Diagnostic Codes. As such a compensable disability rating is not warranted under these Diagnostic Codes. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 10 percent for the Veteran’s service connected right lower areola scar is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, an increased 10 percent rating, but no higher is granted. Increased initial rating for residuals of the left lower areola scar The Veteran contends that he is entitled to an increased initial rating for his left lower areola scar. The Veteran’s left lower areola scar is rated at noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7802. The Board finds that based on the evidence of record a 10 percent rating is warranted under Diagnostic Code 7804. The Board finds that based on the evidence of record the preponderance of the evidence is against finding that a rating in excess of 10 percent for the Veteran’s left lower areola scar is warranted for the entire period on appeal. The Veteran contends that his left lower areola scar is characterized by pain and tenderness and as such an increased rating is warranted. The Veteran’s scar is a residual of an in-service breast lump excision. Based on the evidence of record the Board finds that the preponderance of the evidence is against finding that an increased initial rating in excess of 10 percent is warranted for the appeal. The Veteran was afforded a VA examination in August 2014. The examiner noted bilateral breast lump with gynecomastia status post excision in the left and right breast. The examiner noted that the Veteran’s scars are not painful and/or unstable, or covering a total area greater than 39 sq. cm. The Veteran’s scars were barely visible measuring 2 cm. by 0.20 cm., and linear along the bilateral inferior areola. The examiner noted the Veteran’s scars do not impact his ability to work, or result in functional impairment. Then the Veteran was afforded a VA examination in June 2015. The examiner noted scars on the trunk or extremities, which are not the result of burns. The examiner noted 1 painful scar of the right lower which has sharp pain with palpation. No scars were unstable, with frequent loss of covering of the skin. No scars were both painful and unstable. The Veteran’s left lower areola scar measuring 3 cm. by 0.2 cm., was superficial, non-linear, well healed, stable and non-tender. The Veteran’s scars resulted in no disfigurement of the head, face or neck. The Veteran’s scars do not impact his ability to work. VA treatment records have been associated with the claims file. The Veteran reports ongoing complaints of pain and tenderness. November 2014 treatment records note left chest wall pain related to his scar and prior surgery noting pain and tenderness to touch. Treatment records note ongoing tenderness of the left scar. Based on the lay and medical evidence of record the Board finds that the Veteran’s left areola scar does not more nearly approximate the level of severity contemplated by an increased 20 percent rating. The Board notes the Veteran’s contentions regarding his ongoing pain and tenderness. However, such lay evidence, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports that the Veteran’s left lower areola scar was painful warranting a 10 percent rating under Diagnostic Code 7804 for the entire period on appeal. A 20 percent disabling rating is warranted under Diagnostic Code 7804 when there are three or four scars that are unstable or painful. Note (1) states that “an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” Note (2) states 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.” VA treatment records consistently note the Veteran’s left lower areola scar is painful. The VA examinations in August 2014 and June 2015 reflect that the Veteran’s scar is not unstable, and there is not a frequent loss of covering of skin over the scar. In addition, the scar is not 13 cm. or more in length or 0.6 cm. wide, and there is no visible or palpable tissue loss or gross distortion, abnormal skin texture, abnormal pigmentation or missing underlying soft tissue or an inflexible area. As such the Board finds the Veteran is not entitled to an increased rating in excess of 10 percent for his left lower areola scar. The Board has considered whether a rating is warranted under any other Diagnostic Code. As to other potentially applicable diagnostic codes, Diagnostic Code 7800 related to scars of the head, face or neck and thus is not for consideration. Diagnostic Code 7801 relates to burn scars due to other causes not of the head, face, or neck that are deep and nonlinear. The scars were noted by the June 2015 VA examiner to be not due to burns and that they were superficial. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (holding that the use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met). Therefore, Diagnostic Code 7801 is not applicable to the Veteran’s scars. Diagnostic Code 7802 relates to scars not of the head, face or neck, which are superficial and nonlinear and provides for a compensable rating for areas of 144 sq. inches or greater. While the Veteran’s scar is superficial and non-linear it did not cover 929 sq. cm. or greater. Diagnostic Code 7805 provides that other scars, and other effects of scars, require rating of any disabling effects not considered in a rating provided under Diagnostic Codes 7800 to 7804 under an appropriate diagnostic code. In this case, the Veteran is in receipt of a noncompensable rating under 7805, and an increased rating is not warranted as the effects of the Veteran’s scars have been considered under the above Diagnostic Codes. As such a compensable disability rating is not warranted under these Diagnostic Codes, and no other Diagnostic Codes are applicable. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 10 percent for the Veteran’s service connected left lower areola scar is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, an increased 10 percent rating, but no higher is granted. Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” - the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. 3.303 (b). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Entitlement to service connection for a right wrist disability The Veteran contends that he has a right wrist disability which was caused by an in-service injury. The Veteran reports he has had ongoing right wrist pain since his in-service injury in 2007. The Veteran reports on and off daily pain which increases at the gym, engaging in weight bearing tasks, typing, lifting and heavy gripping. VA treatment records note ongoing consistent reports of wrist pain. The Veteran is competent to describe his ongoing symptoms since service and his statements are credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is conflicting evidence regarding the existence of a disability. However, we resolve such doubt in the Veteran’s favor, and the Board concludes that the Veteran has a current diagnosis of right wrist tenderness with ongoing pain that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran’s STRs have been associated with the claims file. The Veteran served in the U.S. Army as a military policeman. STRs note an injury to the right wrist when it was shut in a taxi door, and he experienced immediate swelling, pain and reduced range of motion. March 2007 STRs note peristent right wrist pain status post accident. The Veteran reported ongoing pain with handshakes, pushups and reduced strength. STRs note the Veteran was seen for aftercare for a healing traumatic fracture of the lower arm, and reported ongoing wrist, hand and joint pain. In a July 2013 report of medical history at separation, the Veteran reported pain in his wrist and history of broken bones. The Veteran reported ongoing wrist and hand pain due to prior right-hand injury while stationed in Korea. Examination noted treatment in 2007, but an X-ray in 2008 was normal. On examination range of motion was normal with 5/5 strength and neurovascular system was intact. The Veteran was afforded a VA examination in November 2014. The examiner noted minor right wrist tenderness. The examiner noted a prior healed right wrist small avulsion fracture in-service. Symptoms noted on and off daily pain which increased with weightbearing including exercising, typing, heavy gripping and lifting. The Veteran denied weakness, decreased range of motion, numbness, tingling, redness or bruising. Range of motion testing and muscle strength testing was normal. Imaging noted no arthritis. The examiner noted that while the Veteran’s right wrist condition has virtually resolved it was at least as likely as not caused by or incurred in-service. The examiner noted the Veteran’s in-service injury and on examination there was tenderness on palpation. The Board notes that pain alone can cause functional impairment and establish a current disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). While not all pain results in a disability, herein however, pain raises to the level of functional impairment in working ability and contributes to the Veteran’s disability. The Veteran continues to report ongoing pain and tenderness and increased difficulty with weightbearing. As such, resolving reasonable doubt in the Veteran’s favor the Board finds that a right wrist disability is present. The Board has competent and credible reports from the Veteran regarding his right wrist injury in-service and continuity of symptoms since service and a VA examination identifying right wrist tenderness and pain and ongoing functional impairment. The preponderance of the evidence favors in granting the Veteran’s claim of entitlement to service connection for a right wrist disability. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for a left wrist disability The Veteran contends that he is entitled to a left wrist disability due to an injury in-service. The Veteran contends he injured his right wrist in-service and has had ongoing residuals of such since service. The question for the Board is whether the Veteran has a current left wrist disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a left wrist disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s STRs have been associated with the claims file. The Board notes that the Veteran reports ongoing right wrist pain, and as discussed above STRs note an in-service injury to the Veteran’s right wrist. STRs note an injury to the right wrist when it was shut in a taxi door, and he experienced immediate swelling, pain and reduced range of motion. In A July 2013 report of medical history at separation, the Veteran reported wrist pain and history of broken bones. The Veteran reported ongoing wrist and hand pain due to prior right-hand injury while stationed in Korea. Examination noted prior treatment in 2007, but an X-ray in 2008 noted