Citation Nr: 21000053 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 14-15 633 DATE: January 4, 2021 ORDER A rating in excess of 30 percent for residuals of gunshot wound of the left thigh is denied. The assignment of a separate rating for scars of the left lower extremity, evaluated as noncompensably disabling as of June 23, 2010, is proper; the appeal is denied. The assignment of a separate rating for painful scars of the left lower extremity, evaluated as 10 percent disabling as of June 8, 2018, is proper; the appeal is denied. A rating in excess of 30 percent for posttraumatic stress disorder (PTSD), exclusive of the periods where a temporary total rating has been assigned, is denied. REMANDED Entitlement to a separate rating for neurological impairment associated with residuals of gunshot wound of the left thigh is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s residuals of gunshot wound of the left thigh resulted in no more than a moderately severe injury to Muscle Group XIV. 2. For the entire appeal period, the Veteran’s scars of the left lower extremity are not of a size to warrant a compensable rating, were not painful prior to June 8, 2018, and do not result in any disabling effects. 3. As of June 8, 2018, the Veteran’s scars of the left lower extremity result in 2 scars that are painful, but not unstable. 4. For the entire appeal period, exclusive of the periods where a temporary total rating has been assigned, the Veteran’s PTSD is manifested by psychiatric symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for residuals of gunshot wound of the left thigh have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code 5314. 2. The assignment of a separate rating for scars of the left lower extremity, evaluated as noncompensably disabling as of June 23, 2010, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7802. 3. The assignment of a separate rating for painful scars of the left lower extremity, evaluated as 10 percent disabling as of June 8, 2018, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7804. 4. Exclusive of the periods where a temporary total rating has been assigned, the criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1992 to January 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in August 2012 and January 2013 by a Department of Veterans Affairs (VA) Regional Office. In September 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In May 2018, the Board remanded the issues of entitlement to a rating in excess of 30 percent prior to April 1, 2013, and in excess of 20 percent thereafter for gunshot wound of the left thigh with residual scars, to include the propriety of the reduction, entitlement to a rating in excess of 30 percent for PTSD, exclusive of the periods where a temporary total rating has been assigned, and entitlement to a TDIU for additional development. While on remand, an April 2020 rating decision awarded a 30 percent rating for the Veteran’s residuals of gunshot wound of the left thigh for the entire appeal period, a separate noncompensable rating as of June 23, 2010, for scars of the left lower extremity, and a separate 10 percent rating as of June 8, 2018, for painful scars of the left lower extremity. In this regard, while the Veteran did not enter a notice of disagreement as to the propriety of the assigned ratings or effective dates for the separate ratings for his scars, such issues are part and parcel of his claim for an increased rating for his residuals of gunshot wound of the left thigh. Thus, the Board has assumed jurisdiction over such matters. The case returns for further appellate review. Additionally, as will be further discussed herein, as the evidence suggests that the Veteran’s residuals of gunshot wound of the left thigh is manifested by neurological impairment, the Board has assumed jurisdiction over whether a separate rating for such residual disability is warranted. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The appeal period before the Board begins on June 23, 2010, the date VA received the Veteran’s claim for increased ratings, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). 1. Entitlement to a rating in excess of 30 percent for residuals of gunshot wound of the left thigh. The Veteran contends the severity of his residuals of gunshot wound of the left thigh warrants a rating in excess of the 30 percent currently assigned. By way of background, the January 2013 rating decision on appeal reduced the rating assigned for the Veteran’s left thigh muscle disability from 30 percent to 10 percent, effective April 1, 2014. The Veteran timely disagreed with the assigned ratings, and in a rating decision issued in March 2014, the Agency of Original Jurisdiction (AOJ) assigned a 20 percent rating, effective April 1, 2013. Thereafter, the Veteran perfected an appeal of the assigned ratings, to include the propriety of the reduction. Subsequent to the May 2018 Remand, the April 2020 rating decision restored the 30 percent rating, effective April 1, 2013, and indicated that such constituted a full grant of the benefit sought on appeal. However, upon review, the Board finds the Veteran’s initial disagreement addressed both the reduction in rating as well as the assignment of the 30 percent rating. Thus, the issue remains on appeal and is characterized accordingly. Consequently, the Veteran’s left thigh muscle disability is evaluated as 30 percent disabling for the entire appeal period. Prior to April 1, 2013, such