Citation Nr: 20037586 Decision Date: 06/02/20 Archive Date: 06/02/20 DOCKET NO. 14-30 060 DATE: June 2, 2020 ORDER Entitlement to an increased rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted, effective September 27, 2010, for substitution and/or accrued benefits purposes, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating higher than 30 percent for renal dysfunction, for substitution and/or accrued benefits purposes, is denied. Entitlement to an increased rating higher than 10 percent for left lower extremity neuropathy, for substitution and/or accrued benefits purposes, is denied. Entitlement to an increased rating higher than 10 percent for right lower extremity neuropathy, for substitution and/or accrued benefits purposes, is denied. Entitlement to an increased rating higher than 20 percent for diabetes mellitus, for substitution and/or accrued benefits purposes, is denied. Entitlement to an increased rating higher than 20 percent for disability of Muscle Group IV, left, residual of gunshot wound, for substitution and/or accrued benefits purposes, is denied. Entitlement to a compensable rating for hepatitis C, for substitution and/or accrued benefits purposes, is denied. Entitlement to a compensable disability rating for scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin (claimed as disfigurement), for substitution and/or accrued benefits purposes, is denied. Entitlement to a compensable rating for appendectomy, for substitution and/or accrued benefits purposes, is denied. Entitlement to service connection for neuropathy of the right hand, for substitution and/or accrued benefits purposes, is denied. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran’s PTSD symptoms more closely approximated occupational and social impairment with deficiencies in most areas, including suicidal ideation and impaired impulse control, but did not more closely approximate total occupational and social impairment. 2. The Veteran’s renal dysfunction was not manifested by constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code (DC) 7101. 3. The Veteran’s left lower extremity neuropathy was manifest by no more than mild incomplete paralysis. 4. The Veteran’s right lower extremity neuropathy was manifest by no more than mild incomplete paralysis. 5. The Veteran’s diabetes mellitus required only restricted diet and daily injection of insulin. 6. The Veteran’s left shoulder disability was manifested by moderately severe to severe impairment of Muscle Group IV, with left shoulder range of motion most severely limited to 90 degrees of flexion and 80 degrees of abduction. 7. The Veteran’s hepatitis C was asymptomatic. 8. The Veteran’s scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin were not manifest by any disabling effects not considered under Diagnostic Codes 7800-04. 9. The Veteran did not have any residuals from his appendectomy. 10. The Veteran’s neuropathy of the right hand was not secondary to service-connected diabetes mellitus and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, but no higher, for PTSD have been met for the entire appeal, effective September 27, 2010, for substitution and/or accrued benefits purposes. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating higher than 30 percent for renal dysfunction, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.115(a), 4.115b, Diagnostic Code 7599-7529. 3. The criteria for a disability rating in excess of 10 percent for left lower extremity neuropathy, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8521. 4. The criteria for a disability rating in excess of 10 percent for right lower extremity neuropathy, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8521. 5. The criteria for a disability rating in excess of 20 percent for diabetes mellitus, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913. 6. The criteria for a disability rating in excess of 20 percent for disability of muscle group IV, left, residual of gunshot wound, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.41, 4.45, 4.56, 4.73, Diagnostic Code 5304. 7. The criteria for a compensable disability rating for hepatitis C, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.14, 4.114, Diagnostic Code 7354. 8. The criteria for a compensable disability rating for scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. 9. The criteria for a compensable rating for appendectomy residuals, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.114, 4.118, Diagnostic Codes 7329. 