Citation Nr: 20075996 Decision Date: 11/30/20 Archive Date: 11/30/20 DOCKET NO. 13-18 913 DATE: November 30, 2020 ORDER Entitlement to an initial rating higher than 10 percent for coronary artery disease (CAD) prior to July 12, 2013, and higher than 30 percent for the period from July 12, 2013 to December 1, 2016 exclusive of any period of temporary total rating, is denied. Entitlement to an increased rating higher than 10 percent for left calf scar and shell fragment wound residuals (left calf disability) is denied. Entitlement to an increased rating of 10 percent, but not higher, for left lower extremity lateral plantar sensory terminal latency is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial compensable rating for right thigh meralgia paresthetica (right thigh disability) is denied. For the period from July 9, 2013 to July 9, 2020, entitlement to an increased compensable rating for bilateral hearing loss is denied. For the period from July 10, 2020, entitlement to an increased rating of 10 percent, but not higher, for bilateral hearing loss is granted subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating of 100 percent for service-connected posttraumatic stress disorder with depression (PTSD) is granted for the entire period on appeal, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to service connection for migraine headaches, secondary to service-connected PTSD on a causation basis, is granted. FINDINGS OF FACT 1. For the period prior to July 12, 2013, the Veteran’s CAD symptoms did not more nearly approximate a workload of greater than 5 metabolic equivalents of task (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 2. For the period from July 12, 2013 to December 1, 2016, exclusive of any period of temporary total rating, the Veteran’s CAD symptoms did not more nearly approximate more than one episode of acute congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular ejection fraction (LVEF) of 30 to 50 percent. 3. The Veteran’s left calf disability more nearly approximates a moderate muscle injury, and does not more nearly approximate a moderately severe muscle injury. 4. Throughout the period on appeal, the Veteran’s left lateral plantar sensory terminal latency of the lower left extremity symptomatology more nearly approximates moderate incomplete paralysis of the left deep peroneal nerve, but not severe incomplete paralysis. 5. Throughout the period on appeal, the Veteran’s chronic right thigh disability symptomatology does not more nearly approximate severe to complete paralysis of the external cutaneous nerve of the thigh. 6. For the period from July 9, 2013, to July 9, 2020, the evidence of record does not reflect that the Veteran demonstrated worse than the level I hearing acuity in his right ear, and level III hearing acuity in his left ear that was demonstrated prior to July 9, 2013. 7. For the period from July 10, 2020, the Veteran demonstrated, at worst, level II hearing acuity in his right ear and level V hearing acuity in his left ear. 8. The evidence is at least evenly balanced as to whether for the entire period on appeal, the Veteran’s PTSD symptomatology has more nearly approximated total occupational and social impairment. 9. The evidence of record reflects that the Veteran’s migraine headaches were caused by his service connected PTSD. CONCLUSIONS OF LAW 1. For the period prior to July 12, 2013, the criteria for an initial rating higher than 10 percent, and for the period from July 12, 2013 to December 1, 2016, the criteria for a rating higher than 30 percent, exclusive of any period of temporary total rating, for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.104, Diagnostic Code (DC) 7006. 2. The criteria for an increased rating higher than 10 percent for left calf disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.10, 4.14, 4.72, DC 5311. 3. The criteria for an increased rating of 10 percent, but not higher, for left lateral plantar sensory terminal latency of the lower left extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8523. 4. The criteria for a compensable rating for right thigh disability have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.124a, DC 8529. 5. For the period from July 9, 2013 to July 9, 2020, the criteria for an increased, compensable rating for bilateral hearing loss have not been met; for the period from July 10, 2020, the criteria for an increased 10 percent rating, but not higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.85, DC 6100. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for an increased rating of 100 percent for PTSD have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411. 7. The criteria for service connection for migraine headaches, secondary to service-connected PTSD on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 U.S.C. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 to July 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from May 2009, December 2010, and July 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, and respectively: continued a 30 percent rating for PTSD, a 10 percent rating for left calf residuals, a noncompensable rating for bilateral hearing loss; granted service connection for CAD evaluating it as 10 percent disabling; and granted service connection for right thigh disability, evaluating it as noncompensable, continued a noncompensable evaluation of left lower extremity plantar sensory terminal latency, and denied service connection for migraines. In December 2009, the Veteran filed his notice of disagreement with the 30 percent evaluation for PTSD, the 10 percent evaluation for left calf residuals, and the noncompensable rating for bilateral hearing loss. In February 2011, the Veteran filed his notice of disagreement with the 10 percent evaluation for CAD. In May 2013, the Veteran was issued statements of the case regarding the 10 percent rating for left calf residuals, the 10 percent rating for CAD, and the 30 percent rating for PTSD, and in July 2013 perfected his appeal as to these issues. In September 2013, the Veteran filed his notice of disagreement with the noncompensable evaluations for right thigh disability, bilateral hearing loss, and left plantar sensory terminal latency of the lower left extremity, and the denial of service connection for migraines among other things. In an October 2014 rating decision, the RO granted a 30 percent rating for the Veteran’s CAD, effective July 12, 2013, creating a staged rating. In October 2014, the Veteran was issued a statement of the case regarding, among other things, the denial of service connection for migraines, and the noncompensable evaluations for bilateral hearing loss, right thigh disability, and left lateral plantar sensory disability, and perfected his appeal as to these issues in December 2014. The Board notes that on his July 2013 and December 2014 Form 9 appeals, the Veteran requested a Board hearing before a Veterans Law Judge. However, in a November 2015 letter to VA, the Veteran withdrew his request. Therefore, the Board considered the hearing request withdrawn and adjudicated the case based on the evidence of record. See 38 C.F.R. § 20.704 (d). In August 2017, the Board, among other things, granted a 50 percent rating for the Veteran’s PTSD, denied a compensable rating for the Veteran’s bilateral hearing loss prior to July 9, 2013, and remanded the ratings claims for CAD, bilateral hearing loss post July 9, 2013, left calf residuals, right thigh disability, and PTSD higher than 50 percent, and the claim for service connection for migraines for outstanding VA and private treatment records, and for VA examinations. For the reasons indicated in the discussion below, the RO substantially complied with the Board’s remand instructions, to include by affording the with adequate VA examinations and opinions, and no further action is necessary in this regard. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with). An August 2017 rating decision implemented the 50 percent rating for PTSD. In July 2018, the Veteran filed his notice of disagreement with the 50 percent rating. In an August 2020 supplemental statement of the case, the RO notified the Veteran that it had granted a 100 percent rating for CAD from August 15, 2016, a 30 percent rating from December 1, 2016, and an 100 percent rating from July 2, 2020, denied a rating higher than 50 percent for PTSD, denied a rating higher than 10 percent for left calf residuals, denied a compensable rating for bilateral hearing loss, left lower extremity lateral plantar sensory terminal latency, right thigh disability, and denied service connection for migraine headaches. As these constitute either a denial or a partial grant of the benefits sought on appeal, the issues remain on appeal before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 1. CAD The Veteran’s CAD is currently rated 10 percent disabling prior to July 12, 2013, 30 percent disabling from July 12, 2013 to August 14, 2016, 100 percent disabling from August 15, 2016 to November 30, 2016, 30 percent disabling from December 1, 2016 to July 1, 2020, and 100 percent disabling from July 2, 2020 under DCs 7005, and 7006. DC 7005 evaluates arteriosclerotic heart disease, including CAD, and assigns a 30 percent rating when workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure, or; when workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of less than 30 percent. Under DC 7006, a 10 percent rating requires a workload of greater than 7 METs but not greater than 10 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope, or; requires continuous medication. A 30 percent rating requires a workload of greater than 5 METs but not greater than 7 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating requires more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating requires documented myocardial infarction resulting in chronic congestive heart failure, or; workload of 3 METs or less, which results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7006. Additionally, a 100 percent rating is provided for 3 months following a myocardial infarction, documented by laboratory testing. Id. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. at Note 2. An October 2010 examination report reflected that the Veteran reported CAD symptoms which included angina a couple times per week, constant fatigue, and weekly dizziness. The examiner noted a moderate myocardial infarction and angioplasty in December 2004. The Veteran’s symptoms were treated with medication which included Nitroglycerin which caused occasional headaches. The Veteran’s blood pressure readings were as follows: lying, 124 systolic over 80 diastolic; sitting, 124 systolic over 80 diastolic; and standing, 134 systolic over 84 diastolic. There was no evidence of congestive heart failure, and the examiner noted that the Veteran’s CAD had a mild effect on activities of daily life. A November 2010 cardiopulmonary report reflected that the Veteran’s resting heart rate was 80 beats per minute, his blood pressure was 99 systolic over 70 diastolic, and the examining physician reported that there was no evidence of symptomatic CAD at this level of exercise. A July 2013 VA examination report reflected that the Veteran’s CAD required taking continuous medication, and indicated that the Veteran had percutaneous coronary intervention and myocardial infarction in 2004. The Veteran had not had coronary bypass surgery, a heart transplant, cardiac pacemaker, or implanted automatic implantable cardioverter defibrillator. The examiner noted that the Veteran did not have congestive heart failure. No diagnostic exercise test was conducted, and the Veteran’s lowest level of activity at which the Veteran reported symptoms of fatigue was greater than 3 to 5 METS. There was no evidence of cardiac hypertrophy or dilatation, and LVEF was at 71 percent as of 2004. The examiner noted that the Veteran’s CAD did not impact his ability to work, but stated the Veteran is unable to ambulate on the treadmill. A July 2020 imaging service report reflected left ventricle ejection fraction of 60 percent, mild to moderate stenosis of the aortic valve, and mild regurgitation of the mitral valve. A July 2020 disability benefits questionnaire (DBQ) reflected diagnosis of acute, subacute, or old myocardial infarction, atherosclerotic cardiovascular disease, CAD, valvular heart disease, and percutaneous coronary intervention with stent placement. The Veteran’s heart conditions required use of continuous medication, the examiner noted that the Veteran had a myocardial infarction, but the Veteran had not had congestive heart failure or a cardiac arrhythmia. The DBQ reflected that the Veteran had not had any infectious cardiac conditions, pericardial adhesions, but has had non-surgical or surgical procedures for treatment of a heart condition. His heart rate was 60 beats per minute, and blood pressure was 118 systolic over 70 diastolic. There was no evidence of cardiac hypertrophy or cardiac dilatation noted, and the examiner reported the results of a July 2017 exercise stress test with the Veteran achieving 10.10 METS and 86 percent of maximum predicted heart rate, and SPECT perfusion revealing no evidence of stress-induced myocardial ischemia or infarction with normal LVEF of 67 percent. The DBQ reflected an interview based METs test which indicated dyspnea, and fatigue when walking 80 yards or less, and the Veteran also reported being tired all of the time. The examiner noted MET level of 1 to 3 METs due solely to the Veteran’s cardiac conditions. The examiner also opined that the Veteran’s heart conditions impacted his ability to work as he had decreased ability to perform strenuous physical activities, prolonged walking, and stair climbing. The Board finds that for the period prior to July 12, 2013, a disability rating higher than 10 percent for the Veteran’s CAD is not warranted. The Veteran’s October 2010 examination report indicated that the Veteran had a myocardial infarction and angioplasty in 2004, there was no evidence of congestive heart failure, and the examiner noted that the Veteran’s CAD had a mild effect on his activities of daily life. There is no indication that the Veteran’s CAD symptoms more nearly approximated those contemplated by a higher, 30 percent rating under DCs 7005 or 7006 such as dyspnea, fatigue, angina, dizziness, or syncope for workload of greater than 5 METs but not greater than 7 METs, and there is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Therefore, for the period prior to July 12, 2013, a higher 30 percent rating for CAD is not warranted. For the period from July 12, 2013 to August 14, 2016, and from December 1, 2016 to July 1, 2020, the Veteran’s CAD symptomatology does not more nearly approximate that contemplated by a higher 60 percent rating under DCs 7005 or 7006. While the July 2013 VA examination report reflected that the Veteran took continuous medication for his CAD symptoms, the examiner noted no congestive heart failure, and the lowest level of activity at which the Veteran reported fatigue was greater than 3 to 5 METs. At no time during the period at issue does the evidence of record reflect that the Veteran’s CAD symptomatology more nearly approximated workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of 30 to 50 percent. Therefore, a higher 60 percent rating is not warranted for the Veteran’s CAD under DCs 7005 or 7006 for the period from July 12, 2013 to August 14, 2016, and from December 1, 2016 to July 1, 2020. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 2. Left calf disability The Veteran’s left calf disability is currently rated 10 percent disabling under DC 5311. Injuries to muscle group XI are rated under 38 C.F.R. § 4.73, DC 5311. These muscles include the posterior and lateral crural muscles and muscles of the calf, including the triceps surae (gastrocnemius and soleus), tibialis, posterior, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus, popliteus, and plantaris. The functions of these muscles are propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes and flexion of the knee. Under DC 5311, the following ratings apply: a noncompensable rating is warranted for slight injury, a 10 percent rating is warranted for moderate injury, a 20 percent rating is warranted for moderately to severe injury, and a 30 percent rating is warranted for severe injury. Id. The words “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Muscle injuries are evaluated in accordance with 38 C.F.R. § 4.56. The pertinent provisions of 38 C.F.R. § 4.56 are as follows: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be rated as no less than a moderate injury for each group of muscles damaged. (c) 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. (d) Under DC Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles (i) Type of injury. Simple wound of muscle without debridement of infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in the muscle tissue. (2) Moderate disability of muscles (i) Type of injury. Through-and-through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles (i) Type of injury. Through-and-through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period of treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles (i) Type of injury. Through-and-through or deep penetrating would due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or of flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. In a March 2009 letter to VA, the Veteran stated that he has complained about the pain in his left calf for years which becomes very painful when walking or standing, and causes his hip and back to hurt from favoring his leg. He also stated that it hurts when he is relaxing and that it limits the physical activities he can perform. In an April 2009 VA examination report, the examiner noted that the Veteran stated that he suffered a shell fragment wound when he was near a mortar blast in Vietnam, and that the shell fragments were left in his calf as they were too deep to remove. The Veteran complained of daily chronic pain in his left calf which he reported as being in the posterior aspect of his left calf leg, and described the pain as sharp occasionally radiating both up and down. He described the pain as a 4 on a scale of 1 to 10, occasionally reaching an 8 out of 10 in severity. He reported taking ibuprofen every day to treat the pain, and applying heat and cold. The Veteran reported exacerbating factors, including standing and walking a block or more. He stated that he is most comfortable when straightening his leg out and moving his knees, and reported that he is completely independent in his daily life, working in a sedentary job with the Bonne Terre Prison. The Veteran stated that he has lost about 3 days in the past year from work due to his leg pain. The examiner noted a 2 by 5 mm radiopaque metallic fragment in the soft tissue of the left calf, but no fractures or periosteal reactions. The Veteran reported no further care for his wound, nor any medical attention except for his pain medications. There were no tumors of his muscle, and the examiner noted that the muscle affected would be muscle group XI. The examiner noted that the Veteran ambulated independently without the use of any assistive devices with a normal gait, and that examination showed a very faint, almost imperceptible, irregular, circular, 0.5 cm scar on the posteriolateral distal left calf which was nontender to touch. There were no foreign bodies palpable in the Veteran’s calf, skin/musculature was nontender, there was no evidence of damage to underlying tissue, and the miniscule scar was nonadherent. The examiner noted no evidence of skin breakdown or keloid formation, it was not depressed nor raised, but was slightly depigmented. The lower legs showed normal musculature with no difference between the left and right leg, normal movement of the knees and ankles with no discernible deformity, minimally decreased perception to light touch along the posterolateral aspect of the left leg, and no decrease in muscle strength, bone or joint movement, or adhesions upon examination. A March 2011 VA examination report reflected a left posterior calf scar that was small and difficult to see measuring approximately 0.4 cm by 0.4 cm. The Veteran did not report any symptoms, but reported pain in the underlying calf muscles. The scar was nontender and nonadherent, superficial, and not deep with no skin breakdown. It did not limit motion or affect function, there was no evidence of inflammation, edema or keloid formation. The Veteran stated that he experiences pain in his calf muscles when he walks, and as he grows older, the pain increases. He reported using a cane to walk when he is not working. He reported that he can stand for an hour with pain in the leg, walk for a mile if he tolerates the pain in his leg, and that his activities of daily living are occasionally affected by the pain. The examiner noted that there were no deformities in the left calf muscles, no disparity in the size as compared to the right calf muscles, no tenderness to palpation, and range of motion of the left ankle was normal. A separate July 2013 VA examination report reflected that the Veteran’s left calf disability included an associated entrance and exit scar indicating track of missile through one or more muscle groups. The examiner noted that the Veteran did not have any known fascial defects or evidence of fascial defects associated with any muscle injuries, and that the Veteran’s muscle injuries did not affect muscle substance or function. The examination report reflected consistent lowered threshold of fatigue, and consistent fatigue and pain in the left side affecting muscle group XI. Muscle strength was normal, and the Veteran did not have muscle atrophy, but did report occasional use of a cane for long ambulation. The examiner noted that the Veteran’s muscle injury impacted his ability to work as physically demanding situations would prove difficult. A July 2020 DBQ reflected that the Veteran continued to suffer from