disability was evaluated pursuant to Diagnostic Code 5315, which pertains to injuries affecting Muscle Group XV. 38 C.F.R. § 4.73. In accordance with a September 2019 clarifying medical opinion, however, his left thigh muscle disability is evaluated as 30 percent disabling as of April 1, 2013, pursuant to Diagnostic Code 5314, which pertains to injuries affecting Muscle Group XIV. 38 C.F.R. § 4.73. Notably, the change in Diagnostic Code provides the potential for a higher assigned rating. Specifically, whereas 30 percent is the highest rating available under Diagnostic Code 5315, a rating of 40 percent is available under Diagnostic Code 5314. Given such potential benefit, the Board finds there is no prejudice to the Veteran in evaluating his disability under the latter Diagnostic Code, which, according to the medical opinion, is the appropriate Diagnostic Code, for the entire appeal period. Under 38 C.F.R. § 4.73, Diagnostic Codes 5301 to 5323 prescribe the evaluation of disabilities manifested by muscle injuries based upon the classifications of slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d)(1)-(4). The corresponding level of severity of a service-connected muscle injury is determined to a significant extent by the presence or absence of cardinal signs and symptoms of muscle disability, which consist of loss of power, lowered threshold of fatigue, weakness, pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic 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 or 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 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 particular 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 for treatment of wound. Record of consistent complaints 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 compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound 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 complaints 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 soft 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. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d). As noted above, a September 2019 VA examiner corroborated a January 2011 VA examiner’s determination that the Veteran’s left thigh muscle disability affects Muscle Group XIV, which affects extension of the knee, simultaneous flexion of the hip and flexion of the knee, tension of the fascia lata and iliotibial band, acts with Group XVII in postural support of the body and with the hamstrings in synchronizing the hip and the knee, and includes the anterior thigh group: sartorius, rectus femoris, vastus externus, vastus intermedius, vastus internus, and tensor vaginae femoris. Under Diagnostic Code 5314, a 30 percent rating is assigned for a moderately severe disability and a 40 percent rating is provided for a severe disability. Thus, the evidence must demonstrate a severe disability to warrant a rating in excess of that already assigned. Pertinent to the criteria for a severe disability of muscles, the record reflects that, he sustained a through and through injury to the left thigh from a high velocity, large caliber single bullet. However, the medical evidence does not show hospitalization for a prolonged period for treatment of the wound; rather, the Veteran was taken to the hospital for exploratory surgery and released the next day. In addition, there was no associated bone, nerve, vascular, or tendon injuries. With respect to the cardinal signs and symptoms of muscle disability, a January 2011 VA examination report shows the Veteran denied any associated pain, decreased coordination, or increased fatigability. However, he did complain of muscle spasms, the flare-ups of which involved symptoms of weakness and uncertainty of movement. Nevertheless, there were no reports of additional limitation of motion or functional impairment as a result of the gunshot wound. In this respect, the Veteran had full range of motion of the hips and knees without affected functioning. Although deep tendon reflexes were two out of four bilaterally, the report reflects normal bulk, tone and strength, intact sensory examination, no dysesthesias, no noted sensory abnormalities, no imbalance or tremor, and no evidence of fasciculation. Thus, despite the notation that “there is residual nerve damage, tendon damage, bone damage, muscle herniation, loss of deep fascia or muscle substance including atrophy or muscle disease”, the Board finds such is directly contradicted by the remainder of the report. In sum, it appears the conclusory statement contains a typographical error; specifically, the word “no” to indicate a negative finding of residual nerve damage, tendon damage, bone damage, muscle herniation, loss of deep fascia or muscle substance. The Board finds such correction particularly compelling when considering the use of “or” in lieu of the conjunction “and” to show exclusion of, rather than inclusion of, each disabling factor. Given that a July 2012 VA examiner inaccurately identified the affected muscle group, the Board finds the reliability of the findings from the associated examination is questionable. To ensure completeness, the Board notes muscle strength was normal on examination, and the Veteran did not have any muscle atrophy. The examination also indicates the Veteran did not have any known fascial defects with his muscle disability and such did not affect muscle substance or function. Further, the VA examiner indicated the Veteran did not have any cardinal signs or symptoms attributable