Citation Nr: 20035623 Decision Date: 05/21/20 Archive Date: 05/21/20 DOCKET NO. 14-00 707 DATE: May 21, 2020 ORDER Entitlement to service connection for an acquired psychiatric disability, to include depression, and to include as secondary to a service-connected ventral hernia disability, is granted. Entitlement to an initial rating in excess of 20 percent for a ventral hernia disability is denied. For the appellate period prior to October 10, 2014, entitlement to a separate 20 percent rating for abdominal scars secondary to a service-connected ventral hernia disability is granted. From October 10, 2014 to June 30, 2015, entitlement to a separate 30 percent rating for abdominal scars secondary to a service-connected ventral hernia disability is granted. Beginning July 1, 2015, entitlement to a 20 percent rating for abdominal scars secondary to a service-connected ventral hernia disability is granted. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran’s acquired psychiatric disability is aggravated by a service-connected ventral hernia disability. 2. The Veteran has a small ventral hernia that is not well supported by a belt under ordinary conditions; there is no evidence of a large ventral hernia, and referral for extraschedular consideration is not warranted. 3. For the appellate period prior to October 10, 2014, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were painful. 4. From October 10, 2014 to June 30, 2015, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were painful and unstable. 5. Beginning July 1, 2015, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries are painful. CONCLUSIONS OF LAW 1. With resolution of all doubt in the Veteran’s favor, the criteria to establish service connection for an acquired psychiatric disability as secondary to a service-connected ventral hernia disability have been met. 38 U.S.C. §§ 1131; 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for an initial rating in excess of 20 percent for a ventral hernia disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.114, Diagnostic Code (DC) 7339. 3. For the appellate period prior to October 10, 2014, with resolution of all doubt in the Veteran’s favor, the criteria for a separate rating of 20 percent, but no higher, for painful abdominal scars have been met. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7804. 4. From October 10, 2014 to June 30, 2015, with resolution of all doubt in the Veteran’s favor, the criteria for a separate rating of 30 percent, but no higher, for painful and unstable abdominal scars have been met. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7804. 5. Beginning July 1, 2015, the criteria for a separate rating of 20 percent, but no higher, for painful abdominal scars have been met. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from July 1977 to June 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated April 2010, January 2016, March 2017, and April 2017 of a Department of Veterans Affairs (VA) Regional Office (RO). VA treatment records dated as recently as October 2019 indicated that the Veteran is homeless, which is evidence of financial hardship. Appeals must be considered in docket number order but may be advanced if sufficient cause is shown. See 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.902(c). Here, the Board finds that good cause was shown, and as such, the undersigned Veterans Law Judge grants the motion to have this case advanced on the docket. The Board observes that relevant VA medical records have been added to the claims file since the RO’s adjudication in the August 2019 and February 2020 Supplemental Statements of the Case (SSOCs), with a waiver of initial RO consideration. See January 2020 Correspondence; see also Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide that if new evidence is submitted with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the Veteran explicitly requests agency of original jurisdiction (AOJ) consideration). As reflected above, the Board takes jurisdiction of the issue of entitlement to a separate compensable rating for abdominal scars as manifestations of the service-connected ventral hernia disability because this issue is essentially a component of the issue of entitlement to an increased rating for a ventral hernia disability, insofar as the scars were incurred from hernia repair surgeries. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Procedural History As detailed below, this case has a complicated procedural history. In an April 2010 rating decision, the RO denied entitlement to service connection for an acquired psychiatric disability. In a July 2013 rating decision, the RO denied entitlement to service connection for a hernia disability. In January 2014, the RO continued the denial of service connection for an acquired psychiatric disability, as reflected in a Statement of the Case (SOC). In a June 2014 rating decision, the RO continued the denial of entitlement to service connection for a hernia disability because no new and material evidence had been received. In an August 2015 decision, the Board remanded the issue of entitlement to service connection for an acquired psychiatric disability to obtain a VA examination. In December 2015, the RO issued an SSOC continuing the denial of service connection for an acquired psychiatric condition. In a January 2016 rating decision, the RO granted service connection for a hernia disability under 38 U.S.C. § 1151 and assigned an initial 10 percent rating pursuant to DC 7338, effective November 7, 2011. In a December 2016 decision, the Board remanded the issue of entitlement to an acquired psychiatric disability to obtain an adequate VA examination and medical opinion. In March 2017, the RO issued an SSOC continuing the denial of service connection for an acquired psychiatric condition. In a March 2017 rating decision, the RO increased the initial evaluation of the ventral hernia disability to 20 percent disabling under DC 7339, effective November 7, 2011. In an April 2017 SOC, the RO denied entitlement to an initial rating in excess of 20 percent for a ventral hernia disability. In an April 2017 rating decision, the RO granted service connection for abdominal scars secondary to the service-connected ventral hernia disability and assigned a 0 percent evaluation under DC 7805, effective November 7, 2011. In a January 2018 decision, the Board denied entitlement to a rating in excess of 20 percent for a ventral hernia disability and remanded the issue of entitlement to service connection for an acquired psychiatric disability to obtain outstanding private treatment records from St. Margaret’s Hospital and for an addendum VA medical opinion that considered these records. The Veteran then appealed the January 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In July 2018, the Court granted the parties’ Joint Motion for Partial Remand, vacated the Board’s decision denying entitlement to a rating in excess of 20 percent for a ventral hernia disability, and remanded the matter to the Board to properly address the Veteran’s request to obtain private treatment records from St. Margaret’s Hospital. In a January 2019 decision, the Board remanded the issue of entitlement to a rating in excess of 20 percent for a ventral hernia disability due to evidence or worsening and to obtain any outstanding, relevant private treatment records from St. Margaret’s Hospital. In an August 2019 SSOC, the RO continued the denial of entitlement to an acquired psychiatric disability. In a February 2020 SSOC, the RO continued the denial of entitlement to a rating in excess of 20 percent for a ventral hernia disability. The matters have now returned to the Board for further appellate consideration. 1. Entitlement to service connection for an acquired psychiatric disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). Any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation or worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). A lay person is competent to report on the onset and reoccurrence of current symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board must determine on a case-by-case basis whether a Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). When all evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Here, the Veteran asserts that he currently has an acquired psychiatric disability that is related to his active service, or, in the alternative, that is caused or aggravated by his service-connected ventral hernia disability. As an initial matter, the Board finds that the Veteran has a current disability, as he has a current diagnosis of unspecified depressive disorder. See January 2017 VA examination. Turning to the evidence, in a June 2003 VA mental health note, the provider wrote the following regarding the Veteran’s military history: “Veteran served in the Army from 1977 to 1979. He reports that he was stationed in Germany and his MOS was in transportation. He states that his highest rank was a corporal. However, he was demoted to E1, after getting into a fight. Veteran received a[n] honorable discharge and is non-service connected. Veteran denies any treatment for any medical or psychiatric problems while in the service.” In terms of his legal history, the