numbness, pain and cramping in his left calf and lateral left ankle region that impedes his ambulation at times. Symptoms included moderate intermittent pain, paresthesias and/or dysesthesias, and numbness of the left lower extremity. There was no muscle atrophy noted, but there was decreased light touch sensation of the left lower leg/ankle, no lower extremity hair, and the Veteran walked with a limp secondary to left calf pain. The Veteran reported occasional use of a cane due to left calf pain. The examiner noted a left calf scar measuring 1 by 1 cm, and indicated that the Veteran’s left calf disability impacted his ability to work as he could do no prolonged walking, stair climbing, or heavy lifting greater than 50 lbs. In a separate DBQ in July 2020, the Veteran described left calf flare-up pain as sharp muscle pain that he rated as 5 or 6 out of 10 which increased with walking, but which could also occur out of the blue while sitting. He stated that the flare-up pain occurs several times per month. The DBQ reflected a left muscle group XI injury. The examiner noted that the Veteran did not have any known fascial defects or evidence of fascial defects associated with any muscle injuries, and that the Veteran’s muscle injuries did not affect muscle substance or function. The Veteran reported use of a cane at times due to left calf muscle cramping and soreness, and the examiner opined that the Veteran’s muscle injuries impacted his ability to work as he would have to take frequent breaks, and would experience difficulty walking up and down stairs. Based on the relevant evidence above, the Board finds that the Veteran’s left calf shell fragment wound residuals more nearly approximates moderate injury, and not moderately severe muscle injury. While the Veteran’s DBQs and VA examination reports reflect that the Veteran’s left calf disability symptomatology included fatigue, sharp muscle pain that increased with walking, and a lowered threshold of fatigue, the examiners noted that the Veteran had no known fascial defects associated with any muscle injuries, no deformities in the left calf muscle, and no decrease in muscle strength, bone or joint movement, or adhesions upon examination. Additionally, the Veteran reported no further care for his wound, nor any medical attention except for pain medications, and the examiner noted a 2 by 5 mm radiopaque metallic fragment in the soft tissue of the left calf, but no fractures or periosteal reactions. The relevant evidence of record does not more nearly approximate moderately severe disability of muscles as contemplated by a 20 percent disability rating under DC 5311. While the July 2013 examination report indicated that the Veteran had consistent lowered threshold of fatigue, and consistent fatigue and pain, the Veteran’s left calf disability symptomatology did not more nearly approximate consistent complaint of additional cardinal signs and symptoms of muscle disability, hospitalization for a prolonged period of treatment of the wound, or evidence of inability to keep up with work requirements. Therefore, a higher 20 percent rating for left calf disability is not warranted under DC 5311. The Board recognizes the contentions of the Veteran with regard to the severity of his symptoms including his statements regarding calf pain when walking or standing which causes his hip and back to hurt from favoring his leg. However, the schedular rating criteria for rating muscle disabilities contain specific requirements with regard to type of injury, history and complaint, and objective findings. While the Board is sympathetic to the Veteran, it is bound by the laws and regulations relating to veterans claims, and the medical evidence specifically addressing the criteria in the applicable regulation are more probative than the more general lay statements. 38 U.S.C. § 7104 (c) (2012); 38 C.F.R. §§ 19.5, 20.101(a). For the foregoing reasons, the preponderance of the evidence is against a rating higher than 10 percent for the Veteran’s left calf disability. The benefit of the doubt rule is therefore not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 3. Left lateral plantar sensory terminal latency of left lower extremity The Veteran’s left lateral plantar sensory terminal latency of left lower extremity is rated as noncompensable under DC 8599-8523 for paralysis of the anterior tibial (deep peroneal) nerve. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using “99” for the last 2 digits. Id. Under DC 8523, a noncompensable (0 percent) rating is warranted for mild incomplete paralysis; a 10 percent rating is warranted for moderate incomplete paralysis; a 20 percent rating is warranted for severe incomplete paralysis; and a 30 percent rating is warranted for complete paralysis resulting in loss of dorsal flexion of the foot. 38 C.F.R. § 4.124a, DC 8523. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. A July 2013 VA examination report indicated that the Veteran did not have any symptoms of pain, or paresthesias/dysesthesias attributable to any peripheral nerve conditions of the left lower extremity. Sensation testing for light touch was normal, and there were no trophic changes attributable to peripheral neuropathy. The left deep peroneal nerve was noted as normal, and the Veteran did not report use of any assistive devices as a normal mode of locomotion. A July 2020 DBQ reflected that the Veteran’s electromyography and nerve conduction velocity (EMG/NCV) on October 28, 2003 was essentially normal for the left upper and lower extremity, but a delay in the left lateral plantar sensory terminal latency was seen in the nerve conduction of the left lower extremity that was noted to be nonspecific and probably not clinically significant. The Veteran reported numbness in the posterolateral aspect of his left calf and ankle. The examiner noted moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the left lower extremity, decreased sensation for light touch in the left lower leg/ankle, and trophic changes of the lower extremity, specifically no lower extremity hair, with normal skin texture. The DBQ reflected normal left lower extremity nerves including the left deep peroneal nerve. The examiner noted that the Veteran’s peripheral neuropathy conditions impacted his ability to work as he could do no prolonged walking, stair climbing, or heavy lifting greater than 50 lbs., and also noted that the decreased sensation to light touch was around the defined scar regions only. The examiner reported that the plantar sensory terminal latency of the left lower extremity is not a diagnosis, but a finding noted on a past EMG/NCV that was stated to be nonspecific and probably not clinically significant. She stated that the sensory examination findings do not reveal any specific dermatomal sensory deficits, but rather, decreased sensation about the shell fragment scar sites, thus the diagnosis of plantar sensory terminal latency of the left lower extremity does not correlate with a peripheral nerve deficit at this time. Based on the evidence of record, the Veteran’s left lateral plantar sensory terminal latency of the lower left extremity symptomatology more nearly approximates moderate incomplete paralysis of the left deep peroneal nerve. While the July 2020 examiner noted normal left lower extremity nerves, she also noted moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the left lower extremity. Thus, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s noted symptomatology more nearly approximates that which is contemplated by a 10 percent disability rating under DC 8523. While the July 2013 VA examination report indicated no symptoms of the lower left extremity, it is reasonable to conclude that the Veteran’s symptoms were intermittent, and thus, undetectable at the time of the examination. There is no other indication that the Veteran’s symptomatology suddenly worsened, thus the 10 percent disability rating is warranted for the entire period on appeal. There is no evidence of record within the VA examination report or DBQ, and the Veteran does not otherwise contend, that his left lateral plantar sensory terminal latency symptomatology more nearly approximates severe incomplete paralysis. In fact, the July 2020 examiner specifically noted normal left lower extremity nerves. Therefore, a higher 20 percent rating is not warranted. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s left lateral plantar sensory terminal latency more nearly approximates symptomatology contemplated by a 10 percent rating, but not higher, under DC 8523. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to an increased 10 percent rating, but not higher is warranted for the entire period on appeal. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 4. Right thigh meralgia paresthetica The Veteran’s right thigh disability is currently rated noncompensable under DC 8529. DC 8529, which evaluates paralysis of the external cutaneous nerve of the thigh, assigns a noncompensable (0 percent) rating for mild to moderate incomplete paralysis of the external cutaneous nerve of the thigh. A maximum 10 percent schedular rating is assigned for severe to complete paralysis of the external cutaneous nerve of the thigh. 38 C.F.R. § 4.124a, DC 8529. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. Special consideration should be given to any psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, and injury to the skull. 38 C.F.R. § 4.120. A July 2013 VA examination report reflected that the Veteran is right hand dominant, and had symptoms related to his right thigh disability which included mild constant pain, paresthesias and/or dysesthesias, and numbness, but no muscle atrophy. There was decreased right upper anterior thigh sensation for pin and light touch, but the Veteran did not have any trophic changes attributable to peripheral neuropathy. The Veteran’s gait was noted to be normal, and the examiner noted mild incomplete paralysis of the external cutaneous nerve of the thigh. The examination report reflected that the Veteran had a scar or scars related to his left thigh disability, but they were not painful or unstable, and did not have a total area greater than 39 square cm. The examiner opined that the right thigh disability did not impact the Veteran’s ability to work. A July 2020 DBQ reflected that the Veteran continued to suffer from numbness and burning in his right thigh. Symptoms included moderate intermittent pain, paresthesias and/or dysesthesias, and numbness of the right lower extremity. There was no muscle atrophy noted, but there was decreased light touch sensation of the upper anterior right thigh, and no lower extremity hair. The examiner noted mild incomplete paralysis of the right external cutaneous nerve of the thigh, and 2 scars of the right thigh measuring 2.5 by 2 cm, and 2 by 0.5 cm. In a separate DBQ, the Veteran described burning and numbing pain which increased with activity that he rated as 5 or 6 out of 10. The DBQ reflected right thigh muscle groups XIII and XIV injuries. The examiner noted that the Veteran did not have any known fascial defects or evidence of fascial defects associated with any muscle injuries, and that the Veteran’s muscle injuries did not affect muscle substance or function. There were no signs or symptoms attributable to any muscle injuries, and muscle strength testing was normal. The evidence of record reflects that the Veteran’s right thigh disability symptomatology more nearly approximates mild to moderate incomplete paralysis of the external cutaneous nerve of the thigh. While the Veteran reported burning and numbing pain which increased with activity, the VA examination report and DBQ overwhelmingly described the Veteran’s right thigh disability symptomatology as mild to moderate. The July 2013 examiner noted mild constant pain, paresthesias and/or dysesthesias and numbness, and the July 2020 examiner noted mild incomplete paralysis of the right external cutaneous nerve of the thigh, and moderate intermittent pain, paresthesias and/or dysesthesias, and numbness. The VA examination report and DBQ do not support a finding that the Veteran’s right thigh disability was either severe or complete, and the Veteran has not otherwise provided evidence suggesting that his right thigh disability symptomatology is severe or complete. The Board finds the July 2013 and July 2020 VA examiners’ medical opinions highly probative to the issue of the severity of the Veteran’s right thigh disability as the examiners conducted a physical examination and have the requisite medical expertise and sufficient facts and data upon which to base their conclusions. Therefore, the VA examination report and DBQ are afforded significant probative weight. The Board notes that the Veteran has a diagnosis of right thigh meralgia paresthetica. Accordingly, Diagnostic Code 8529 is the most appropriate Code for application in this case as the Veteran’s right thigh meralgia paresthetica symptomatology is clearly accounted for in the non-compensable rating pursuant to DC 8529. In this regard, the selection of a particular diagnostic code “is a determination that is completely dependent upon the facts of a particular case,” and the Board has discretion in determining the appropriate diagnostic code. Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (applying the more deferential “arbitrary, capricious” standard, rather than de novo review, to the Board’s determination of the appropriate diagnostic code). Accordingly, the Board finds that the Veteran’s right thigh disability symptomatology more nearly approximates mild to moderate incomplete paralysis. Therefore, based on the preponderance of the evidence, a compensable rating under DC 8529 is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 5. Hearing loss As previously discussed, the Veteran’s claim for a compensable rating for bilateral hearing loss for the period from July 9, 2013 was previously remanded by the Board in an August 2017 decision, and the RO denied a compensable rating, notifying the Veteran in an August 2020 supplemental statement of the case. Thus, the issue of a compensable rating for the period from July 9, 2013 remains before the Board. Ratings for hearing loss disability are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level, in decibels (dB) as measured by pure tone audiometric tests in frequencies 1000, 2000, 3000, and 4000 Hertz (Hz). 38 C.F.R. § 4.85, DC 6100. An examination for hearing impairment for VA purposes must include a controlled speech discrimination test (Maryland CNC). Id. To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Id. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Id. Exceptional patterns of hearing impairment allow for assignment of the Roman numeral designation through the use of Table VI or an alternate table, Table VIA, whichever is more beneficial to the Veteran. 38 C.F.R. § 4.86. This applies to two patterns. In both patterns each ear will be evaluated separately. Id. The first pattern is where the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 dB or more. 38C.F.R. § 4.86(a). The second pattern is where the pure tone threshold is 30 decibels or less at 1000 Hz and 70 dB or more at 2000 Hz. Id. If the second pattern exists, the Roman numeral will be elevated to the next higher numeral. Id. As the evidence described below shows, neither of the patterns are present in this case. In describing the evidence, the Board refers to the frequencies of 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz, as the frequencies of interest. On the authorized audiological evaluation in April 2009, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 40 60 60 LEFT 25 50 65 65 60 The Veteran’s pure tone threshold average was 44 dB for the right ear and 60 dB for the left ear. Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 92 percent in the left ear. The otoscopic evaluation revealed ear canals free of cerumen bilaterally. The Veteran reported bilateral hearing loss stating that he feels his left ear hearing has decreased since his last evaluation. A July 2013 VA examination report reflected pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 45 60 65 LEFT 25 55 70 65 65 The Veteran’s pure tone threshold average was 45 dB for the right ear and 64 dB for the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 92 percent in the left ear. The otoscopic evaluation revealed ear canals free of cerumen bilaterally. The Veteran stated that he has difficulty hearing his grandchildren and the television. He stated that he stopped working for the Department of Corrections due to several physical conditions in May 2011, none of which were hearing loss or tinnitus. July 2015 VA treatment records reflect normal hearing to conversational voice in a quiet examination room. A July 2020 DBQ reflected pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 55 65 70 LEFT 35 45 70 70 65 The Veteran’s pure tone threshold average was 50 dB for the right ear and 63 dB for the left ear. Speech audiometry revealed speech recognition ability of 88 percent in the right ear, and of 78 percent in the left ear. The Veteran reported that he has a lot of trouble hearing most of the time, stating that he avoids a lot of communication with family or friends, as well as with strangers. He stated that if there is background noise in a room, it is hard to understand what is said. The Veteran reported wearing hearing aids which did not provide much help. The Board notes that the examination report and DBQ noted above describe the effects of the Veteran’s hearing impairments on his daily life, consistent with the requirements of Martinak v. Nicholson, 21 Vet. App. 447 (2007). For the period from July 9, 2013 to July 9, 2020, the evidence of record does not reflect that the Veteran’s bilateral hearing loss disability warrants a compensable rating. The Veteran’s July 2015 VA treatment records reflect normal hearing, and there is no other evidence, to include additional audiological examinations, which indicate that the Veteran’s bilateral hearing loss warrants a compensable rating. While the Board acknowledges the Veteran’s contention that his bilateral hearing loss warrants a compensable rating for the period from July 9, 2013 to July 9, 2020, the Board is bound in its decisions by the VA regulations governing the rating of hearing loss. 38 U.S.C. § 7104 (c); 38 C.F.R. §§ 19.5, 20.101(a). Rating hearing loss requires the use of the Maryland CNC speech discrimination test and the pure tone threshold average determined by an audiometry test. See Lendenmann v. Principi, 3 Vet. App. at 349. The Board has considered the Veteran’s contentions that his hearing had worsened and notes that hearing loss evaluations must evaluate the effects of the hearing loss disability upon the person’s ordinary activities. However, as these symptoms are contemplated by the criteria, consideration of an extraschedular rating is not warranted. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (difficulty in distinguishing sounds in a crowded environment, locating the source of sounds, understanding conversational speech, hearing the television, and using the telephone are each a manifestation of difficulty hearing or understanding speech, which is contemplated by the schedular rating criteria for hearing loss). However, for the period from July 10, 2020, with application of the above test results to 38 C.F.R. § 4.85, Table VI and Table VII, the Veteran’s right ear hearing loss, at its worst, is assigned a numeric designation of II, and the left ear hearing loss, at its worst, is assigned a numeric designation of V, applying the Roman numeral designation appropriate for an exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 for the left ear. These test scores show that for the period from July 10, 2020, the date of the DBQ, the Veteran meets the criteria for a 10 percent disability rating for his bilateral hearing loss. As noted above, the assigned evaluation for hearing loss is determined by mechanically applying the rating criteria to certified results. See Lendenmann, 3 Vet. App. at 349. These results reflect that a 10 percent rating, and not higher, is warranted from July 10, 2020. With regard to the increased rating, the general rule is date of claim or date entitlement arose, whichever is later. See 38 U.S.C. § 5110. Specifically, as to an increased rating claim, section 5110(b)(3) provides that “[t]he effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date.” See also 38 C.F.R. § 3.400(o)(2); Swain v. McDonald, 27 Vet. App. 219, 224 (2015) (“effective date should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that [the veteran’s disability] first manifested”). Here, evidence of record indicates that the earliest date as of which it is ascertainable that the Veteran’s bilateral hearing loss met the criteria for a 10 percent disability rating is July 10, 2020, the date of the DBQ. There is no additional evidence, including lay statements, private or VA audiologist reports, which reflect that the Veteran’s hearing loss meets the criteria for a compensable rating prior to July 10, 2020. For the foregoing reasons, for the period from July 9, 2013 to July 9, 2020, a compensable rating for the Veteran’s bilateral hearing loss is not warranted; and for the period from July 10, 2020, a higher 10 percent rating, but not higher, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 6. PTSD The Veteran’s PTSD is currently rated 50 percent disabling under DC 9411. The criteria for rating PTSD are found at 38 C.F.R. § 4.130, DC 9411. PTSD is rated under the General Rating Formula for Mental Disorders. Under this formula, a 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Symptoms listed in the VA’s general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words “such as” that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held “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.” Id. at 117. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. When evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran’s capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, not solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126 (b). In a January 2009 letter, the Veteran’s ex-wife stated that after service, the Veteran’s behaviour changed dramatically and got progressively worse over the years. She stated that he was frequently unhappy and would drink to excess, had difficulty sleeping, had frequent nightmares, became more distant and withdrawn, and less compassionate. His ex-wife stated that the Veteran has a distant relationship with their daughter and grandchildren, and a volatile relationship with their son. She explained that as his anger and inability to form relationships has progressed, his mental and physical health has declined. In a separate January 2009 letter, the Veteran’s brother stated that the Veteran no longer comes to family events, lost a job he held for over thirty years due to his attitude, and has a very bad relationship with his children. The Veteran’s daughter also submitted a letter in January 2009 in which she stated that the Veteran has a hard time in any aspect of life that requires him to be around other people and that his relationship with all members of the family has been very strained. She stated that the Veteran does not leave his home and does not receive visitors. The Veteran’s daughter reported that the Veteran has a lot of trouble sleeping, suffers from a lot of headaches, and is in an overall melancholy mood almost all of the time. In an April 2009 VA examination, the examining psychologist noted that the Veteran complained of violent nightmares where he ends up in cold sweats and falling out of the bed. The Veteran stated that he has a short attention span, is tired all the time, and is a loner. He reported increased nerve pain as a causative factor for his increase in symptoms, as the pain and his tinnitus are constant reminders of Vietnam. The psychologist noted that the Veteran was oriented to person, place and time, there were no deficits in attention or concentration noted, abstract reasoning skills were somewhat concrete, but within normal limits, and the Veteran was able to complete tasks of immediate and intermediate memory without error. The examination report indicated that the Veteran was well groomed, but had poor eye contact throughout the examination. There were no auditory or visual hallucinations reported or observed, judgment and insight were considered within normal limits, mood was depressed, and affect was restricted. The Veteran endorsed recent suicidal ideation, stating that he had thoughts that he would be better off “not here”, and took out his gun during this contemplation. He denied any current suicidal ideation or plan or intent to harm himself, and denied homicidal ideation. The Veteran reported less interest in things he used to enjoy, not associating with anyone, increased irritability and anger, difficulty following conversations, and difficulty concentrating. He reported a depressed mood about 60 to 70 percent of the time, loss of energy, and issues getting along with supervisors. He reported leaving his job of 31 and a half years in 2003 due to a “hostile work environment”, but has been working since July 2003 as a corrections officer. He stated that he missed work about 9 times the previous year due to his PTSD symptoms stating that did not feel like being around anyone and would call in sick as an excuse. The Veteran reported that he has not been involved in any romantic relationship in the past 3 years, and reported not having any friends. The psychologist opined that the Veteran’s PTSD symptoms are considered serious, have a serious impact on his social functioning, and a moderate impact on his occupational functioning. An October 2010 examination report reflected that the Veteran reported PTSD symptoms which included nightmares, intrusive recollections, depressed mood, isolation, poor concentration, irritability, hypervigilance, and auditory hallucinations. The examination report indicated that the Veteran has not had any previous hospitalizations due to a psychiatric condition, but did require outpatient care due to a psychiatric condition. The Veteran reported being employed and indicated that he misses about 3 to 4 days each month due to his PTSD. The examiner noted that the Veteran did not have impairment of thought process or communication, and no delusions, but did note hallucinations. The Veteran reported hearing voices sometimes telling him to do “bad things” or “suggest” things he could do 3 times a month. There was no inappropriate behavior noted, but the examiner indicated that there have been suicidal and homicidal thoughts or intent. The Veteran reported some difficulty with his long term memory and stated that he sometimes struggles for words and has forgotten the names of people he knows and sees every day, including some extended family members. He also reported forgetting dates and often forgets why he goes into another room to get something. He reported that he feels embarrassed when these things happen. The Veteran stated that he has to be in the back corner with a view of the setting with no one behind him when he goes into a restaurant, and has to recheck all windows, and checks windows and locks every day. The Veteran also reported moderate panic attacks which occur a couple of times a week, and admitted watching action and military shows that can trigger panic attacks. The examination report indicated that the Veteran had depressed mood and impaired impulse control, but no anxiety. The Veteran stated that he has had several run-ins at work and has been disciplined for being “too harsh” with inmates. A July 2013 VA examination report indicated that the Veteran had PTSD symptoms which included re-experiencing trauma, and avoidance of reminders and arousal, and depressive symptoms secondary to PTSD including depressed mood, suicidal ideation, lethargy, diminished interest, and minimal involvement in enjoyable activities. The examiner noted that it was not possible to differentiate what symptoms are attributable to each diagnosis. The examination report reflected that the Veteran’s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported spending his time mostly at home, visiting his father, and going to the store every 2 weeks at night as he is avoidant of people. He stated that he spends much of his day sitting and staring out of the window. The Veteran reported that he retired April 26, 2011 after 8 years as a corrections officer, turning down opportunities for advancement due to concerns about his anger and ability to cope with people and stress. He has not sought further employment due to his irritability and not wanting to socialize with other people, his constant leg pain, and shortness of breath. The Veteran identified suicidal ideation with no plan or intent, described memory impairment, increased anger and irritability, and being verbally antagonistic towards family, but denied physical aggression. The Veteran reported depressed mood, minimal enjoyment of activities, minimal interest in activities, low energy, and stated that his physical condition interferes with his activity level and abilities. He stated he experienced “panic attacks” in his home and at work which occur 1 to 2 times each week. The examiner opined that the Veteran’s symptoms were moderate, and while they may cause difficulties