to his muscle disability. The Veteran underwent additional examination in September 2019. Following examination, the VA examiner reviewed the record, identified the injury to Muscle Group XIV, and noted the Veteran now reported a burning dysesthesia from the nerve injury associated with his left thigh muscle disability as well as occasional spasm in the thigh muscles. However, the Veteran did not have loss of power, weakness, lowered threshold of fatigue, pain, impairment of coordination, or uncertainty of movement attributable to his left thigh muscle disability. The VA examiner specifically noted the Veteran had normal muscle functioning and no atrophy. Although the Veteran had occasional muscle spasms, he had full strength on examination, and the VA examiner determined the Veteran was not limited by the muscle injury. With respect to objective findings, the January 2011 VA examination report shows the Veteran had an entrance wound on the lateral side of the left thigh measuring 1.5 centimeters, circular in nature, that was mildly depressed, nontender, freely moveable, and non-adherent. There was no visible skin loss or ulceration, skin breakdown, distortion, or limitation of function. The medial exit wound scar measured three centimeters by one centimeter and was mildly depressed and slightly adherent with minimal deformity. There was no tissue tenderness to palpation, visible skin breakdown or ulcerations, and no limitation of function. The September 2019 VA examination report also indicates the Veteran had entrance and exit scars indicating the track of missile through one or more muscle groups but no ragged, depressed, or adherent scars indicating wide damage to the muscle groups in the missile track. In addition, the Veteran did not have any fascial defects, and his muscle injury did not affect muscle substance or function. In particular, there was no loss of deep fascia or muscle substance and no soft flabby muscles. The Veteran’s muscles did not swell and harden abnormally in contractions, and tests of endurance and coordinated movements did not indicate severe impairment of function. Based on the above, the Board finds the evidence does not demonstrate that the Veteran’s left thigh muscle disability resulted in a severe injury to Muscle Group XIV at any time during the appeal period. Specifically, the evidence does not show consistent complaints of cardinal signs and symptoms of a muscle disability or the objective findings that generally constitute severe disability. Moreover, the record does not contain X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile, adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle, diminished muscle excitability to pulsed electrical current in electrodiagnostic tests, visible or measurable atrophy, or adaptive contraction of an opposing group of muscles, atrophy of muscle groups not in the track of the missile, or induration or atrophy of an entire muscle following simple piercing by a projectile. While the Board acknowledges the Veteran’s competent reports of his symptomatology, the Board finds the medical evidence is most probative as it considers his reported symptoms and provides clinical evaluation of the disability, to include the functional impairment caused thereby, as contemplated by the rating criteria. Consequently, even considering the Veteran’s self-reported symptomatology, the Board finds a rating in excess of 30 percent for left thigh muscle disability is not warranted at any time during the appeal period. 38 C.F.R. § 4.73, Diagnostic Code 5314. 2. Propriety of the assignment of a separate rating for scars of the left lower extremity, evaluated as noncompensably disabling as of June 23, 2010. 3. Propriety of the assignment of a separate rating for painful scars of the left lower extremity, evaluated as 10 percent disabling as of June 8, 2018. As previously noted, an April 2020 rating decision awarded a separate noncompensable rating as of June 23, 2010, for scars of the left lower extremity, which are evaluated pursuant to Diagnostic Code 7802, and a separate 10 percent rating as of June 8, 2018, for painful scars of the left lower extremity, which are evaluated pursuant to Diagnostic Code 7804. 38 C.F.R. § 4.118. In this regard, Diagnostic Code 7802 pertains to burn scars or scars due to other causes not of the head, face, or neck that are superficial and nonlinear. Under this Diagnostic Code, a 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater. Note (1) states that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). If one or more scars are both unstable and painful, the rater is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). Scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. Id. at Note (3). As noted previously, at a January 2011 VA examination, the Veteran reported that he had skin breakdown over his left thigh scar that occurred two or more times a year, but less than monthly, and flaking that occurred with a change in season. He denied any pain, infection, warmth, or redness associated with the scar. Upon examination, the Veteran had an entrance wound on the lateral side of the left thigh measuring 1.5 centimeter (cm), which was circular in nature. Such was mildly depressed, nontender, freely moveable, and non-adherent. There was no visible skin loss or ulceration, skin breakdown, distortion, or limitation of function. There an exit wound on the medial side of the thigh, which measured 3 cm by 1 cm, which was mildly depressed in