provider wrote, “Veteran reports that in the early 1980s he was charged with involuntary manslaughter and had some jail term and was placed on three years [of] probation. Veteran reports that he accidently killed his best friend due to a hunting accident with the hunting riffle (sic). Veteran reports that he has had severe depression as a result of the death of his friend and feels that this is an issue that has never been resolved. Veteran became somewhat tearful when discussing the death of his friend. Veteran reports that he was incarcerated in the Allegheny County Jail for six to seven months in the early 1980s for selling cocaine. Veteran reports that he was released on probation within 6 months.” The provider wrote the following regarding the Veteran’s psychiatric history: “Veteran reports a history of depression since the early 1980s. Veteran denies any inpatient or outpatient psychiatric treatment. When asked what symptoms veteran has had in the past, he identifies tendency for increased sleep, poor motivation, feeling sad, tearful and isolating. Veteran reports that he has had possibly two episodes in the past where he contemplated suicide. However, veteran denies any suicidal gestures in the past. Veteran reports that his last suicidal ideation was sometime in 2002. Veteran currently rates his mood from the scale of 0-10 with 10 being the most depressed, 0 no depression. He currently rates his mood as 4. Veteran states that if he feels any suicidal or homicidal ideations, he will report this to the staff. Veteran denies any history of anxiety. Veteran does not exhibit any symptoms of hallucinations, paranoia or any other psychotic symptoms. Veteran is alert and oriented times three. According to medical records, on 06/24/03, veteran reported some suicidal ideations with a previous plan of ‘jumping off a bridge or possibly cutting his wrist with a knife.’ He also reported some vague homicidal ideations at that point for those selling him drugs.” In a June 2003 VA treatment plan note, the provider wrote, that the Veteran “will be referred to CTAD Psychiatry to evaluate his reports of long term mild to moderate depression after the death of his friend in the 1980's.” In a June 2003 VA social work E & M note, the Veteran reported “years of depressive symptoms,” and the provider found that the Veteran “would benefit from psychological counseling for his depression due to the death of his friend in the 1980’s. He has not resolved his guilt.” In a July 2003 VA initial evaluation note, the provider wrote, “The veteran was referred to me due to distress over an incident, in which he accidentally killed a friend 10-12 years ago. He reports that he has never discussed this extensively with anyone, and that he does not feel prepared to do so today.” The Veteran reported that in 1979, while in the Army, “he returned to his barracks to find someone consuming [his] alcohol, and a fight ensued. He reports that he cut the other individual with a knife, resulting in fairly extensive injuries to his arms. He reports that he asked his commanding officer to obtain a discharge for him, as he feared being jailed, and he was given a discharge general under honorable condition[s].” On mental status examination, the Veteran reported that he is depressed a lot, stays sad every day, and has experienced problems with his sleep since the death of his friend. In a November 2003 VA psychiatry consultation, the provider noted that the Veteran had “a remote history of depression and anxiety spectrum disorder without any formal treatment...Veteran has a long history of affective disturbance characterized mainly by depressive symptoms which has been affecting him [over] the past 15-20 years since the death of his friend which he may have accidentally contributed to.” The provider assessed him with a “long history of psychiatric disturbance characterized mainly by depressive symptoms. Symptoms began approximately 15 years ago after the death of his friend” and diagnosed him with “Depressive disorder, Not Otherwise Specified (rule out major depressive disorder versus depression secondary to medical condition).” In an April 2004 VA mental health note, the provider noted that the Veteran had a “history of depression disorder, NOS (probable mood disorder due to medical condition) and alcohol dependency, which appears to be in early remission” and noted a diagnostic impression of “Depression, not otherwise specified (probable depression due to general medical condition).” In an August 2004 letter, K.N. wrote that the Veteran was “under the care of the Hepatitis C Clinic at the Pittsburgh Veteran's Healthcare System. The medications to treat Hepatitis C can cause flu-like symptoms such as nausea, vomiting, diarrhea, fever, chills, aches and pains plus depression. These symptoms may prevent him from working. He began this treatment on July 30, 2004 and is expected to continue on it for 48 weeks. End-of-treatment is predicted to be on approximately 7/1/2005 and he will require 6-8 weeks recovery time after treatment.” In a December 2004 VA addendum, the provider noted that the Veteran’s psychiatric history was remarkable for substance abuse and depression, and the Veteran reported that he began drinking heavily while in the military. He acknowledged a history of depression, which began following military service and worsened following the death of his friend. The Veteran reported difficulty sleeping and his appetite was described as “fair.” The provider diagnosed the Veteran with “Cognitive Disorder NOS” and “Depression NOS, probable depression due to a general medical condition (see medical chart).” In a February 2005 VA mental health note, the provider wrote, “The patient is overall doing relatively well. He continues to have subsyndromal affective disturbances (attenuated emotional, cognitive, and neurovegetative symptoms of depression), but he denies severe symptoms of depression. He is not hopeless. He is future oriented. He is not suicidal. His affect was concerned. He is apparently experiencing some medical disturbances at this time and they are being evaluated. He is to have a CAT scan of his liver later this week and also is scheduled to see the ENT Clinic for vocal cord lesion next month. Most of his stressors continue to be related to complicated and involved medical issues, and this seems to be further complicating his presentation.” The provider assessed the Veteran with “Depressive disorder not otherwise specified (mood disorder secondary to medical condition).” In a July 2005 VA mental health note, the provider noted that the Veteran continued to experience significant emotional, cognitive, and neurovegetative symptoms of depression and diagnosed him with “Depressive disorder (major depressive disorder versus depression due to medical condition).” In a July 2005 letter, Dr. C.C.I., the Veteran’s private physician, wrote, “The first time I saw [the Veteran], June 16, 2005, he was complaining of chronic profound fatigue caused by Hepatitis C, liver pain, stomach pain, insomnia, hoarseness and throat pain, nausea, muscle spasms, recurrent open sore on his lower right ankle, confusion at times. He could not sit too long, stand too long, he could not bend twist or turn without feeling like he was going to fall and his legs felt "like wooden poles." I spent some time listening to his history and examining this patient rather thoroughly. I am enclosing a copy of that initial examination. My diagnoses at that time were as follows: (1) Active Hepatitis C; (2) chronic profound fatigue; (3) diabetes mellitus; (4) diabetic retinopathy; (5) diabetic neuropathy; (6) diabetic myalgia and arthralgia; (7) insipient diabetic ulceration of the lateral maleosis (sic) of the right ankle…He has a multitude of symptoms that help his depression, affect this regulation, panic and anxiety symptoms and the other symptoms described above.” In a November 2005 psychological evaluation completed as part of the Veteran’s application for Social Security disability benefits, Dr. M.W. indicated that the Veteran denied any preoccupations with illness, environmental issues, phobias, or obsessions, but admits to thoughts of suicide at times, denying any plan or intent. Dr. M.W. diagnosed the Veteran with Depressive Disorder, NOS and a history of substance abuse. In a November 2006 VA initial evaluation note, the Veteran indicated that he felt that his depression was mainly focused on his significant medical problems, to include two liver surgeries and current consideration for the liver transplant list. The provider noted the following regarding the Veteran’s military history: “The veteran reportedly served in the Army for 2 years, from 1977 to 1979. The veteran stated that his primary duties were as a reconnaissance specialist. He reportedly had one disciplinary action in the military for fighting. The veteran indicated an honorable discharge from the military in 1979...he was charged with possession of a weapon. Of particular importance in regard to military history is an involuntary manslaughter charge that the veteran has from 20 years ago. The veteran stated that his discharge stems from an accidental shooting in which he and his friend were preparing to go hunting. He indicated that while he was