10. The criteria for service connection for neuropathy of the right hand due to service or service-connected disease or injury, for substitution and/or accrued benefits purposes, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1968 to November 1969, including service in Vietnam. He died in April 2016. The appellant is his surviving spouse. In an August 2018 decision, substitution of the appellant for the Veteran was granted for this ongoing appeal. This matter is on appeal before the Board of Veterans’ Appeals (Board) from a June 2011 rating decision of the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOD). The Board remanded this case for additional development in September 2018. The directives of the Board’s remand having been substantially complied with the case is now returned for appellate review. The Board also remanded the issues of entitlement to an effective date earlier than September 27, 2010, for the assignment of a 50 percent for PTSD, and an increased rating higher than 20 percent for pleural cavity injury, residual of gunshot wound so that a statement of the case could be issued. A statement of the case was provided in April 15, 2020. As the time frame for appealing these matters has not expired (June 15, 2020), the issues of issues of entitlement to an effective date earlier than September 27, 2010, for the assignment of a 50 percent for PTSD, and an increased rating higher than 20 percent for pleural cavity injury, residual of gunshot wound are deferred pending a completed appeal. Increased Rating 1. Entitlement to an increased rating higher than 50 percent for posttraumatic stress disorder (PTSD) The appellant seeks a rating higher than 50 percent for PTSD as a substituted claimant on behalf of the deceased Veteran. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms caused the level of impairment required for a disability rating of 70 percent, but no higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. A November 2010 VA examination report shows that the Veteran had been very emotional about not being able to do anything. He noted that he used to work and provide for his family but felt like he was just sitting there. He noted that he wanted to work but with his condition, he could not. He also thought about suicide occasionally. He noted that he experienced these symptoms weekly to daily in frequency, and currently at a moderate severity since his last PTSD examination. Occupationally, he had been retired since 2005. Previously, he had been employed as a letter carrier for 35 years and retired because his legs were bothering him. Socially, he had been married for the past 12 years. He noted that it was going great but sometimes he got into rages and had homicidal thoughts. He noted that he could not even get out and rake the yard and sometimes would get these feelings like he wanted to kill someone. He noted that he sometimes could get along with people but then all of the sudden they would say something, and he would just jump into a very defensive mood. He indicated that he liked to fish but mostly stayed to himself. On mental status examination, the Veteran was fully oriented. He was well-groomed, friendly, and cooperative. His mood was presented as mildly depressed with generally somewhat restricted affect. He denied suicidal intent or planning, homicidal ideation, hallucinations, and delusions. His attention, memory, and judgment appeared to be within normal limits. Psychological testing was consistent with moderately severe PTSD. There were no signs of total occupational and social impairment or symptoms that resulted in deficiencies in judgment, thinking, family relations, work, mood, or school. There was reduced reliability and productivity due to PTSD symptoms. The Veteran reported disturbances of motivation and mood, as well as difficulty in establishing and maintaining effective work and social relationships. Based on the findings that the Veteran had homicidal thoughts toward others, and suicidal ideation, and also had psychological testing consistent with moderately severe PTSD symptoms, the criteria for a 70 percent rating are more closely approximated. It is noteworthy that not all of the criteria for a 70 percent rating were met and the VA examiner found that the Veteran did not have deficiencies in areas such as judgment, thinking, family relations, work, mood, or school. However, overall, these findings are more consistent with the criteria for a 70 percent rating, including suicidal ideation, and impaired impulse control. The next higher rating of 100 percent is not warranted. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation had not risen to the level contemplated by the 100 percent disability rating. The Veteran denied thoughts, intent, or a plan involving self-harm on the November 2010 VA examination report. While he indicated that he would keep to himself, he was not shown as being totally socially impaired. He had maintained a relationship with his wife for more than 12 years. Furthermore, with respect to employment, while his PTSD would certainly affect his employment, his PTSD was not shown as being the cause for his unemployment or causing him to be totally impaired occupationally. He noted that he had problems with his legs as a factor for not working. In short, the next higher rating of 70 percent for the Veteran’s PTSD is warranted, but no higher. 2. Entitlement to an increased rating higher than 30 percent for renal dysfunction The appellant seeks a rating higher than 30 percent for renal dysfunction as a substituted claimant on behalf of the deceased Veteran. By way of history, the record shows that the Veteran had his left kidney removed in 1969. Removal of a kidney is assigned a minimum 30 percent rating, or it is rated as renal dysfunction or infection. 