the middle 0.3 cm. Such was slightly adherent in the middle with minimal deformity. There was no tissue tenderness to palpation, visible skin breakdown or ulceration, or limitation of function. Upon a July 2012 VA examination, it was observed that the Veteran had two scars of the left thigh, with an entrance wound on the lateral side and an exit wound on the medial side, which measured 4 cm by 1 cm and 2 cm by 1 cm, respectively, and were annular in shape. The exit scar had an area of depression in the center that measured 0.5 cm in depth. Both scars were superficial and non-linear, were not painful or unstable, and did not result in limitation of motion or function. At a June 8, 2018, VA examination, it was observed that the Veteran had two scars of the left thigh residual to his gunshot wound. Specifically, the entrance scar was observed to be on the left lateral thigh and measured 1.5 cm by 2 cm, which was noted to be healed, but painful. Additionally, the exit scar was observed to be on the left medial thigh and measured 4 cm by 2 cm, which was noted to be healed, but painful. While both were deep and tender to palpation, neither scar was unstable, together they measured 11 cm squared, and did not result in any functional limitations. At a September 2019 VA examination, it was again noted that the Veteran had a lateral entrance scar measuring 2 cm by 1.5 cm, and a medial exit scar on the left thigh measuring 4 cm by 1.75 cm, which was indented. The examiner found that both scars were painful and tender to palpation and the exit scar had underlying tissue damage, but such were not unstable and did not result in limitation of function. Based on the foregoing, the Board finds that the separate ratings assigned for the Veteran’s scars of the left lower extremity are appropriate. In this regard, for the entire appeal period extending from his June 23, 2010, claim for an increased rating, such scars have been assigned a noncompensable rating under Diagnostic Code 7802 in contemplation of the fact that such are superficial and nonlinear, but such do not cover an area or areas, i.e., 144 square inches (929 sq. cm) or greater, that warrants a compensable rating under such Diagnostic Code. Furthermore, as of June 8, 2018, the date a VA examination revealed the presence of pain associated with both scars, a separate 10 percent rating under Diagnostic Code 7804 has been assigned. However, as such only affects 2 scars and neither is shown to be unstable, a higher rating under such Diagnostic Code is not warranted. The Board has also considered whether higher or separate ratings are warranted under any other potentially applicable Diagnostic Code. However, as the Veteran’s scars do not affect the head, face, or neck, Diagnostic Code 7800 is inapplicable. Furthermore, while the Veteran’s exit scar of the medial left thigh was noted to be deep and non-linear at the most recent September 2019 VA examination, a higher or separate rating is not warranted under Diagnostic Code 7801 as such does not affect an area or areas of at least 6 square inches (39 sq. cm). In this regard, such scar has been found to measure, at most, 4 cm by 2 cm, which affects 8 sq. cm. Furthermore, as the Veteran’s scars are not shown to result in limitation of motion or function, or any disabling effects, a higher or separate rating is not warranted under Diagnostic Code 7805. Therefore, based on the foregoing, the Board finds that assignment of a separate rating for scars of the left lower extremity, evaluated as noncompensably disabling as of June 23, 2010, and a separate rating for painful scars of the left lower extremity, evaluated as 10 percent disabling as of June 8, 2018, were proper. 4. Entitlement to a rating in excess of 30 percent for PTSD, exclusive of the periods where a temporary total rating has been assigned. The Veteran asserts the severity of his service-connected PTSD warrants a higher rating than that currently assigned for the periods on appeal. The Veteran’s PTSD is rated under Diagnostic Code 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. The General Rating Formula provides a 30 percent rating when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). Exclusive of the periods where a temporary total rating has been assigned, the Veteran’s service-connected PTSD is rated as 30 percent disabling for the period on appeal. Therefore, to warrant a higher rating, the evidence must demonstrate manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. As an initial matter, the Board observes that, in addition to PTSD, the Veteran has been diagnosed with multiple other psychiatric disorders; however, as will be discussed further herein, VA examiners have been able to separate the effects of the former service-connected disorder from those of the latter nonservice-connected disorders. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Concerning the Veteran’s psychiatric symptomatology, the record reflects consistent reports of anxiety, irritability, depressed mood, restricted affect, sleep impairment, hypervigilance, mild memory loss, and avoidance/isolationism. The Veteran also reported suicidal thoughts approximately twice a year in January 2011, and a single June 2019 VA treatment record indicates he had significant suicidal ideation in 1994 and 2016, with fleeting suicidal ideation in May 2019. In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the United States Court of Appeals for Veterans Claims (Court) held that the language of the general rating formula “indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas.” However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran’s service-connected psychiatric disability, and their resulting social and occupational impairment. In this respect, the remainder of the medical evidence demonstrates the Veteran’s repeated denial of suicidal ideations and any history of suicide attempts. The Board also notes that he reported significant paranoid delusions on VA examination in January 2011; however, such do not appear on a consistent basis throughout the appeal period. Furthermore, as will be discussed further herein, the Board finds that the nature, frequency, severity, and duration of the Veteran’s reported suicidal ideation and paranoid delusions do not result in occupational and social impairment that more nearly approximates the assignment of a rating in excess of 30 percent under the General Rating Formula. In this regard, a VA examiner found the Veteran’s employability was impaired by his psychiatric condition and his quality of life was significant impaired due to his symptoms in January 2011. In this respect, the Board notes the generality of “psychiatric” condition considering the VA examiner’s diagnosis of not only PTSD but also major depressive disorder and polysubstance abuse. Thus, the examination report does not make it entirely clear as to the level impairment resulting specifically from the Veteran’s PTSD. However, the VA examiner did report when addressing the Criterion for PTSD that the Veteran’s symptoms caused “significant impairment in social, occupational, or other areas of functioning”. On VA examination in July 2012, the VA examiner attributed the following symptoms to the Veteran’s PTSD: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, gross impairment in thought processes or communication, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. Diagnosing PTSD, bipolar I disorder, alcohol and marijuana dependence, and borderline and antisocial personality traits, the VA examiner summarized the Veteran’s level of impairment as occupational and social impairment with deficiencies in most areas. However, the VA examiner specifically determined that the Veteran’s “PTSD and its traumas probably made a minor contribution to his overall psychological impairment”. The VA examiner noted the Veteran had life-long challenges in maintaining stable relationships but found such was largely due to his bipolar disorder and borderline personality traits. The VA examiner commented that his PTSD perhaps slightly worsened his social and family relationships, and noted that the Veteran’s poor decisions, which caused his job loss and frustrations, were largely due to the impulsivity of his personality traits and less his PTSD. In May 2013, the VA examiner attributed re-experiencing, sensitivity to and avoidance of reminders, hypervigilance, estrangement, anger difficulty, and easy startle-ability to the Veteran’s PTSD. Additional symptomatology on examination included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, low self-esteem, problems making decisions, and violent fantasies. Overall, the VA examiner found the Veteran’s mental diagnoses resulted in occupational and social impairment with reduced reliability and productivity. However, similar to the July 2012 VA examiner, the May 2013 VA examiner opined the Veteran’s PTSD made a relatively minor contribution to the overall impairment and, in fact, the impairment resulting from the Veteran’s PTSD had not increased. The VA examiner explained that the Veteran’s distress appeared to be ascribable to temporary situational factors and to the combined effects of the diagnosed conditions other than PTSD. Following examination of the Veteran in April 2015, the VA examiner found the Veteran’s PTSD was manifested by psychiatric symptomatology resulting 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. Such symptomatology included depressed mood, anxiety, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. In January 2017, a private psychiatrist opined the Veteran would not be able to perform any employment in the foreseeable future due to his psychiatric conditions. Notably, the private psychiatrist provided diagnoses of both bipolar I disorder and PTSD and did not distinguish the impairment separately attributable to each of the different diagnoses. Following examination in October 2018, the VA examiner repeated the April 2015 VA examiner’s determination, opining that the Veteran’s PTSD was manifested by psychiatric symptomatology that resulted in occupational and social impairment 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 October 2018 VA examiner added that the bulk of the Veteran’s functional impairment was attributed to his PTSD, with his cannabis use disorder having some impact on his memory, concentration, and reduced desire to engage in other activities. Likewise, a September 2019 VA examiner found the Veteran’s level of impairment was best summarized as 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 VA examiner attributed chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, depression, and anxiety to the Veteran’s PTSD and mild memory loss to his traumatic brain injury, noting, however, that both overlapped to a great degree. Providing an addendum opinion after a review of the record, the September 2019 VA examiner noted the Veteran’s reported symptoms had been consistent and pervasive, although variable in