handling a rifle in preparation for hunting, he accidentally shot his best friend and killed him. The veteran stated that he has never been to prison for this charge. The veteran also indicates that this incident was obviously quite traumatic, and some of his depression and likely resultant abuse and dependence on drugs relates to the trauma of this incident. The veteran stated that he has a DUI charge from approximately one month ago, but at this time is not on parole or probation...” In May 2007, the Social Security Administration (SSA) issued a disability determination in the Veteran’s case. The SSA administrative law judge (ALJ) determined that the Veteran had severe impairments of diabetes mellitus, depression, and chronic liver disease with cirrhosis. In an April 2008 letter, Dr. P.B., the Veteran’s VA mental health provider, wrote, “[The Veteran] is under the care of this clinic...His care consists of both pharmacotherapy & psychotherapy. He currently is being maintained on Zoloft & Seroquel. He has a diagnosis of Depression NOS (probable Depression due to medical condition) and a history of alcohol dependency in remission further complicated by significant interpersonal & health stressors. His condition makes him sensitive to stressors of all kinds. Given this, he would have difficulty sustaining gainful employment at this time.” In an April 2009 VA primary care note, the Veteran complained to depression and sadness due to his chronic medical conditions. In a February 2010 Statement in Support of Claim, the Veteran wrote, “I was discharge[d] from Germany [in] 1979 with General under Honorable condition[s]. My SSD records will show my mental health conditions. Which caused other health problems. Which includes drinking, drugs which occur in 1978. My DD2-14 cannot be found (so I'm told). My reason for discharge should indicate service connected.” In a March 2010 Statement in Support of Claim, the Veteran wrote, “My problem 1st started in Germany. When my 1st seargent (sic) had to come get me out [of] M.P. station for losing it on a soldier and was discharge[d] approx[imately] days or a week or so [later]. Before this happen[ed] I told my 1st seargant (sic) that I was depress[ed] and didn't feel like myself.” In a February 2013 VA initial evaluation note, the Veteran reported that he had been experiencing periodic depressive symptoms secondary to his medical and functional decline. He endorsed periods of hopelessness regarding his medical health. The provider diagnosed the Veteran with alcohol dependence, cannabis dependence, cocaine dependence in sustained full remission, and “Adjustment Disorder, with depressed mood.” In a July 2014 VA mental health note, the provider wrote, “[The Veteran] is a 53-year-old with history of depressive disorder complicated by multiple medical problems and history of substance use disorder, in remission. In general, he reports doing okay. He has no specific complaints. He reports a relatively stable mood. He reports mostly occasional low moods and intermittent low moods of mild to moderate intensity and these appear to be in the setting of various medical disabilities. In general, seems to be coping well with current interpersonal stressors.” The provider assessed the Veteran with “Unspecified depressive disorder with anxious distress, decently controlled at this time,” and “History of mixed substance use disorder, in full remission.” The provider also noted Axis III impressions of “Multiple medical problems” and Axis IV impressions of “Mild to moderate stressors, mostly related to primary support system concerns, financial concerns and medical disabilities.” In a February 2015 VA psychiatry note, the provider wrote, “[The Veteran] is a 55-year-old with history of depressive disorder, complicated by multiple medical problems. In general, has no specific complaints. Reporting mainly occasional low moods with episodic anxious distress and this setting of ongoing psychosocial/interpersonal stressors, including stressors involving chronic and acute medical disabilities. Appears to be coping well with ongoing stressors, on the whole.” In an October 2015 VA psychiatry note, the provider wrote that the Veteran presented “with history of unspecified depressive disorder with anxiety complicated by multiple medical problems including some vascular risk factors, hepatitis C and unspecified substance use disorder that is in remission. Today, reporting struggles with more frequent anxiety spectrum symptoms and brief depressive episodes...Much of his emotional distress appears to be in the setting of ongoing physical disabilities. He is currently receiving treatment for hepatitis C and this appears to be going okay.”. In October 2015, the Veteran was provided a VA examination to determine the likely etiology of his claimed acquired psychiatric disability. The VA examiner diagnosed the Veteran with: (1) “Unspecified Depressive Disorder with Anxious Distress,” commenting, “Not caused, nor exacerbated by, military service”; (2) mild cannabis use disorder, commenting, “Not caused, nor exacerbated by, military service; not secondary to Unspecified Depressive Disorder with Anxious Distress”; and (3) severe alcohol use disorder in remission, commenting, “Not caused, nor exacerbated by, military service; not secondary to Unspecified Depressive Disorder with Anxious Distress.” The VA examiner indicated that the following medical diagnoses were relevant to the understanding or management of the mental health disorder: Hepatitis C, liver cancer history, and cirrhosis, commenting that the “Veteran reported that the stress of his chronic medical conditions exacerbates his depression.” In terms of military history, the Veteran reported that the highest rank he achieved was E-4 and that his rank at discharge was E-1. The examiner wrote, “He reported that he experienced symptoms of depression a couple of months after arriving in Germany. He described that being separated from his wife and son, in addition to experiencing some racism from the local townspeople, was stressful to him. According to the veteran, he told his 1st Sgt. about this approximately 4-7 months after getting to Germany. Veteran reported that his 1st Sgt. told him that the veteran was homesick, and that he would work through it. Veteran stated that he did not send him for counseling. Veteran reported that a couple of weeks later, he returned to his first Sgt. to tell him that he was ‘afraid of snapping’ and had fear that he would hurt someone. Veteran reported that it was at this time that he asked to go back to the United States, and to receive counseling. Veteran reported that his 1st Sgt. told him that his record was ‘too good’ and that they would not allow him to leave the military or send him back to the United States. This recollection and statement is in contrast to veteran's report to this writer that he had received Article 15s during his time in the service. When queried about these disciplinary actions, veteran stated that he could not recall how many he received or why he was disciplined. According to the veteran, it was a few weeks later that he got into a physical altercation with another soldier while intoxicated and cut him with his service knife. At first, veteran reported that he did not recall anything about the incident. He then added that he vaguely recalls punching the other soldier upon finding him in his room drinking his alcohol. He reported that he has a vague recollection of the other soldier punching him, and that he was knocked over his bed. He stated that he has no recollection after that until he woke up in the stockade. He reported that he was quickly dropped in rank to E-1 and within a couple of days, he was discharged from the military with General Under Honorable Conditions and was sent home. There was no DD-2214 that could be located in VBMS. Additionally, there were no documents related to why he was discharged or any disciplinary actions received in service.” In terms of legal and behavioral history, the Veteran reported that approximately 30 years ago, he was convicted of involuntary manslaughter for accidentally killing one of his friends when they were using firearms and the safety was not on properly. The Veteran denied that his alcohol and cannabis abuse caused him any problems until he was involved in a physical altercation with another soldier in his room on base and stabbed the other soldier with his military knife. When asked how his military service continues to impact him today, the Veteran stated, “I haven't been right since…I have been in trouble since the service, I killed my friend, I got divorced, and nothing has gone right.” In a summary of the examination, the VA examiner wrote the following, “Based on the record review, clinical interview, and psychometric testing, veteran currently meets DSM-5 diagnostic criteria for Unspecified Depressive Disorder with Anxious Distress. Veteran has been diagnosed with this disorder in the past, beginning in the 2000s, and this is documented in his VA, Social Security Administration, and non-VA provider medical records. It should be noted that there is no nexus found between veteran's current and past symptoms of depression (first documented in the early 2000s), and his military