Citation Nr: 21021649 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 17-32 163 DATE: April 13, 2021 ORDER Service connection for a skin disease/disorder, to include chloracne, is denied. Entitlement to a disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to October 29, 2014 is denied. Entitlement to a 70 percent disability evaluation for posttraumatic stress disorder (PTSD) from October 29, 2014 is granted. Entitlement to a 100 percent disability evaluation for PTSD is denied. Entitlement to a 30 percent disability evaluation for residuals of a shell fragment wound (SFW) to the left shoulder with damage to Muscle Group III, is granted. Entitlement to a disability evaluation in excess of 30 percent for residuals of a SFW to the left shoulder with damage to Muscle Group III, is denied. Entitlement to a disability evaluation in excess of 10 percent for left shoulder shell fragment wound scar is denied. FINDINGS OF FACT 1. Any current skin disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, to include herbicide agent exposure. 2. Prior to October 29, 2014, the Veteran’s PTSD symptoms resulted in no more than occupational and social impairment with reduced reliability and productivity 3. From October 29, 2014 psychiatric symptoms due to PTSD, and the severity of such, more nearly approximated a rating based on occupational and social impairment with deficiencies in most areas, such as work, family relations, and mood. 4. The Veteran’s PTSD did not result in total social and industrial impairment at any time during the appeal period. 5. Residuals of a shell fragment wound to the left shoulder region with damage to Muscle Group III have been shown to be severe throughout the appeal period. 6. The Veteran does not have complete functional impairment of his left arm; there is no evidence of any left shoulder ankylosis, fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus; a rating greater than 30 percent is not available under Diagnostic Codes 5201 or 5203. 7. The Veteran's left shoulder scar is characterized as painful. 8. The Veteran's left arm scar is superficial, non-linear, and covers less than 77 centimeters squared. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disease/disorder have not been met. 38 U.S.C. §§ 1110, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for an evaluation in excess of 50 percent for PTSD prior to October 29, 2014 were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.126, 4.130 (Diagnostic Code 9411) (2020). 3. The criteria for a 70 percent disability evaluation for PTSD have been met from October 29, 2014. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.126, 4.130 (Diagnostic Code 9411) (2020). 4. The criteria for a 100 disability evaluation for PTSD have not been met at any time. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.126, 4.130 (Diagnostic Code 9411) (2020). 5. The criteria for a 30 percent evaluation for residuals of a gunshot wound to the left shoulder, Muscle Group III, have been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.55, 4.56, 4.71a, 4.73, Diagnostic Codes 5200-5203, 5303 (2020 & 2021). 6. The criteria for an evaluation in excess of 30 percent for residuals of a SFW wound to the left shoulder, Muscle Group III, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.55, 4.56, 4.71a, 4.73, Diagnostic Codes 5200-5203, 5303 (2020 & 2021). 7. The criteria for a disability rating in excess of 10 percent for the scar on the left shoulder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Codes 7801-7805 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from October 1968 to March 1970. The Veteran appeared at a hearing before the undersigned Veterans Law Judge in November 2019. A transcript of the hearing is of record. In February 2020, the Board remanded this matter for further development. The requested development has been completed and the matter is now ready for appellate review. Service Connection-Skin Disease/Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). Section 3.307(d)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(d)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. The diseases presumed to be associated with herbicide exposure include: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes (also known as type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange (AO) is generally considered an herbicide agent and will be so considered in this decision. The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary, under the authority of the Agent Orange Act of 1991 and based on the studies by the NAS, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-08 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); Final Rule, 74 Fed. Reg. 21,258-260 (May 7, 2009); Final Rule, 75 Fed. Reg. 53,202-16 (Aug. 31, 2010). Notwithstanding the foregoing, a veteran may still establish service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167 (1999). "Of particular relevance to an analysis of medical evidence supporting such a nexus are factors such as whether a medical professional finds studies persuasive, whether there are other risk factors that might be the cause of the condition for which benefits are sought, and whether the condition has manifested itself in an unusual manner." Polovick v. Shinseki, 23 Vet. App. 48, 53 (2009). A statistical correlation between AO and a disease not on the presumptive list may not be the only basis for a positive nexus opinion, it may be part of the analysis, but the entirety of the analysis provided by the medical professional must be weighed and considered. Polovick, 23 Vet. App. at 53-54. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. To the extent that the Veteran is claiming that his current skin disease/disorder arises out of exposure to herbicides, while chloracne is on the presumptive list, the Veteran has not been diagnosed with chloracne. The other identified skin disorders/diseases are not on the presumptive disease list. As noted above, the Secretary of Veterans Affairs has determined that there is no positive association between AO exposure and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. Hence, presumptive service connection for any current skin disorder/disease cannot be provided based upon the regulations governing presumptive exposure or on the basis of studies performed by the NAS on behalf of the Secretary with regard to AO exposure. Service treatment records do not reveal any complaints or findings of skin disorders in service. At the time of the Veteran’s March 1970 service separation examination normal findings were reported for the Veteran’s skin. There were no findings of skin disease/disorders until decades following service. At his hearing, the Veteran testified that he had no skin problems in service. In conjunction with his claim, the Veteran was afforded a VA skin examination in September 2020. The Veteran was found to have dermatitis of the hands. Following examination of the Veteran and review of the file, the examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that the Veteran presented with an exam and history that was significant for and consistent with a diagnosis of dermatitis of the bilateral hands. The examiner observed that the Veteran started having these symptoms in 2014, and he was diagnosed with dermatitis of the hands by dermatology in May 2014. The examiner noted that the Veteran was claiming that his skin problems, claimed as chloracne, were a result of his service, specifically due to herbicide exposure. The Veteran was on active duty in Vietnam, with known herbicide exposure in Danang. The examiner noted that the Veteran’s October 1968 intake exam was silent for any skin issues. The Veteran’s March 1970 separation examination was similarly silent for any issue pertaining to the skin. The examiner observed that the Veteran did not have a diagnosis of chloracne, and there were no records showing that he started having dermatological issues within one year of his leaving the service. The examiner stated that the only skin condition that was presumptive for herbicide exposure was chloracne, which the Veteran did not have, and it needed to occur within one year, for which there was no evidence. The Veteran’s in-service treatment records were also silent on any dermatological issues. The examiner indicated that given all of this, the Veteran’s claimed skin disorder, to include chloracne, was less likely than not (less than 50 percent probability) incurred in or caused his period of service, to include as a result of exposure to herbicides during service. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against the conclusion that the Veteran's current skin disorders had their onset in service or are otherwise related to his period of service. At the time of the Veteran’s March 1970 service separation examination, normal findings were reported for the skin. Moreover, skin disorders/diseases were not diagnosed until many years following service. Given the foregoing, the weight of the evidence demonstrates that neither skin disorders/diseases nor chronic skin disorders/disease symptoms were shown during active service. Furthermore, the Veteran has not reported or indicated that his current skin disorders had their onset in service, rather he has reported, and the record demonstrates, that skin disorders/diseases occurred years following his period of service. The evidence does not show clinical documentation of any skin disorder/disease in service or immediately following service. The Veteran's opinion that purports to establish continuity of symptomatology or relate his current skin disorders/diseases to active service, if that is what is being claimed, is of little probative value. Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. The Veteran was afforded the opportunity to provide medical evidence and/or an opinion relating his current skin disorder/disease to his period of service, to include by way of exposure to AO. He has not provided either medical evidence or an opinion to support this proposition. Significantly, there is also no competent, probative evidence or opinion of record that suggests a nexus between any incident in service and the Veteran's skin disorder/disease, including exposure to AO. Moreover, the September 2020 examiner, following an examination of the Veteran and review of the record opined that it was less likely than not that the Veteran's skin diseases/disorders were related to his period of service, to include as a result of his exposure to AO. The examiner also provided detailed rationale to support the opinion. The opinion was based upon a thorough examination of the Veteran and a comprehensive review of the claims folder. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history, citing to it in the report. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for skin disorder/disease, to include chloracne. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2019). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). PTSD The General Formula for Rating Mental Disorders, Diagnostic Code 9411, provides that a 50 percent evaluation requires 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 abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms cited above follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Veteran maintains that the symptomatology associated with his service-connected PTSD warrants disability evaluations higher than those which are currently assigned. In conjunction with his claim, the Veteran was afforded a VA examination in June 2014. At that time, a diagnosis of PTSD was rendered. The examiner found that the Veteran’s PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was noted to have lived in the same residence for the past seven years with his wife. He stated that his wife's adult son also resided with them. The Veteran reported that "gets along good" with his wife. The Veteran never had children and stated that he did not spend time with anyone other than his wife. The Veteran described himself as a life-long loner. He indicated that his mother was still alive and lived locally and that he saw her 1-2 times per year. The Veteran had no living siblings. He noted that he spent his time walking 5-10 miles/day, and that he got enjoyment from walking. The Veteran had trained as a body builder but was not able to lift weights due to physical injury. The Veteran stated that he was able to help his wife around the house and that he was able to go shopping with her. He did indicate that sometimes he deemed the crowds at a grocery store to be too large and that he was not able to "walk through the door." The Veteran described himself as independent for ADLs and indicated that he was able to support himself with his pension, social security, and service-connected compensation. The Veteran reported that he has been seeing a therapist at the Erie VetCenter for the past 2-3 years. He noted seeing her every two weeks and from his description it appeared that the therapy was primarily supportive in nature. The Veteran stated that since last the VA examination he had tried various psychotropic medications to help with sleep but they were not helpful and he was not taking any medications for his mental health. The Veteran described his mood as "relaxed," but could be "up and down" at times and reported that his mood could be improved by working out. He did disclose that on three occasions he had had thoughts of harming himself/ending his life since his last VA examination, with the most recent of these being six months ago. He described his suicidal ideation as discrete episodes that lasted 2-3 days, that if he were to kill himself he would use a gun, but he stated that he did not currently have access to a gun. The Veteran reported that he was able to talk himself out of wanting to kill himself, stating, "that is the dumbest idea that I ever came up with." The Veteran reported that he had never made a suicide attempt and denied current thoughts of wanting to harm himself. He denied significant symptoms of depression, denied symptoms of psychosis or OCD related thoughts or behaviors, and denied symptoms of mania. There were no self-harm behaviors and no psychiatric hospitalizations. The symptoms associated with the PTSD included anxiety; suspiciousness; panic attacks that occurred weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; and disturbances of motivation and mood. Mental status examination revealed he was on time for the appointment, casually dressed, wearing a white tank top, shorts, and displaying multiple tattoos and a blond mohawk hair style. He displayed good eye contact throughout the interview. He was oriented to time, place, and person. His speech was clear and of normal volume, articulation, rate. His mood appeared euthymic, with appropriate affect and mild urgency noted. His thought process was goal oriented and had no major derailment, loose or clanging associations, thought blocking, or neologisms. He also had no signs of delusional belief systems. He denied homicidal/suicidal ideations. The examiner noted that the Veteran had received treatment for the past 2-3 years. He ceased outside employment completely in 2011. While he was working, the Veteran denied any interference of his PTSD symptoms with his ability to attend work. He did report being distracted by noises but that he did enjoy his solitary work environment. The examiner noted that the Veteran met the criteria for a diagnosis of PTSD. The examiner stated that the Veteran’s symptoms of PTSD would likely cause moderate discomfort when interacting with other people, and mildly to moderately reduced communication effectiveness. His level of concentration problems would likely cause mild to moderate work inefficiency and lack of productivity, for example he might lose his train of thought in a conversation, as occurred one time during the interview. He reported significant difficulties with irritability and exaggerated startle, both of which would decrease work efficiency and his ability to cope with workplace stress. The degree of difficulties relating to others would likely interfere with his ability to interact with others in a work setting as well as engage with members of the public. His ability to maintain a logical thinking process appeared adequate and would not likely impact his social or vocational functioning. He did not suffer from gross impairment in thought processes, delusions, or hallucinations. He was not a danger to himself or others. At the time of an October 29, 2014 VetCenter visit, the Veteran reported an increase in pain, irritability, depression, and isolation. He indicated that the irritability would come and go and he found himself pacing alot. He stated that if he isolated, the irritability decreased. He noted continued nightmares which caused him to jump up from his sleep. He discussed hearing things that weren’t there and gave the example that many times he heard a