intensity, and included hypervigilance, isolation, sleep disturbance, and depression. In pertinent part, the VA examiner found the Veteran’s PTSD resulted in an inability to be around people and a history of inappropriate behaviors with others. In addition, such manifested in absenteeism, as he had a history of failure to show up to work and refusal to call in sick. In this respect, the occupational impact of his PTSD was seen in his behavior changes, such as irritability and inappropriate comments to co-workers. The VA examiner found such prevented him from work environments that required multiple people working together or in the same location. In addition, the Veteran’s PTSD symptoms impacted his ability to concentrate, caused low energy/fatigue/sleep disturbance, exaggerated self-doubt, indecisiveness, and cognitive slowing, all of which were associated with decreased work productivity. Further, the VA examiner found depression was a significant symptom of PTSD that had affected the Veteran throughout the years. Available meta-analyses and reviews show neurocognitive deficits can reliably be found in individuals with depression on tasks involving mental flexibility, visual/spatial abilities, verbal fluency, working memory, planning, verbal and nonverbal learning, and attention, all negatively affecting performance. According to the VA examiner, neurocognitive deficits arising from the depression were strongly associated with functional impairment in areas such as work errors, increased injuries, and difficulty attending to tasks and time management. The VA examiner found the Veteran’s work history highlighted these impairments, as he had held 25 jobs in 22 years, and stated the Veteran could not remain employed longer than a couple of months in any one job before he was terminated for his behavior. Upon review, the Board finds that, exclusive of the periods where a temporary total rating has been assigned, the Veteran’s PTSD was manifested by psychiatric symptomatology result in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Here, the Board affords the VA examiners’ determinations in July 2012, May 2013, April 2015, and October 2018 great probative value with respect to the effects of the Veteran’s PTSD on his social and occupational functioning as they were based on psychological evaluations of the Veteran during the appeal periods and consideration of his own contemporaneous lay statements of his symptoms in light of the rating criteria. Notably, even when the VA examiners found the Veteran’s psychiatric symptomatology resulted in greater impairment, they specified that the resulting impairment from the symptoms directly attributable to the Veteran’s PTSD was only mild in severity. Conversely, neither the January 2011 VA examiner nor the January 2017 private psychiatrist distinguish the impairment directly attributable to the Veteran’s PTSD symptomatology. Notably, such opinions include consideration of multiple diagnoses of psychiatric conditions. Consequently, the Board does not afford the opinions provided in January 2011 and January 2017 significant probative weight. Additionally, the Board notes the September 2019 VA examiner’s addendum opinion is inconsistent with the findings presented in the associated VA examination report. Specifically, the addendum opinion appears to present a disability picture of total occupational and social impairment throughout the periods on appeal, whereas the original VA examination report reflects a finding of only occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, a much lower level of severity of symptomatology. Here, the Board finds such internal inconsistency detracts from the probative value of the opinion. Moreover, the Board affords greater probative value to the evidence contemporaneous to the periods on appeal than the September 2019 opinion provided thereafter with respect to the severity of the Veteran’s symptomatology and resulting impairment during those periods. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting the enhanced probative value of contemporaneous evidence). The Board acknowledges the Veteran’s competent reports of his symptomatology, to include his assertions regarding the impact of such on his ability to maintain employment and interact with other people. In this respect, the Board notes the Veteran’s reports that symptoms of depression associated with his PTSD often prevented him from going into work and that his inappropriate behavior precluded his ability to maintain effective relationships in the workplace. Additionally, the Veteran reports isolating behavior and angry outbursts that have caused him to sever ties with people in the past. However, the Board notes the evidence shows the Veteran has maintained some familial and romantic relationships as well as friendships on and off throughout the periods on appeal, whether living with others or on his own. Moreover, the medical professionals have opined that such behaviors and inability to maintain employment are due, in large part, to non-service-connected psychiatric disorders, to include his substance use disorder. In this regard, the Board finds the medical evidence is most probative as it considers the Veteran’s reported symptoms and provides clinical evaluation of the disability, to include the functional impairment caused thereby, as contemplated by the rating criteria. In the instant case, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of his PTSD, particularly considering