38 C.F.R. § 4.115b, Diagnostic Code 7500. The Veteran has been in receipt of a 30 percent rating under Diagnostic Code 7500, effective November 28, 1969. However, he also was granted service connection for renal dysfunction, secondary to service-connected diabetes mellitus under 38 C.F.R. § 4.115b, Diagnostic Code 7599-7529, effective July 16, 2008. This is the disability rating on appeal. Renal dysfunction is rated under 38 C.F.R. § 4.115a. When there is albumin and casts with history of acute nephritis; or, hypertension non-compensable under Diagnostic Code 7101, a 0 percent rating is assigned. A 30 percent rating is assigned when there is albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension is at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is assigned when there is constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension is at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assigned when there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion, 80 percent rating. A 100 percent rating is assigned when the condition requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, 100 percent rating. 38 C.F.R. § 4.115a. A November 2010 VA examination report shows the Veteran had renal dysfunction secondary to his service-connected diabetes mellitus. VA treatment records note a diagnosis of chronic kidney disease. See, e.g., July 2011 VA treatment records. The Veteran also had a prescription for fosinopril to regulate his blood pressure to protect his kidneys. However, while there are some findings of abnormal laboratory readings, there is no medical evidence of a definite decrease in kidney function. A November 2010 VA examination report shows per lab findings in July 2008 the creatinine levels in his urine was 1.6 mg/dL with normal range from .5 to 1.4 mg/dL. In March 2009, his lab findings were 1.22 mg/dL. A March 2010 private laboratory report notes creatinine was high at 1.40 mg/dL with a normal range being .5 to 1.20 mg/dL. It also was noted that his BUN was high at 40.5 mg/dL with normal range being 8.0 to 23.0 mg/dL. A March 2011 VA treatment record shows a creatinine level of 1.14 mg/dL. An April 2011 VA treatment record also shows normal creatinine levels. In November 2012, a VA treatment record shows a creatinine level of 1.03 mg/dL. While the Veteran had occasional abnormal laboratory findings, such as in July 2008, and March 2010, from March 2011 to November 2012, his creatinine levels were normal. These findings do not support a definite decrease in kidney function per the rating criteria. There also is no medical evidence of constant albuminuria with some edema. In addition, there is no medical evidence that his hypertension would warrant a 40 percent rating. For reference regarding Diagnostic Code 7101 for hypertension, hypertensive vascular disease with diastolic pressure predominantly 120 or more is rated 40 percent disabling. 38 C.F.R. § 4.104. The blood pressure readings of record do not support a rating of 40 percent under Diagnostic Code 7101. See, e.g., November 2010 VA examination report showing blood pressure readings of 151/76, 150/88, and 145/78; and June 2011 VA treatment record showing blood pressure readings of 153/79 and 140/78. Based on the medical records, a rating higher than 30 percent for renal dysfunction was not warranted. 3. Entitlement to an increased rating higher than 10 percent for left lower extremity neuropathy 4. Entitlement to an increased rating higher than 10 percent for right lower extremity neuropathy The appellant seeks ratings higher than 10 percent, each for bilateral lower extremity neuropathies as a substituted claimant on behalf of the deceased Veteran. Paralysis of the external popliteal nerve (common peroneal) is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8521. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8621 and 8721, respectively. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 percent disabling. Complete paralysis with foot drop and slight drop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalange of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes is rated as 40 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Regarding impairment of motor functions, a November 2010 VA examination report shows that the Veteran had weakness and fatigue. He had functional loss in that he was limited to walking and standing for 15 minutes. There was no pain or flare-ups. There was moderate interference with daily activities. The examiner noted that (other than being limited to walking and standing for 15 minutes), the Veteran had no functional impairment due to neuropathy of the bilateral lower extremities. A July 2011 VA treatment record shows bilateral tibial motor studies noted “low normal” amplitudes, and normal latency on the right side that was marked abnormal. Left peroneal motor distal latency was mildly prolonged, and amplitude was mildly diminished. Conduction velocity was borderline. There was electrodiagnostic evidence consistent with an axonal sensory motor polyneuropathy with demyelinating features. It was noted that this type of neuropathy was commonly seen in diabetes. There were no findings regarding trophic changes. Regarding sensory