service, which was in the late 1970s. Veteran's military service records and treatment records do not contain any information related to mental health symptoms, requests for treatment, or treatment related to any psychiatric condition. The first mention of mental health symptoms in veteran's medical records was not until the early 2000s. Thus, veteran's current diagnosis of Unspecified Depressive Disorder with Anxious Distress was not caused, nor exacerbated by, military service. There is no in-service stressor or event that is the etiology for his current Depressive Disorder. Veteran has a long history of substance abuse and dependence, including cocaine, alcohol, and cannabis. He currently meets the diagnostic criteria for Cannabis Use Disorder, mild, as well as Alcohol Use Disorder, in remission. Veteran's substance use disorders were not caused, nor exacerbated by, military service. Additionally, the substance use disorders are not secondary to his Unspecified Depressive Disorder with Anxious Distress.” Ultimately, the examiner opined that the Veteran’s “current DSM-5 diagnosis of Unspecified Depressive Disorder with Anxious Distress was less likely than not (i.e., less than 50% probability) manifested in military service and is less likely than not (less than 50% probability) related to the Veteran's military service.” The Board notes that in its December 2016 decision, the Board found this VA examination inadequate because the VA examiner did not address whether the Veteran’s currently diagnosed unspecified depressive disorder with anxious distress was related to the Veteran’s reports of depression symptoms in service. In a December 2015 VA mental health note, the provider noted that the Veteran had a history of unspecified depressive disorder with anxiety “complicated by multiple medical problems” and finding “much of his depression is in the setting of ongoing physical issues.” In January 2017, the Veteran was provided an additional VA examination to determine the likely etiology of his acquired psychiatric disability. The VA examiner diagnosed the Veteran with an unspecified depressive disorder. The Veteran endorsed sadness, anger, resentment about being mistreated, “I don't have love for people like I used to,” and feeling suffocated by concerns related to his diabetes, liver problems, pain, and medications. The VA examiner was first asked to opine whether it was at least as likely as not that the Veteran’s current disability was related to the Veteran’s service or events that occurred during service. The examiner responded, “The veteran reports initially feeling depressed while in the service. He describes this in terms of frustration related to misleading information provided by the military. He specifies that he was misled into thinking that the military would facilitate the relocation of his family to his station in Germany at that time. He states that he became depressed after learning that his family would not be relocated. When discussing factors relevant to his current depression, the veteran did not connect his current symptoms to this reported bout of depression in service nor did he contextualize his current depression in terms of the non-relocation of his family to Germany. Furthermore, any kind of depression in response to such stress, at that time, would not be expected to have lasted until now. Thus it is less likely than not that veteran's Unspecified Depressive Disorder relates to the reported in-service depression discussed here.” Next, the VA examiner was asked to opine whether it was at least as likely as not that the Veteran’s current disability was proximately due to his hernia disability. The examiner responded, “It is less likely than not that veteran's Unspecified Depressive Disorder was proximately due to the Veteran's compensable hernia disability. Veteran's depressive symptoms appear to relate to a number of negative events that pre-date his hernia.” Then, the VA examiner was asked whether it was at least as likely as not that the Veteran’s current disability has been aggravated by the Veteran’s compensable hernia disability, with the instruction that “In this case, aggravation means that the psychiatric disability has been permanently increased in severity beyond the natural progression of the disorder as a result of the hernia disability.” The examiner responded, “While the veteran's hernia may be one of many stressors contributing to his current depression, it is less likely than not that the medical condition has permanently worsened the natural progression of what would be expected for his depressive symptoms. Medical conditions such as hernias can prompt negative emotional reactions but they do not necessarily permanently exacerbate depression. Also, veteran's report of psychiatric symptoms in response to the hernia is of questionable reliability. The veteran states that VA providers attempted to repair his hernia in 2006. The veteran's report was confusing but he appeared to indicate that relevant interventions somehow led to an infection that resulted in a three week coma in March 2016. Veteran states that he was monitored at this time at St. Margret's Hospital. The veteran states that he awoke from coma remembering a nightmare about having been shot in church. He states that because of this nightmare, he has less energy to leave his home. When asked to elaborate, the veteran responded, ‘What stops me from going out? Nightmares in the coma - thinking I got shot in church. I get confused a lot...the dream was so real. It stops me from going out.’ This description is unusual and falls outside the limits of what would be expected from an emotional reaction to nightmares. The veteran initially seemed to describe impairments in reality-testing, implying that the nightmare continued to impact his functioning while awake. Veteran's chart is not significant for any psychiatric disorders that could account for long term impairments in reality testing. There is no evidence of any acute changes in mental status (such as delirium) due to medical conditions/procedures/medications relevant to hernia. Also, had such an acute change occurred, it would be expected to have resolved by now. Also, nightmares, as described by the veteran, would not be expected to impair his functioning while awake. C&P Hernia exam, dated 4/08/2016, does not indicate any reports of coma and the current writer was unable to locate any other CPRS records significant for reports of coma. It should also be noted that the veteran later attributed his tendency to remain at home to his physical pain. Taken together, this information leads the current writer to opine that it is less likely than not that the veteran's Unspecified Depressive Disorder was aggravated by the Veteran's compensable hernia disability.” Lastly, the VA examiner was asked to identify the more likely cause of the Veteran’s current disability, if unrelated to the Veteran’s service or his hernia disability. The examiner responded, “It appears that the veteran's depression relates to an accumulation of negative events throughout his life. The veteran attributes his current depression to the following: Using a knife to cut a soldier in service (veteran today expressed concern regarding the severity of his violence at that time, wondering why his behavior was so extreme); Mistreatment from the government. Veteran appeared to imply that he felt that it was unfair that he was discharged (general under honorable conditions) related to the aforementioned violence. He seemed to imply that the military failed to address the depressive symptoms and his potential for harm to others that he reportedly indicated to superiors prior to this violence; Accidental killing of a friend. Mental Disorders DBQ, dated 10/22/2015, indicates, ‘Veteran reported that approximately 30 years ago, he was convicted of involuntary manslaughter for accidentally killing one of his friends when they were using firearms and the safety was not on properly.’; The trajectory of veteran's life; Medical concerns including diabetes, liver problems, hernia, complications related to hernia procedure, and relevant medications. The determination of etiology is complicated by inconsistencies regarding veteran's report of onset of depressive symptoms. The veteran states that the last time he remembers feeling emotionally well was when he worked as a welder. He specified that he enjoyed golfing and other social activities at that time. He states that he worked as a welder in 1976, prior to his military service. But the Mental Disorders DBQ, dated 10/22/2015, indicates that he reported having worked as a welder from June 1997 through April 2001. At another point in today's exam, the veteran seemed to say that his depression began around 2006, at the time he underwent interventions relevant to his hernia. At another point, he seemed to say that his depression began around 2002, the time at which he was diagnosed with diabetes. In the Mental Disorders exam, dated 10/22/2015, the veteran stated ‘I haven't been right since [serving in the military]’ and ‘I have been in trouble since the service, I killed my friend, I got divorced, and nothing has gone right’. This overall sentiment is consistent with what the veteran expressed today, that he is unhappy with the overall trajectory of his life. At one point during today's exam, the veteran commented, ‘I've been depressed since 1979 because I never got over it- I thought the military did me wrong for discharging me. They said I could bring my family, then they said I couldn't bring my family. I told my first sergeant I was depressed, I got in a fight, cut a man up. I never been that kind of man. They sent me home, two days later. Six months later, I accidentally killed my friend, everything has been drama.’ While he attributes the negative trajectory of his life to events related to his military service, there is no evidence to indicate that this trajectory or his Unspecified Depressive Disorder was an inevitable result of his military service. Thus the veteran's Unspecified Depressive Disorder was less likely than not incurred in or caused by his service. In addition to the varied history of medical and psychosocial stressors reported by the veteran today, the course of veteran's life has included prior history of substance abuse (as per chart) and what appears to be inconsistent employment and probable financial insecurity. It's at least as likely as not that the veteran's Unspecified Depressive Disorder is due to what the veteran deems to be a disappointing overall life trajectory, subsequent to his military discharge.” In a January 2017 VA primary care note, the Veteran reported that he was still recovering from ventral hernia surgery, endorsing persistent fatigue, and indicated that he was “just tired from ongoing medical issues.” In a February 2017 VA mental health transplant candidate evaluation note, the Veteran reported that he served in the Army from 1977 to 1979 and was discharged due to getting in a fight and “cutting a guy up.” He endorsed a depressed mood for a variety of reasons, including as due to his health as well as past traumas. In a March 2017 VA social work transplant candidate evaluation note, the Veteran reported feelings of depression related to his medical issues. In a January 2018 VA psychiatry note, the provider noted that the Veteran’s mood was “fairly stable but struggles with some degree of intermittent depression, dysphoria and anxious distress that appears to be related to various stressors related to medical disabilities, some frustrations related with care and other primary support system stressors.” In a September 2018 VA psychiatry note, the provider indicated that the Veteran endorsed “some degree of intermittent depression, anxiety and dysphoria, though much of his emotional distress appears to be in the context of being frustrated with ongoing medical problems. We talked about coping with this (sic) chronic medical disabilities.” In October 2018, an addendum VA medical opinion was obtained to address private treatment records from St. Margaret’s Hospital. The VA examiner, who also conducted the January 2017 VA examination, did not change any of his previous opinions, noting that the records from St. Margaret’s Hospital “contain no evidence that the veteran's Unspecified Depressive Disorder relates to the veteran's service, which was from July 1977 to June 1979, events that occurred during service, or his reported in-service depression,” that they “contain no evidence that the veteran's Unspecified Depressive Disorder is proximately due to the Veteran's service-connected ventral hernia, and that they “contain no evidence that the veteran's Unspecified Depressive Disorder was permanently aggravated by the Veteran's service-connected ventral hernia.” Regarding aggravation, the VA examiner found that “The veteran's description of psychiatric symptoms and relevant functional impairments in response to the hernia (and relevant complications) did not make etiological sense. It should also be noted that during the 1/30/17 exam, the veteran later attributed his tendency to remain at home to his physical pain rather than psychiatric symptoms.” In a December 2018 VA vocational rehabilitation note, when asked about his history of disciplinary problems in the military, the Veteran reported that he got into a fight. He indicated that in 2016, he had complications from a hernia surgery and was in a coma for 3 to 4 weeks at St. Margaret’s Hospital. In a June 2019 VA psychiatry note, the provider noted that the Veteran had a “history of recurrent depression with anxious distress complicated by possible and mild neurocognitive disorder [and] multiple medical problems.” On review, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s acquired psychiatric disorder, to include depression, was aggravated by his service-connected ventral hernia disability. The record reflects a diagnosis of depressive disorder as early as 2003. See June 2003 to November 2003 VA treatment records. The Veteran’s ventral hernia first manifested in 2006, and he underwent surgeries to treat the hernia in 2006, 2014, and 2016. See April 2016 VA examination report. In numerous VA treatment records, both before and after his hernia first manifested, providers noted that the Veteran’s depression was exacerbated by the stress caused by his multiple chronic medical problems. See VA treatment records dated July 2003 to June 2019. Specifically, in a January 2017 VA primary care note, the Veteran reported that he was still recovering from ventral hernia surgery, endorsing persistent fatigue, and indicated that he was “just tired from ongoing medical issues.” While the January 2017 and October 2018 VA examiner opined that it was less likely than not that the Veteran’s unspecified depressive disorder was aggravated by the Veteran’s hernia disability, the Board notes that he was instructed that “In this case, aggravation means that the psychiatric disability has been permanently increased in severity beyond the natural progression of the disorder as a result of the hernia disability,” and the examiner repeatedly emphasized that the hernia disability would not permanently exacerbate the Veteran’s depression. However, as mentioned previously, any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation or worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). Indeed, the VA examiner conceded that the Veteran’s hernia “may be one of many stressors contributing to his current depression” and that “Medical conditions such as hernias can prompt negative emotional reactions.” See January 2017 VA examination report. Accordingly, after resolution of all reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for an acquired psychiatric disorder based on secondary aggravation by a service-connected ventral hernia disability have been met. Having granted service-connection on this basis, the Board need not address the Veteran’s other theories of entitlement. Increased Ratings Disability evaluations are determined by comparing a Veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Where a Veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). 2. Entitlement to an initial rating in excess of 20 percent for a ventral hernia disability The Veteran is currently in receipt of an initial rating of 20 percent for a ventral hernia disability under DC 7339. He asserts that a higher rating is warranted. Under DC 7339, a 20 percent rating is warranted for a small ventral hernia, postoperative, not well supported by belt under ordinary conditions, or healed ventral hernia; or, postoperative wounds with weakening of the abdominal wall and indication for a supporting belt. A 40 percent rating is warranted for a large ventral hernia, postoperative, not well supported by belt under ordinary conditions. A 100 percent rating is warranted for a massive ventral hernia, postoperative, persistent, severe diastasis of recti muscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. Id. Turning to the evidence, in VA treatment records dated January 2012 to August 2013, after physical examination, providers found that the Veteran had a small periumbilical hernia that was easily reducible. In an August 2013 letter, Dr. T.C. wrote that the Veteran acquired an abdominal hernia after insertion of a port to treat his liver cancer. In a September 2013 VA preventive medicine note, the Veteran endorsed chronic pain, rated 7 out of 10 in severity, in the “hernia area on lower left side,” describing the worst pain as aching, burning, dull, needle-like, sharp, and sore. In a VA treatment records dated October 2013 to March 2014, after physical examination, providers found a small midline incisional hernia which was reducible and not tender. In an April 2014 VA hepatology note, after physical examination, the provider found a “moderate mid abd ventral hernia, soft, NT.” In an April 2014 letter, Dr. J.L. wrote, “[The Veteran] has a ventral hernia that has been present since 2006 after an operation that he needed. His symptoms have been stable and he continues to be recommended for non-surgical management.” In a May 2014 VA surgery consultation, the Veteran indicated that he has had a ventral hernia for years but it recently started to bother him, endorsing mild pain with sitting up. On physical examination, the provider found that the Veteran’s ventral hernia was reducible and nontender. In a May 2014 VA education note, the Veteran complained of chronic, dull pain in the