the medical expertise required to delineate the symptomatology and resulting impairment specifically attributable to the Veteran’s multiple psychiatric diagnoses. Therefore, in consideration of the totality of the nature, frequency, duration, and severity of the Veteran’s psychiatric symptomatology, the Board finds that such results in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal. Consequently, a rating in excess of 30 percent is not warranted under the General Rating Formula. Other Considerations The Board has considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected left thigh disability, associated scars, and PTSD; however, the Board finds that his symptomatology had been stable throughout the aforementioned periods on appeal. Therefore, assigning additional staged ratings is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (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). Therefore, the Board finds that increased ratings for the Veteran’s left thigh disability and PTSD are not warranted, and the separate ratings assigned for his scars associated with his gunshot wound of the left thigh are proper. Consequently, as the preponderance of the evidence is against such claims, the benefit-of-the-doubt doctrine is inapplicable and his increased rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 5. Entitlement to a separate rating for neurological impairment associated with residuals of gunshot wound of the left thigh. The Veteran contends he has nerve damage proximately due to his service-connected left thigh muscle disability. In this regard, the Board notes that, at a January 2011 VA examination, he reported that he had some tingling at the site of the gunshot wound in the left thigh, which had been a chronic gradual onset. However, as indicated previously, the examiner noted that there was no associated nerve injury with the Veteran’s in-service gunshot wound. At a July 2012 VA examination, the Veteran reported some increased sensitivity to the exit wound of the left thigh and fasciculations to the muscle. In this regard, he described experiencing mild intermittent pain and moderate paresthesias and/or dysesthesias of the left lower extremity. While physical examination reflected normal muscle, reflex, and sensory testing, the examiner observed that the Veteran had hyperesthesia to the medial thigh at the femoral cutaneous nerve medially. Finally, at a September 2019 VA examination, the Veteran reported a burning sensation where the bullet struck his left thigh, which the examiner described as a burning dysesthesia from a nerve injury. Further, as relevant, he diagnosed gunshot wound of the left thigh with residual post-traumatic neuropathy of the left leg. In this regard, the examiner noted that the Veteran’s in-service gunshot wound had attendant nerve damage to the sural, tibia, and left peroneal nerves. On examination, the Veteran reported moderate constant pain and paresthesias and/or dysesthesias of the left lower extremity. While muscle and reflex testing was normal, he had decreased sensation to the left thigh/knee and lower leg/ankle. The examiner assessed mild incomplete paralysis of the left external popliteal, musculocutaneous, anterior tibial, internal popliteal, and posterior tibial nerves. Consequently, as there are conflicting findings as to whether the Veteran’s residuals of gunshot wound to the left thigh results in neurological impairment, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such matter. 6. Entitlement to a TDIU. The Veteran asserts that his service-connected disabilities have prevented him from securing and following a substantially gainful occupation since May 4, 1994. Although VA did not receive the Veteran’s Application for Increased Compensation Based on Unemployability (VA 21-8940), until January 19, 2011, the appeal period before the Board stems from June 23, 2010, the date VA received the Veteran’s increased rating claims for his left thigh muscle disability and PTSD, plus the one-year look-back period. As noted above, the Board has remanded the claim for a separate rating for neurological impairment associated with residuals of gunshot wound of the left thigh. As such may affect the overall combined rating during the appeal period, the claim for a TDIU is inextricably intertwined with such claim. Therefore, adjudication of the former claim must be deferred pending the outcome of the latter claim. Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183. The matters are REMANDED for the following action: Forward the record, to include a copy of this Remand, to an appropriate VA clinician for an opinion addressing whether the Veteran’s residuals of gunshot wound to the left thigh results in neurological impairment. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s residuals of gunshot wound to the left thigh results in neurological impairment. In offering such opinion, the examiner should reconcile the evidence of record showing that there was no injury to the nerve at the time the Veteran sustained the gunshot wound to his left thigh with subsequent neurological complaints at January 2011, July 2012, and September 2019 VA examinations, and a diagnosis of residual post-traumatic neuropathy of the left leg resulting in mild incomplete paralysis of the left external popliteal, musculocutaneous, anterior tibial, internal popliteal, and posterior tibial nerves at the September 2019 VA examination. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.