a normal hand. On examination range of motion was normal with 5/5 strength and neurovascular system was intact. The Veteran was afforded a VA examination in November 2014. The November 2014 VA examiner evaluated the Veteran and determined that, while he has experienced prior subjective symptoms of left wrist pain, he did not report current symptoms related to his left wrist and did not have a diagnosis of a left wrist disability. The Veteran reported on and off daily pain with exercising, working and weight bearing relating to an in-service injury of his right wrist. Range of motion testing was normal, with no pain on examination. The examiner noted no malalignment, erythema, ecchymosis, instability, swelling or scars, with no evidence of weakness, decreased strength with range of motion testing. Muscle strength testing was 5/5. The examiner noted that the Veteran reported no problems with his left wrist in-service, and STRs were absent complaints, diagnosis or treatment for a left wrist disability. The examiner found that the Veteran’s left wrist condition was not caused by or incurred in-service, noting the normal examination and absence of treatment, diagnosis and in-service complaints of a left wrist disability in-service both by the Veteran and in STRs. The Veteran does not have a current left wrist disability. The Board notes the Veteran’s reports of ongoing wrist pain; however, there is no evidence that the Veteran’s reported pain interferes with his functioning as evidenced by VA treatment records and examinations noting normal range of motion. Under 38 U.S.C. § 1110 there must be a disability due to an identified personal injury suffered or disease or injury, contracted in-service. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no functional limitation. Further, not all pain results in a disability, as in here, or rises to the level of impairment of working ability. Under 38 C.F.R. § 3.317, the Board notes that service connection can be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). However, the Veteran has not contended that his reported wrist disability is generally a result of exposure in Southwest Asia, rather he has reported his right wrist pain is attributable to his in-service accident while stationed in Korea. As with all claims for service connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board notes the Veteran’s reports regarding his symptoms in-service and ongoing manifestations which he is competent to report. However, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a left wrist disability. The Board notes that the medical evidence is more probative and more credible than the lay opinions of record. The November 2014 VA examination did not find any indication of a current left wrist disability, and on examination the Veteran denied left wrist or symptomology. Further, VA treatment records are absent indications of a left wrist disability. Thus, the more probative evidence of record indicates the Veteran does not have a current left wrist disability and service connection is not warranted. As such, the Board finds that service connection for a left wrist disability is not warranted. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. Entitlement to service connection for headaches The Veteran contends that service connection is warranted for his headaches. The Veteran reports that he began experiencing headaches in-service while stationed in Southwest Asia, and these have continued since. The Board concludes that the Veteran has a current diagnosis of migraine headaches that began during active service, and continued since. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA treatment records and lay statements note ongoing reports of headaches and symptomology. The Veteran contends his headaches began while stationed in Southwest Asia and have continued since with worsening symptomology. The Veteran’s service treatment records (STRs) have been associated with the claims file. In June 2009 the Veteran reported ongoing headaches. March 2013 STRs note intermittent headaches. In July 2013 the Veteran reported and treatment records note daily headaches. In July 2013 on the report of medical history the Veteran reported near daily severe headaches, which at times make it difficult for him to think, concentrate and open his eyes. The Veteran was afforded a VA examination in December 2014. The examiner found it was less likely than not that the Veteran’s migraine headaches had onset during military service. The examiner noted no history of headaches documented in the Veteran’s in-service medical records. The examiner noted an absence of STRs indicating treatment for or a diagnosis of migraines during service. The examiner noted no direct association with exposure to environmental hazards experienced during Gulf War service, and that his headaches represent a specific etiology and are not an undiagnosed illness. The examiner noted the Veteran’s reported onset of headaches while deployed and that he was able to manage his symptoms with over the counter medications. The Veteran reported post service his headaches worsened with increased symptomology including nausea, vomiting, light and sound sensitivity and increased irritability. The examiner noted a diagnosis of migraines in January 2014, and the Veteran’s reported onset in 2011 or 2012. The examiner found it was less likely than not that the