disturbance, the November 2010 VA examination report shows that the Veteran experienced symptoms of tingling and burning sensation, daily and intermittent, day and night. There also was paresthesia along the bilateral anterior thigh down to the bilateral toes. There was no dysesthesia. A June 2011 VA treatment record shows the Veteran had decreased pin and temperature in a stocking/ glove formation from the mid-calves down. A July 2011 VA treatment record shows a five-year history of numbness and burning below the knees, especially in the feet. As noted, there was electrodiagnostic evidence consistent with an axonal sensory motor polyneuropathy with demyelinating features. A July 2011 VA treatment record notes that there was pain in the bilateral lower extremities and there also was no vibration sense and pathologic evidence of loss of reflexes in the feet. There was no medical evidence of muscle atrophy or complete paralysis. Based on the above, the Board finds that the neurological disability in the bilateral lower extremities was primarily manifest by impairment of motor functions, sensory disturbance, pain, and pathologic loss of reflexes. The Board also finds that the most probative evidence of record is against a finding that the disability in the bilateral lower extremities was manifest by trophic changes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to mild incomplete paralysis. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran had neurological impairment associated with any other peripheral nerves that had not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim for a rating in excess of 10 percent each for bilateral extremity neuropathy. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an increased rating higher than 20 percent for diabetes mellitus The appellant seeks a rating higher than 20 percent for diabetes mellitus as a substituted claimant on behalf of the deceased Veteran. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran’s diabetes mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Board finds that the Veteran’s diabetes mellitus required only restricted diet and daily injection of insulin during the period on appeal. A November 2010 VA examination report shows that the Veteran was told to follow a restricted diet and took insulin injections two times per day. He did not have restricted activity prescribed. These findings are consistent with other medical records in the file. The Veteran had complications of diabetes, including renal dysfunction, and neuropathy of the bilateral lower extremities. However, these complications were already service connected and separately rated. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 20 percent during the period on appeal. 6. Entitlement to an increased rating higher than 20 percent for disability of Muscle Group IV, left, residual of gunshot wound The appellant seeks a rating higher than 20 percent for disability of Muscle Group IV, left, residual of gunshot wound as a substituted claimant on behalf of the deceased Veteran. The Veteran’s 20 percent disability rating for his residual of gunshot wound to the left Muscle Group IV has been in effect since November 1969. See, e.g., April 1970. Thus, it is a protected rating under 38 C.F.R. § 3.951. Rating decisions in June 2006 and the rating decision on appeal in June 2011, which denied an increased disability rating for residual of gunshot wound to Muscle Group IV, note that the Veteran’s left shoulder is his dominant shoulder. However, this appears to be an error as the medical evidence of record shows that his right side is his dominant side. See, e.g., June 2006 VA examination report; November 2010 VA examination report; July 2011 VA physical therapy consult. This distinction is important because the diagnostic code the Veteran’s left shoulder disability is rated under, Diagnostic Code 5304, provides for a maximum rating of 20 percent for impairment of Muscle Group IV, on the nondominant side, whether the impairment is considered moderately severe or severe (as opposed to the dominant side, which provides for a rating of 30 percent for severe impairment). Diagnostic Code 5304 pertains to Muscle Group IV, the intrinsic muscles of the shoulder girdle which include the supraspinatus, infraspinatus and teres minor, subscapularis, and coracobrachialis muscles. The functions of these muscles are stabilization of the shoulder against injury in strong movements, holding the head of the humerus in the socket, abduction, and outward and inward rotation of the arm. 38 C.F.R. § 4.73, Diagnostic Code 5304. Under Diagnostic Code 5304, for the minor arm (as applicable in this case), slight impairment is assigned a noncompensable rating; moderate impairment is assigned a 10 percent rating; moderately severe or severe is assigned a 20 percent rating. Id. Evaluation of muscle injuries as slight, moderate, moderately severe, or severe, is based on the type of injury, the history and complaints of the injury, and objective findings. 38 C.F.R. § 4.56 (d). A slight disability of the muscles contemplates a simple wound of the muscle without debridement or infection; a service department record of a superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability. 