in social relationships, they are not interfering with his employment status. A July 2020 DBQ reflected that the Veteran had a diagnosis of PTSD with depression that results in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he lives alone and that his sister comes over to help out occasionally with meals. He reported limited contact with his children and noticed an increase in isolation and avoidance of peers, noting that he prefers to stay home and do nothing. The Veteran reported that he tries to complete tasks around the house, but requires assistance as he loses interest. The DBQ indicated that the Veteran’s PTSD symptoms include depressed mood, anxiety, suspiciousness, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The evidence of record reflects that the Veteran’s PTSD symptoms have included sleep impairment, irritability, diminished interest, and depression. While the July 2013 VA examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks and described the Veteran’s symptoms as moderate, the examiner also noted suicidal ideation, memory impairment, and low energy. The Veteran has reported hallucinations, recurrent nightmares, isolation, and panic attacks throughout the period on appeal. The Veteran’s family members described the Veteran’s inability to socialize with family and friends, and the aforementioned examination reports indicated that he required some assistance at home due to losing interest in completing tasks. The Veteran also reported going to the store at night to avoid social interaction, turning down employment opportunities due to an inability to cope with people and stress, and not having a romantic relationship in several years or any friends. The Board thus finds that the evidence of record including the Veteran’s and his family members’ statements, and the DBQs and examination reports indicate that the symptoms and overall impairment caused by the Veteran’s PTSD more nearly approximate total occupational and social impairment contemplated by the criteria for a 100 percent rating under DC 9411 for the entire period on appeal. Therefore, entitlement to a rating of 100 percent for PTSD is warranted for the entire appeal period. The Board notes the Veteran’s contention that his PTSD symptoms often cause embarrassment as he forgets dates or why he has gone into a room for something, symptoms which may not be contemplated by the schedular rating for PTSD under DC 9411. However, as the Board has granted the maximum 100 percent rating, consideration of an extraschedular rating is not warranted. Cf. Colayong v. West, 12 Vet. App. 524, 537 (1999) (“Hence, on remand the Board is required to address an extraschedular rating for the veteran’s service-connected Pott’s disease if it is not rated 100% as a schedular matter”). Service connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). In a July 2020 DBQ, the examiner noted a diagnosis of migraine headaches from 2016, and that the Veteran reported experiencing chronic headache pain for at least 20 years which had worsened over the past few years. The examiner noted that the Veteran has a history of recurrent sinus infections and sinus headache pain that is distinct from his migraine headache pain. The Veteran reported that his migraine pain is associated with nausea and vomiting, occurs 4 to 5 times per month, and can last all day. He noted sensitivity to light and sound, and stated when the headaches are intense, he has to lay down in a darkened room. The Veteran reported treating his migraine headaches with Fioricet and Tylenol as needed. The examiner opined that the Veteran’s migraine headache pain was less likely than not (less than a 50 percent probability) incurred in or caused by any in-service injury, event, or illness, stating that there is no documented evidence of in-service headache complaints or an in-service head injury. The Veteran does not report an in-service head injury or headache pain and post-service treatment records note complaints of headache pain in 2003/2004. The examiner stated that the Veteran’s headache pain is less likely than not (less than a 50 percent probability) proximately related to any service connected disabilities, noting, among other things, that while there is an association between migraines and PTSD, it cannot be stated that his migraine headache pain is secondary to PTSD, rather, there is a high incidence of comorbidity. The examiner did opine however that the Veteran’s migraine headache pain is at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by his service connected PTSD, stating that studies have shown an increased incidence of psychiatric comorbidities in patients with migraines and in the case of PTSD, the prevalence of migraine in one study was 25.7 percent compared to the control prevalence of 14.2 percent. The examiner continued that while these associations have yet to be proven, studies note an association between PTSD and migraine chronification which is present in the Veteran and an issue that affects his quality of life. The evidence of record thus reflects that service connection for migraine headaches is warranted. The Veteran has provided competent lay evidence that he suffers from headaches and the July 2020 examiner noted a diagnosis of migraine headaches, thus the current disability requirement for service connection has been established. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). The dispositive issue is whether there is a nexus between his service-connected PTSD and his migraines. The July 2020 examiner opined that the Veteran’s migraine headache pain was at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by service connected PTSD and provided a thorough rationale based on and accurate characterization of the evidence of record. Therefore, her opinion is afforded significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There is no other opinion of record other than that of the July 2020 examiner as to the etiology of the Veteran’s migraine headaches. However, the Board finds the July 2020 examiner opinion somewhat ambiguous as to whether the relationship between the migraines and PTSD was one based on causation or aggravation. While the examiner explicitly opined that the migraine headache pain was at least as likely as not aggravated beyond its natural progression by PTSD and not caused by PTSD, she provided as rationale to support both conclusions evidence of the fact that there is a high incidence of comorbidity, and noted an association between PTSD and migraine chronification. The evidence also reflects that the Veteran has suffered from migraine headache pain for approximately 20 years, with pain noted in post-service treatment records in 2003/2004, while the Veteran has been service connected for PTSD since 2003, indicating a temporal relationship in the development of the 2 disabilities. Taken together, the medical opinion and additional evidence contained within is at least evenly balanced as to whether the Veteran’s migraines are related to his service-connected PTSD, and whether the relationship is on an aggravation or causation basis. Resolving interpretive and reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection for migraines secondary to service-connected PTSD, on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Maddox, Associate 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.