location of his hernia. In a July 2014 VA surgery note, the Veteran reported that his ventral hernia had been present for 8 years, since a surgery in 2006, but had not bothered him until recently. He indicated that it was uncomfortable at times, especially in the morning after he eats, but the pain goes away throughout the day. On physical examination of the abdomen, the provider noted three small incisional scars with a reducible hernia above the umbilicus. The provider found that “given the small size of his defect and his good overall functional status (patient works and is fairly active), we recommend surgical ventral hernia repair under MAC and without mesh, to minimize complications.” In a September 2014 VA hepatology note, the Veteran endorsed occasional belly discomfort due to his ventral hernia. In an October 2014 VA surgery pre-operative E & M note, after physical examination of the abdomen, the provider found a “~2cm incisional hernia, reducible...” In a January 2015 VA emergency department note, the Veteran endorsed redness and pain near his hernia repair site for the past day. The provider wrote, “54 M with a history of DM, HTN, hyperlipidemia, exlap with subsequent hernia repair in 10-2014 presents with 2 days of pain and redness at the site of hernia repair site just superior to umbilicus. Pt reports that he has had a ‘jabbing’ sensation under his skin since just after his surgery, but reports that it did not bother him much. Two days ago, he noticed some redness and has had increasing pain.” On physical examination, the provider noted a “well healed incision just superior to umbilicus with small hypertrophic tissue and some fluctuance and induration noted with 2 cm surrounding erythema; symmetric, nondistended, soft to deep palpation…” In a January 2015 VA surgery consultation, the Veteran reported that a few weeks after his hernia repair surgery in October 2014, “he began to feel as if something were poking up under his skin. He then developed a small nodule at the incision site which he did not seek treatment for. One day ago, he began to have severe pain, redness, and swelling around the incision site. The pain was sharp and did not move or radiate, and was very tender to palpation. He believes the swelling has gone down some this morning but continues to have pain and erythema. He denies fevers but has had some chills and thinks that his nodule occasionally drains…” In an April 2015 VA surgery attending note, the Veteran returned for treatment of a stitch abscess after his hernia repair surgery. He endorsed still having purulent drainage from the incision site and believed that the hernia was back. On physical examination, the provider noted that the hernia had returned and was reducible, and that the Veteran had a scab with some purulent drainage. The provider opened up the scab to see a Prolene suture, which was cut out. In an April 2015 private treatment record from St. Margaret's Hospital, the provider wrote, “Patient presents for evaluation of an incisional hernia repair which was done at the VA in October of 2014. He reports he discovered some spitting sutures and went to the VA where the sutures were removed. He also feels that there is some infection at the suture site which they did not treat. At this time, he does not want the VA to take care of this issue. States he is having pain 6/10 in his abdomen. Describes it as a stinging pain.” On physical examination, the provider noted “a recurrent reducible incisional hernia containing intestines. He has what looks like a chronic ulceration at the site of a Prolene suture that no sutures poking through the skin.” In an April 2015 VA primary care note, the Veteran complained of “bothersome hernia symptoms” and on physical examination, the provider noted “a reducible hernia with some prior scars from previous surgery.” A May 2015 operative report from St. Margaret's Hospital showed a diagnosis of “Infected abdominal wall foreign body” which was treated by “sharp excisional debridement of abdominal wall, 2 x 1 cm deep of skin and subcutaneous fat and removal of abdominal wall foreign body.” The procedure revealed findings of “an infected Prolene stitch with abscess, chronically infected skin overlying this. There was pus and we sent cultures. He has recurrent hernia…” A June 2015 operative report from St. Margaret's Hospital showed a diagnosis of “infected foreign body of the abdominal wall” which was treated by removal. The provider noted that the procedure revealed the following findings: “I could identify a single Prolene suture, which had a drop of pus around it and this was the source of his current infection. I could not palpate any other sutures. Although I did not do his initial hernia repair. He may have other suture in there and we [have] to wait and see how this heals up...” In an August 2015 VA vocational rehabilitation note, the Veteran reported that he was “currently suffering from this hernia and is not slated to have it operated on until November. [He] stated he is not permitted to lift or push heavy items while dealing with this ailment.” In an August 2015 VA addendum, the provider noted a reducible abdominal hernia on physical examination of the abdomen. In an August 2015 VA primary care note, the Veteran indicated that his hernia had improved “s/p surgery at St. Margaret's.” In a September 2015 VA nutrition consultation, the Veteran endorsed occasional nausea which he attributed to his hernia. In a September 2015 VA primary care note, the Veteran reported that his hernia had returned and that he did not have pain. On physical examination, the provider found a “3 cm reducible ventral hernia. Non tender. No guarding.” In a March 2016 operative report from St. Margaret's Hospital, the provider noted a diagnosis of “Incarcerated recurrent ventral incisional hernia” which was treated by “Laparoscopic reduction and repair of incarcerated recurrent ventral incisional hernia and laparoscopic placement of mesh.” The provider noted that the procedure revealed “a 4 x 4 cm recurrent incarcerated incisional hernia. There was only omentum in the hernia and this easily reduced...” An April 2016 discharge summary from St. Margaret's Hospital indicated that the Veteran was admitted due to “debility s/p hernia repair” in March 2016. The provider noted that the Veteran’s hospital course was complicated by “postoperative ileus, agitation and encephalopathy with tachycardia 2/2 alcohol withdrawal and infection, respiratory failure, pneumonia - treated with unasyn -> vanc/zosyn, renal injury with ATN, postoperative anemia s/p transfusions with appropriate response, dysphagia…” The Veteran endorsed some abdominal distention and pain rated as 3 out of 10 in severity. The discharge summary indicated that the Veteran should “wear Abd binder at all times…” In April 2016, the Veteran was provided a VA examination to assess his claimed ventral hernia disability. The VA examiner noted that the ventral hernia was first diagnosed in 2006 and that the Veteran underwent hernia repairs in 2006, 2014, and 2016. In describing the history of the Veteran’s hernia condition, the examiner wrote, “The Veteran developed an (sic) ventral abdominal hernia following an insertion of a port to treat his liver cancer in 2006. The Veteran reports he recently had a hernia repair (3/8/2016). Per Veteran report this is the third repair to his ventral abdominal hernia. Per Veteran report he was discharged on 4/2016 from St. Margaret's Hospital. He reports pain to the hernia area. Currently, the pain is constant and described as an ache with soreness rate averaging at a 7/10. Treatment includes Oxycodone for pain as needed. He is unable to bend at his waist without pain. He arrives to exam without assistive devices. He is independent with his ADLs. He does wear a support belt constantly. He is able to walk no greater than 15 minutes, sit is limited to 15 minutes, standing for no greater than 20 minutes. Medical records from St. Margaret's Hospital dated 3/8/2016 reveal an operative report for an incarcerated recurrent ventral incisional hernia. He had laparoscopic reduction and repair of incarcerated recurrent ventral incisional hernia.” Physical examination of the Veteran’s abdomen revealed healed postoperative wounds with weakening of the abdominal wall, as well as an indication for a supporting belt. The VA examiner found that the hernia can be supported by truss or belt. The examiner noted that the Veteran had four abdominal scars related to his hernia repairs that were not painful or unstable. The examiner found that the Veteran’s hernia condition did not impact his ability to work. In a May 2016 VA preventive medicine note, the Veteran endorsed acute pain, rated as 3 out of 10 in severity, in the location of “Stitches where hernia operation done,” which he described as soreness. In a May 2016 VA primary care note, the Veteran indicated he was still recovering from his ventral hernia surgery, and the provider noted that his post-operative course was “complicated by Aspiration pneumonia and prolonged ICU stay. Veteran states hospitalized 1 month.” In an August 2016 VA primary care note, the Veteran reported that he was still recovering from hernia surgery at St. Margaret’s Hospital, endorsing intermittent