38 C.F.R. § 4.56 (d)(1). Objectively, there is a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. A moderate disability of the muscles may result from through and through or deep penetrating wounds of relatively short track by a single bullet or small shell or shrapnel fragment. The absence of the explosive effect of a high velocity missile and of residuals of debridement or of prolonged infection also reflects moderate injury. The history of the disability should be considered, including service department records or other sufficient evidence of hospitalization in service for treatment of the wound. Consistent complaints on record from the first examination forward of one or more of the cardinal symptoms of muscle wounds, particularly fatigue and fatigue-pain after moderate use, and an effect on the particular functions controlled by the injured muscles should be noted. Evidence of moderate disability includes entrance and (if present) exit scars which are linear or relatively small and so situated as to indicate relatively short track of missile through muscle tissue, signs of moderate loss of deep fascia or muscle substance or impairment of muscle tonus, and of definite weakness or failure in comparative tests. 38 C.F.R. § 4.56 (d). A moderately severe disability of the muscles is characterized by evidence of a through and through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection, or with sloughing of soft parts, or intermuscular cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Objective findings should include relatively large entrance and (if present) exit scars so situated as to indicate the track of a missile through important muscle groups. Indications on palpation of moderate loss of deep fascia, or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side may be considered. Tests of strength and endurance of the muscle groups involved may also give evidence of marked or moderately severe loss. Id. A severe disability of the muscles is characterized by evidence of through and through or deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or explosive effect of a high velocity missile, or shattering bone fracture with extensive debridement or prolonged infection and sloughing of soft parts, intermuscular binding and cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Id. Objective evidence of severe disability includes extensive ragged, depressed, and adherent scars of skin so situated as to indicate wide damage to muscle groups in the track of a missile. Palpation shows moderate or extensive loss of deep fascia or of muscle substance. Soft or flabby muscles in wound area. Muscles do not swell and harden normally in contraction. Tests of strength or endurance compared with the sound side or of coordinated movements indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. Id. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56 (c). Under 38 C.F.R. § 4.71a , Diagnostic Code 5201, the following ratings apply to limitation of motion of the minor extremity: a 20 percent rating is warranted when arm motion is limited to shoulder level; or when arm motion is limited to midway between the side and shoulder level; and a 30 percent rating is warranted when arm motion is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The normal ranges of motion of the shoulder are 180 degrees of forward elevation (flexion) and abduction (90 degrees is shoulder level), and 90 degrees of internal and external rotation. 38 C.F.R. § 4.71, Plate I. A November 2010 VA examination report notes that per history, the Veteran was struck by a single bullet in Vietnam in April 1969, which entered the left posterior lateral chest and exited in the right flank. On physical examination of the residuals of muscle injury, the Veteran had limited range of motion and pain located in the anterior shoulder to the posterior shoulder in rotator cuff. During flareups, raising his left arm overhead caused pain at a 7 to 8 out of 10. The flare-ups were daily and intermittent depending on use. The severity was mild; and the flare-ups were precipitated by overhead use. There were no additional functional limitations during flare-ups. There also were not any associated vascular, nerve, or bone injuries. Range of motion studies in the left shoulder showed forward flexion to 90 degrees and abduction to 80 degrees after three repetitions. The Veteran was limited by pain and stiffness. He also had tenderness to the rotator cuff. A July 2011 VA neurology note shows the Veteran had a one-year history of left shoulder weakness and occasional numbness and tingling in the medial hand and pinky on the left and some weakness in the grip on the left. Physical examination showed 4 out of 5 strength in the left deltoid and 4 strength in the left infraspinatus. The Veteran complained of occasional numbness and tingling in the left lateral shoulder and medial hand and 5th digit on the left. Nerve conduction studies were performed, which showed that the left median and ulnar distal latency was mildly prolonged. Overall, it was found that there was electrodiagnostic evidence