Veteran’s migraine headaches had onset during active service. Based on the evidence of record the Board finds that the evidence is in relative equipoise as to the onset of the Veteran’s headaches and resolves reasonable doubt in the Veteran’s favor as to the onset of his migraine headaches in-service. The Board notes there is both favorable unfavorable evidence regarding the onset of the Veteran’s current headaches and associated symptomology but finds that the Veteran’s reports of his symptoms developing in-service while deployed with continuous symptoms since service to be credible. The December 2014 VA examiner failed to fully consider the Veteran’s lay statements and the in-service reports of headaches in his STRs. The examiner failed to address the Veteran’s credible lay statements noting his onset of headaches in-service and symptoms that have continued since, noting an absence of reported headaches in the Veteran’s STRs. However, this conclusion, failed to address that on numerous occasions the Veteran reported daily headaches in his STRs. Further, treatment records several months after separation note ongoing treatment for headaches, the VA examiner incorrectly noted that several years passed between the Veteran’s separation from service and onset of his headaches. Thus, resolving reasonable doubt in the Veteran’s favor, the Board finds it is at least as likely as not that the Veteran’s headaches had onset in-service, with continuous symptoms since. As such service connection for headaches is warranted. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for lumbar spine muscle spasms The Veteran contends his low back disability has increased in severity and a compensable rating is warranted. May 2015 VA treatment records note increased low back pain and limited range of motion. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his low back disability. As such a remand is warranted. 2. Entitlement to service connection for fatigue The Veteran contends service connection is warranted for fatigue, to include as due to his service in Southwest Asia. The Board cannot make a fully-informed decision on the issue of service connection for fatigue because no VA examiner has opined whether direct service connection is warranted to include as due to environmental hazardous exposed to in Southwest Asia. As such a remand is warranted. 3. Entitlement to increased initial rating in excess of 10 percent for angina The Veteran contends an increased rating is warranted for angina. VA treatment records note reported chest palpations, chest pain, chest pressure, lightheadedness and an increased heart rate often when waking. In September 2018 treatment records the Veteran expressed ongoing concern related to his heart disability, suggesting an increase in severity since the Veteran was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his heart disability. As such a remand is warranted. 4. Entitlement to an earlier effective date for angina Finally, because a decision on the remanded issue of an increased rating for angina could significantly impact a decision on the issues of entitlement to an earlier effective date, the issues are inextricably intertwined. A remand of the claim for entitlement to an earlier effective date for angina is required. 5. TDIU Lastly, TDIU prior to July 11, 2018 was granted in an October 2018 rating decision. TDIU is part and parcel of an increased rating claim and the Veteran through the record contends that he was unemployable due to his service connected disabilities prior to July 11, 2018. The Board finds that the issue of entitlement to TDIU, prior to July 11, 2018 has been raised by the record. The title page has been updated accordingly. Thus, because a decision on the remanded increased rating and service connected issues could significantly impact a decision on the issue of entitlement to TDIU prior to July 11, 2018, the issues are inextricably intertwined. A remand of the claims for entitlement to TDIU prior to July 11, 2018 is required. The matters are REMANDED for the following action: 1. Associate with the claims file any outstanding Vocational and Rehabilitation and Employment (VR&E) records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service connected low back disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to his low back disability alone and discuss the effect of the Veteran’s low back disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any fatigue. The examiner must opine whether: (a.) Are the Veteran’s symptoms of chronic fatigue a sign of an undiagnosed chronic multi-symptom illness? (b.) If not, does the Veteran have chronic fatigue syndrome? (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s chronic fatigue syndrome is related to an in-service injury or disease, to include service in the Gulf War and environmental exposures in Southwest Asia? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner should consider the Veteran’s contentions that his ongoing symptoms of chronic fatigue began after his service in the Gulf War and have persisted since. The Veteran served in Southwest Asia during the applicable presumptive period. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected angina. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to his heart disability alone and discuss the effect of the Veteran’s heart disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kardian