abdominal cramping. In a December 2016 VA radiology report, the interpreting radiologist noted that a CT scan of the Veteran’s abdomen and pelvis revealed an unchanged “small fat-containing ventral hernia.” In a January 2017 VA primary care note, the Veteran reported that he was still recovering from ventral hernia surgery, noting that his weight had increased but fatigue persisted. In a May 2017 VA radiology report, the interpreting radiologist noted that a CT scan of the revealed an “Unchanged small fat-containing ventral hernia.” In a July 2017 VA e-consultation, the provider noted that following his hernia surgery in April 2016, the Veteran had “post op aspiration pneumonia hospitalized x 1 month.” In a July 2017 VA addendum, the provider noted that the Veteran’s post-operative course after his March 2016 hernia repair was complicated by “postop ileus, alcohol withdrawal (agitation/encephalopathy/tachycardia), ATN, respiratory failure/aspiration pneumonia requiring mechanical ventilation for ~ 11 days, anemia requiring PRBC tranfusions, protein malnutrition -> LE edema.” In a December 2018 VA vocational rehabilitation note, the Veteran reported that in 2016, he had complications from a hernia surgery and was in a coma for 3 to 4 weeks at St. Margaret’s Hospital. In a September 2019 VA primary care note, the Veteran complained that his hernia was bothering him and that it was sore to touch. In an October 2019 VA podiatry attending note, the Veteran reported concerns regarding possible hernia recurrence. In December 2019, the Veteran was provided an additional VA examination to assess the current severity of his ventral hernia disability. The VA examiner noted that the Veteran’s ventral hernia was first diagnosed in 2006 and that it developed following insertion of a port to treat his liver cancer. The examiner found that the hernia condition has progressed since its onset due to “post-op infections” and that the Veteran wears a binder. The examiner noted that the Veteran underwent recurrent incarcerated ventral hernia repair surgery in March 2016. On physical examination, the VA examiner noted a healed postoperative ventral hernia repair, that there was indication for support, and that the hernia can be well supported by truss or belt. The examiner noted that the Veteran had four abdominal scars related to his ventral hernia, but that none were painful or unstable. The examiner opined that the Veteran’s ventral hernia condition did not impact his ability to work. In a January 2020 VA primary care note, on physical examination of the abdomen, the provider found mild abdominal distention near the hernia operative site and noted the presence of a “mild hernia umb without incarceration.” On review, the Board finds that the Veteran’s ventral hernia symptoms do not meet or more nearly approximately the criteria for a rating higher than 20 percent under DC 7339. There is no evidence of a large ventral hernia; indeed, throughout the entire period on appeal, private medical providers, VA medical providers, and VA interpreting radiologists have described the Veteran’s hernia as “small,” noting its size as ranging between 2 and 4 centimeters across. See March 2016 operative report from St. Margaret's Hospital; VA treatment records dated January 2012 to September 2015; VA radiology reports dated December 2016 and May 2017. The Board acknowledges an April 2014 VA hepatology note, in which, after physical examination of the Veteran’s abdomen, the provider noted a “moderate mid abd ventral hernia, soft, NT.” However, it is unclear whether “moderate” is in reference to the size of the hernia; to the extent that it is, the Board finds that the weight of the medical evidence supports a finding that the Veteran’s ventral hernia was, and is, small. Thus, the Board finds the evidence of record during the entire appeal period does not support a rating in excess of 20 percent for the Veteran’s ventral hernia under DC 7339. 3. Entitlement to a compensable rating for abdominal scars As previously indicated, the Board takes jurisdiction of the issue of entitlement to a separate compensable rating for abdominal scars as manifestations of the service-connected ventral hernia disability because this issue is essentially a component of the issue of entitlement to an increased rating for a ventral hernia disability, insofar as the scars were incurred from hernia repair surgeries. The Veteran is currently in receipt of a noncompensable rating for abdominal scars secondary to the service-connected ventral hernia disability under DC 7805 for the entire period on appeal. The Board notes that the Schedule for Rating Skin Disabilities was amended in August 2018 so that it more clearly reflects VA’s policies concerning the evaluation of skin disorders, specifically, 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805, 7806, 7813, 7815-7817, 7820-7822, and 7824-7829. The new regulations apply to claims filed on or after August 13, 2018 and claims pending on August 13, 2018, if the new regulation is more favorable for the Veteran. As this claim was pending before the Board on August 13, 2018 (the Veteran’s claim for a rating in excess of 20 percent for a ventral hernia disability was certified to the Board on June 29, 2017), the Veteran’s claim must be considered under the rating criteria both before and after August 13, 2018. Both versions of DC 7800 address scars and disfigurement of the head, face, or neck. As the Veteran’s residual scars are not on his head, face, or neck, DC 7800 is not applicable. Under the scar regulations in effect prior to August 13, 2018, DC 7801 provided for a 10 percent rating for scars not of the head, face, or neck that are deep and nonlinear with an area or areas exceeding 6 square inches (39 sq. cm.); a 20 percent rating for such scars with an area or areas exceeding 12 square inches (77 sq. cm.); a 30 percent rating for such scars with an area or areas exceeding 72 square inches (465 sq. cm.); and a 40 percent rating for such scars with an area or areas exceeding 144 square inches (929 sq. cm.). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note (1). DC 7802 provided for a 10 percent rating for scars not of the head, face, or neck that are superficial and nonlinear with an area or areas of 144 square inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802, Note (1). DC 7804 provided for a 10 percent disability rating for one or two scars that are unstable or painful, a 20 percent disability rating for three or four scars that are unstable or painful, and a 30 percent rating for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7804, Note (1). If one or more scars are both unstable and painful, an additional 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118, DC 7804, Note (2). DC 7805 provided that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under DCs 7800-04 under an appropriate DC. 38 C.F.R. § 4.118. After August 13, 2018, DC 7801 indicates that for burn scars or scars due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), a 10 percent rating is warranted. Note (1) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. Under DC 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage in an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent evaluation. Pursuant to DC 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful, a 20 percent rating is warranted for three or four scars that are unstable or painful, and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7804 Note (1). Note (2) to DC 7804 provides that if one or more scars are both unstable and painful, 10 percent is added to the evaluation that is based on the total number of unstable or painful scars . DC 7805 provides that other scars (not otherwise considered under the DCs 7800-7804) are to be rated according to their disabling effects under an appropriate diagnostic code. See 38 C.F.R. § 4.118, DC 7805. Turning to the evidence, in a September 2013 VA preventive medicine note, the Veteran endorsed chronic pain, rated 7 out of 10 in severity, in the “hernia area on lower left side,” describing the worst pain as aching, burning, dull, needle-like, sharp, and sore. In a May 2014 VA surgery consultation, the Veteran indicated that he has had a ventral hernia for years but it recently started to bother him, endorsing mild pain with sitting up. On physical examination, the provider found that the Veteran’s ventral hernia was reducible and nontender. In a May 2014 VA education note, the Veteran complained of chronic, dull pain in the location of his hernia. In a July 2014 VA surgery note, the Veteran reported that his ventral hernia had been present for 8 years, since a surgery in 2006, but had not bothered him until recently. He indicated that it was uncomfortable at times, especially in the morning after he eats, but the pain goes away throughout the day. On physical examination of the abdomen, the provider noted three small incisional scars with a reducible hernia above the umbilicus. The provider found that “given the small size of his defect and his good overall functional status (patient works and is fairly active), we recommend surgical ventral hernia repair under MAC and without mesh, to minimize complications.” In a January 2015 VA