consistent with moderately severe left ulnar mononeuropathy localized to somewhere across the elbow. It further was noted that from the MRI findings of the cervical spine that the left arm weakness was probably radicular from the cervical spine. A July 2011 VA physical therapy consult shows the Veteran had a four-year history of left neck pain and left upper extremity weakness. The Veteran described pain that had progressively worsened along with weakness. He also described constant neck/shoulder pain with intermittent pain down to the forearm and numbness/ tingling to the left arm/shoulder. Range of motion studies showed that the Veteran could flex his left shoulder to 138 degrees; and abduct his shoulder to 115 degrees. Neurological findings showed reflexes in the left triceps were absent on the right; the left bicep was 1+ and the brachioradialis was 1+ on the left. Motor studies showed that the left triceps were 4 out of 5. Sensory examination was intact in the upper extremities. The Board concludes that the evidence of record shows the impairment associated with the left shoulder disability does not more nearly approximate a rating higher than 20 percent for moderately severe to severe impairment of Muscle Group IV. See 38 C.F.R. § 4.7. As discussed above, the Veteran reported that his left shoulder hurt if he raised it over his head. Any impairment that is moderately severe or severe under Diagnostic Code 5304 is considered by the 20 percent rating assigned. The Board finds that a rating greater than 20 percent is not warranted under any other diagnostic code for any period on appeal. As to the other Muscle Groups involving the shoulder and arm (Diagnostic Codes 5301 through 5306), several of these diagnostic codes permit a 30 percent rating for the nondominant extremity. That said, given that the objective evidence of record has shown limitation of abduction and rotation of the shoulder, the Board finds that a rating under Diagnostic Code 5304 is most appropriate. In that regard, the Board has considered the Veteran’s complaints of difficulty with overhead activities, in particular, during periods of flare-ups and acknowledges that Diagnostic Code 5301 contemplates problems with overhead activities. However, there has been flexion and abduction of the shoulder to greater than shoulder level during some objective testing and all records are consistent as to the absence of muscle atrophy in the muscle governing left shoulder movement, which demonstrates that the Veteran retains the ability to use his left shoulder in close to a normal manner, to include duration of use and overhead activities. In light of the foregoing, the Board finds that the most appropriate rating under the Muscle Group diagnostic codes is Diagnostic Code 5304 and not Diagnostic Code 5301 or any of the other related codes. As to the Veteran’s limited motion in the left shoulder, assigning a separate evaluation for limitation of motion of the shoulder is not warranted as Diagnostic Code 5304 contemplates limitation of motion, including rotation and abduction of the shoulder joint. See 38 C.F.R. § 4.14 (The evaluation of the same disability under various diagnoses is to be avoided). During the current appellate time period, the Veteran was most severely limited to left shoulder flexion to 90 degrees and left shoulder abduction to 80 degrees, even accounting for pain. Thus, the evidence indicates that his left shoulder symptoms are not so disabling to actually or effectively result in limitation of arm motion to 25 degrees from his side, the requirement for the next higher percentage rating based on limitation of motion of the arm of the minor extremity without evidence of ankylosis (i.e., a 30 percent rating) under Diagnostic Code 5201. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. No higher rating under a different Diagnostic Code can be applied. The Board notes that there are other diagnostic codes relating to shoulder disorders, such as Diagnostic Code 5200 (ankylosis of the shoulder), Diagnostic Code 5202 (impairment of the humerus), and Diagnostic Code 5203 (impairment of the clavicle or scapula). However, the Veteran’s left shoulder disability is not manifested by an impairment of the humerus, clavicle, or scapula, and therefore Diagnostic Codes 5202 and 5203 are inapplicable. Furthermore, ankylosis is “immobility and consolidation of a joint due to disease, injury, surgical procedure.” Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran was able to move his left shoulder, so it was clearly not ankylosed. Finally, the Board does not find any evidence to warrant a separate or higher rating for neurological symptoms. See 38 C.F.R. § 4.124a, Diagnostic Codes 8510, 8511, 8610, 8611, 8710, 8711. The Board acknowledges the Veteran’s reports of numbness in the shoulder, arm, hand, and fingers. The July 2011 VA neurology note, however, indicated that the neurological findings were attributable to the Veteran’s cervical spine disability. The Board notes that the Veteran’s functional loss was considered, as the medical evidence shows that the Veteran consistently complained of pain in the left shoulder. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the original grant of a 20 percent rating under Diagnostic Code 5304 is based in part on the Veteran’s left shoulder pain and, as such, his continued pain in the joint already is contemplated in the disability rating currently assigned. The Board certainly recognizes that the left shoulder resulted in a significant degree of impairment, but examinations of record showed that he had no limitation of flexion or abduction to less than shoulder level (even accounting for pain). Consequently, the Board finds that a higher disability rating based on functional loss is not warranted. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 20 percent for the Veteran’s left shoulder disability. 7. Entitlement to a compensable rating for hepatitis C The appellant seeks a compensable rating for hepatitis C as a substituted claimant on behalf of the deceased Veteran. The Veteran’s hepatitis C was evaluated under 38 C.F.R. § 4.114, DC 7354, hepatitis C (or non-A, non-B hepatitis). Under DC 7354, a 0 percent (noncompensable) rating is assigned for non-symptomatic hepatitis C. A 10 percent rating is assigned for intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past twelve-month period. A 20 percent rating is assigned for daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent rating is assigned for daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A 60 percent rating is assigned for daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A 100 percent rating is assigned for near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). Note (1) to Diagnostic Code 7354 provides that sequelae, such as cirrhosis or malignancy of the liver, is to be rated under an appropriate diagnostic code, but not to use the same signs and symptoms as the basis for a rating under Diagnostic Code 7354 and under a diagnostic code for sequelae. (See 38 C.F.R. § 4.14). Note (2) provides that, for purposes of rating conditions under Diagnostic Code 7354, “incapacitating episode” means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114, DC 7354. The term “substantial weight loss” is defined as a loss of greater than 20 percent of baseline weight, sustained for three months or longer; and the term “minor weight loss” is defined as a weight loss of 10 to 20 percent of baseline weight, sustained for three months or longer. See 38 C.F.R. § 4.112. A November 2010 VA examination report shows that the Veteran’s hepatitis C had been diagnosed by bloodwork in 2003. The Veteran reported that his symptoms included catching a cold quickly and having a weakened immune system. There was no fatigue or malaise, nausea or vomiting, anorexia, weakness, or right upper quadrant pain. The report noted that there was an absence of symptoms. A March 2011 VA examination report also notes that the Veteran did not have any active problems from hepatitis C currently. As the record shows the Veteran’s hepatitis did not have any symptoms associated with it, a rating higher than 0 percent is not warranted. 8. Entitlement to a compensable disability rating for scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin (claimed as disfigurement) The appellant seeks a compensable rating for scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin (claimed as disfigurement) as a substituted claimant on behalf of the deceased Veteran. The Veteran’s scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin are rated under Diagnostic Code 7805 for other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7805 was not changed by the August 13, 2018, amendments. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate Diagnostic Code. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating for the Veteran’s scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin under Diagnostic Code 7805 as there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. A November 2010 VA examination report notes that the Veteran experienced tightness related to his thoracotomy scar and had no other symptoms reported for the remaining scars. On physical examination, the scars were nontender and superficial. They did not cause limitation of motion or function. There was no abnormal texture or pigmentation on the head, face, or neck. The right lower thoracic scar was 12 cm x 1 cm and was horizontal. The abdominal midline scar was 27 cm x 3 cm. The right inguinal scar was 4cm. The larger left anterior chest scar was 23 cm x 1cm. The smaller left anterior scars were 5cm x 0.2cm and 4 cm x 0.2 cm. The left anterior scar to axilla was 6cm x 2cm. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s scar residuals from appendectomy, thoracotomy, laparotomy and cut down scars in the right groin are not of the head, face, or neck, are not deep and nonlinear, and are not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Moreover, the Veteran’s scars, appendectomy, thoracotomy, laparotomy and cut down scars in the right groin are not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. The Board acknowledges that the appellant believes that the disability on appeal has been more severe than the assigned disability rating reflects. However, she does not assert, and medical records do not show, that the Veteran’s scar residuals from appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin were manifest by any disabling effects not considered in a rating provided under Diagnostic Codes 7800-04. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim for a compensable rating for scars, appendectomy, thoracotomy, laparotomy and cut-down scars in the right groin. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to a compensable rating for appendectomy The appellant seeks a compensable rating for appendectomy as a substituted claimant on behalf of the deceased Veteran. The service-connected appendectomy was assigned a 0 percent disability rating pursuant to Diagnostic Code 7399-7329, indicating the condition had been rated by analogy to Diagnostic Code 7329 (for resection of large intestine). 38 C.F.R. §§ 4.20, 4.114. Diagnostic Code 7329 provides for ratings for resection of the large intestine. A 10 percent rating is assigned for slight symptoms. A 20 percent rating is assigned for moderate symptoms. A 40 percent rating is assigned for severe symptoms, objectively supported by examination findings. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The record shows that the Veteran underwent an appendectomy during treatment for his gunshot wound in service. However, a November 2010 VA examination report shows that the Veteran did not have any functional limitations due to his appendectomy. There is no other medical evidence of record associated with any residuals from his appendectomy (other than the scars addressed in the previous section). As the record does not show any symptoms associated with his appendectomy, a compensable rating is not warranted. As such, the appellant’s claim must be denied. 10. Entitlement to service connection for neuropathy of the right hand The appellant seeks service connection for neuropathy of the right hand, secondary to service-connected diabetes mellitus, as a substituted claimant on behalf of the deceased Veteran. Because the appellant or Veteran did not raise, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran had a current right-hand neuropathy that is proximately due to or the result of or was aggravated beyond its natural progress by his service-connected diabetes mellitus. A November 2010 VA examination report found that there was no objective evidence of neuropathy in the right hand. The Veteran complained that he developed a paresthesia in the right upper extremity from the right shoulder down to all five fingers in 2003. He also stated that he had a functional loss with only 45 percent of strength available in the right hand. Objective evaluation, however, showed normal strength testing to gravity and resistance. Sensory examination and vibration sensation also were normal in the right upper extremity. The examiner determined that there was no objective finding of neuropathy in the right upper extremity and no functional limitation. An April 2011 VA neurology consult shows that the Veteran had a past medical history of diabetic neuropathy. (However, treatment had been for symptoms in the bilateral lower extremities.) The Veteran had reportedly noticed weakness in the upper extremities about four years ago, on the left greater than the right, but seldom had any numbness in the upper extremities. Motor testing was 4 to 5 out of 5 in the right wrist flexor and extension, and right finger extension and flexion and abduction. The examiner’s impression was that the Veteran had probable diabetic neuropathy, but the examiner would check for other common causes. The other impression was upper extremity weakness, left greater than right. It was noted that the pattern was not clear, but the examiner suspected this was likely an underlying cervical radiculopathy, although other etiologies had to be considered. In weighing the evidence of record, the preponderance of the evidence is against finding that the Veteran had right hand neuropathy secondary to diabetes mellitus. The Board concludes that, while the Veteran had current symptoms of weakness and numbness in the right upper extremity, there was no functional impairment shown as a result these findings. Moreover, it was found that even though the Veteran had diabetic neuropathy, the weakness in the right upper extremity was likely due to a cervical spine disability (which was not a service-connected disability). See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Thus, the preponderance of the evidence is against finding that the Veteran’s right-hand neuropathy was proximately due to or the result of or aggravated beyond its natural progression by his service-connected diabetes mellitus. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). While the appellant believes that the Veteran’s right-hand neuropathy was due to his diabetes mellitus, the appellant is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the appellant or Veteran in this case because the record does not show that either person had or has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the November 2010 VA examination report and April 2011 VA neurology consult. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.