emergency department note, the Veteran endorsed redness and pain near his hernia repair site for the past day. The provider wrote, “54 M with a history of DM, HTN, hyperlipidemia, exlap with subsequent hernia repair in 10-2014 presents with 2 days of pain and redness at the site of hernia repair site just superior to umbilicus. Pt reports that he has had a ‘jabbing’ sensation under his skin since just after his surgery but reports that it did not bother him much. Two days ago, he noticed some redness and has had increasing pain.” On physical examination, the provider noted a “well healed incision just superior to umbilicus with small hypertrophic tissue and some fluctuance and induration noted with 2 cm surrounding erythema; symmetric, nondistended, soft to deep palpation…” In a January 2015 VA surgery consultation, the Veteran reported that a few weeks after his hernia repair surgery in October 2014, “he began to feel as if something were poking up under his skin. He then developed a small nodule at the incision site which he did not seek treatment for. One day ago, he began to have severe pain, redness, and swelling around the incision site. The pain was sharp and did not move or radiate and was very tender to palpation. He believes the swelling has gone down some this morning but continues to have pain and erythema. He denies fevers but has had some chills and thinks that his nodule occasionally drains…” In an April 2015 VA surgery attending note, the Veteran returned for treatment of a stitch abscess after his hernia repair surgery. He endorsed still having purulent drainage from the incision site and believed that the hernia was back. On physical examination, the provider noted that the hernia had returned and was reducible, and that the Veteran had a scab with some purulent drainage. The provider opened up the scab to see a Prolene suture, which was cut out. In an April 2015 private treatment record from St. Margaret’s Hospital, the provider wrote, “Patient presents for evaluation of an incisional hernia repair which was done at the VA in October of 2014. He reports he discovered some spitting sutures and went to the VA where the sutures were removed. He also feels that there is some infection at the suture site which they did not treat. At this time, he does not want the VA to take care of this issue. States he is having pain 6/10 in his abdomen. Describes it as a stinging pain.” On physical examination, the provider noted “a recurrent reducible incisional hernia containing intestines. He has what looks like a chronic ulceration at the site of a Prolene suture that no sutures poking through the skin.” In an April 2015 VA primary care note, the Veteran complained of “bothersome hernia symptoms” and on physical examination, the provider noted “a reducible hernia with some prior scars from previous surgery.” A May 2015 operative report from St. Margaret’s Hospital showed a diagnosis of “Infected abdominal wall foreign body” which was treated by “sharp excisional debridement of abdominal wall, 2 x 1 cm deep of skin and subcutaneous fat and removal of abdominal wall foreign body.” The procedure revealed findings of “an infected Prolene stitch with abscess, chronically infected skin overlying this. There was pus and we sent cultures. He has recurrent hernia…” A June 2015 operative report from St. Margaret’s Hospital showed a diagnosis of “infected foreign body of the abdominal wall” which was treated by removal. The provider noted that the procedure revealed the following findings: “I could identify a single Prolene suture, which had a drop of pus around it and this was the source of his current infection. I could not palpate any other sutures. Although I did not do his initial hernia repair. He may have other suture in there and we [have] to wait and see how this heals up...” In April 2016, the Veteran was provided a VA examination to assess his claimed ventral hernia disability. The examiner noted that the Veteran had four linear abdominal scars related to his hernia repairs that were not painful or unstable. In a May 2016 VA preventive medicine note, the Veteran endorsed acute pain, rated as 3 out of 10 in severity, in the location of “Stitches where hernia operation done,” which he described as soreness. In the December 2019 VA examination report regarding the Veteran’s ventral hernia disability, the examiner noted that the Veteran had four abdominal scars related to his ventral hernia, but found that none were painful or unstable On review, the Board finds as follows: (1) for the appellate period prior to October 10, 2014, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were painful; (2) from October 10, 2014 to June 30, 2015, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were painful and unstable; (3) beginning July 1, 2015, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were painful. For the appellate periods prior to October 10, 2014 and beginning July 1, 2015, the evidence is at least in equipoise as to whether the Veteran has experienced pain resulting from his four abdominal scars due to his hernia repair surgeries, warranting a 20 percent rating under DC 7804. The evidence reflects that as a result of his surgery in 2006, the Veteran had three small incisional scars. See July 2014 VA surgery note. During later VA examinations in April 2016 and December 2019, after his subsequent hernia repair surgeries in October 2014 and March 2016, the VA examiners noted four abdominal scars. The Board acknowledges that the April 2016 and December 2019 VA examiners did not find that the Veteran’s abdominal scars were painful or unstable. However, the Board affords more probative value to the Veteran’s competent and consistent reports to his medical providers of pain near his hernia, as statements, such as these, made to clinicians for purposes of diagnosis and treatment are exceptionally trustworthy because the Veteran has a strong motive to tell the truth in order to receive proper care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997); see VA treatment records dated September 2013 to May 2016; April 2015 private treatment record from St. Margaret’s Hospital. At no point during these periods has the evidence shown the existence of five or more painful or unstable scars, which would warrant a higher rating under DC 7804. From October 10, 2014 to June 30, 2015, the evidence is in equipoise as to whether the Veteran’s four abdominal scars from his hernia repair surgeries were both painful and unstable, warranting a 30 percent rating under DC 7804. After the Veteran’s hernia repair surgery on October 10, 2014, he experienced recurrent drainage and infection at the site of his sutures, which required several surgical procedures before it healed. See VA treatment records dated January 2015 to April 2015; private treatment records and operative reports from St. Margaret’s Hospital dated April 2015 to June 2015. In a May 2015 operative report from St. Margaret’s Hospital, the surgeon noted that the procedure revealed “an infected Prolene stitch with abscess, chronically infected skin overlying this. There was pus and we sent cultures.” In a June 2015 operative report from St. Margaret’s Hospital, the same surgeon removed another infected suture and indicated that she was not able to palpate any more sutures, stating, “we [have] to wait and see how this heals up...” After the June 2015 procedure, there is no further evidence of frequent loss of covering of skin over the Veteran’s abdominal scars. Thus, a 30 percent disability rating is warranted under DC 7804 between October 10, 2014 and June 30, 2015; this is the maximum rating available under this diagnostic code. The Board notes further that the change in rating from 30 to 20 percent beginning July 1, 2015, does not constitute a reduction per se, but rather a staged rating made coincident with the medical evidence at that time. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff’d, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board may not assign an extraschedular rating in the first instance but must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). (Continued on the next page)   In this case, the Board finds that referral for extraschedular consideration is not warranted. With respect to the first prong of Thun, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. The Veteran asserts that his chronic pain and difficulty sitting, walking, and standing due to his ventral hernia are not contemplated by the schedular criteria. However, the Veteran’s symptoms of inability to walk, stand, and sit for extended periods of time are contemplated by the 20 percent criteria under DC 7339 regarding whether the ventral hernia was manifested by “weakening of the abdominal wall and indication for a supporting belt.” Moreover, the pain at the site of the Veteran’s hernia repairs is contemplated by the 20 percent rating awarded for his four painful abdominal scars under DC 7804. As such, the Board finds the Veteran’s ventral hernia disability picture, to include residual painful scars, is fully addressed by the rating criteria under which it is currently evaluated. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. M. Gill, 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.