knock on the door but when he answered no one was there. He indicated that the weather was already getting him down and he was getting cabin fever. He reported limited contact with his wife, with arguments when they did get together, and no contact with his mom. He noted continued frustration with no response to his claim. At the time of a February 2015 outpatient visit, the Veteran was oriented times three and denied any current SI/HI or hallucinations. He stated that he continued to have trouble sleeping, as he slept on the floor and would wake up throughout the night and see shadows. He stated that that depression continued as the weather kept him from getting out and walking. He reported lifting weights released some anger but this was impaired as a result of his shoulder/elbow injuries. He noted feeling like a "time bomb" and wanted to "jerk their heads off” referring to the behavioral health staff who did his VA examination. He reported an increase in anger and wanted to move to a more secluded apartment where he was not around people. He noted minimal interaction with his wife and no contact with his mom. He reported little tolerance for his wife or her son who was an addict. He noted having no social activities and he continued to be upset about his denial on appeal. VA treatment and VetCenter records note similar to worsening symptoms in subsequent visits. In conjunction with the February 2020 remand, the Veteran was afforded an additional VA examination in September 2020, at which time he was again diagnosed as having PTSD. The PTSD symptoms were noted to cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran was noted to have resided in the same residence with his wife of 14 years. The Veteran indicated that his wife's sister was living with them due to her health problems. He stated that his relationship with his wife was "good". He reported that his wife's son, who had lived with them for periods of time, died of a drug overdose in the past several years. The Veteran stated that he did not spend time with anyone other than his wife and described himself as a lifelong loner. He indicated that his mother was still alive and lived locally and that he saw her occasionally. He had no living siblings. The Veteran reported that he currently spent his time exercising within his physical limitations and helping with household chores. The Veteran’s PTSD caused symptoms of anxiety; suspiciousness; panic attacks that occurred weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and disturbance of mood and motivation. Mental status examination revealed he appeared his chronological age and was well-nourished and in no apparent distress. No unusual/remarkable physical features were noted. The Veteran was dressed appropriately in casual attire, with good hygiene and grooming. He was alert and oriented to person, place, time and to the nature of the exam. His mood was subdued and his affect reserved, somewhat aloof. He interacted in a cooperative manner. His speech was normal in rate, volume, productivity, with no evidence of pressured speech. He displayed no language impairment, either receptively or expressively and his language was without obvious impairment. There were no abnormal movements, tics, or involuntary movements and no agitation or psychomotor retardation was observed. Thought process was logical and goal-directed without evidence of thought disorder. The Veteran did not exhibit tangential thinking, circumstantial thinking, loose associations, flight of ideas, incoherent thoughts, difficulty in understanding complex commands, or gross impairment in thought process or communication. There were no auditory, visual or tactile hallucinations or sensory distortions. The Veteran revealed no fixed delusions of paranoia, grandiosity, or reference, and there were no specific obsessions or preoccupations during the interview. There was no grossly inappropriate behavior described or observed. The Veteran established/maintained appropriate eye contact and memory was without obvious impairment, he was able to recall history in normal manner. Attention and concentration were without obvious impairment. The Veteran was able to attend to interview and respond appropriately without hesitation. His fund of knowledge was good and his intelligence was at least within the average range, based upon vocabulary and academic/occupational accomplishment. Insight and judgment were grossly intact, and abstract and reasoning were without obvious impairment. He denied suicidal or homicidal ideation, intent, or plan. PTSD Prior to October 29, 2014 After a review of all the evidence, lay and medical, the Board finds that the criteria for a disability evaluation in excess of 50 percent have not been met or nearly approximated at any time prior to October 29, 2014. The Board finds the Veteran's PTSD symptoms and the severity of his symptoms did not more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, to include as due to such symptoms as: obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships during this time period, and the criteria for a 70 percent rating are not met. 38 C.F.R. §§ 4.3, 4.7. The Veteran was not shown to have obsessional rituals which interfered with routine activities. Speech was not found to be intermittently illogical, obscure, or irrelevant at any time during this period, including at the time of the VA examination. While depression has been diagnosed throughout the appeal, it was not found to be near-continuous affecting the ability to function independently, appropriately and effectively during this time frame. Although the Veteran did have panic attacks this occurred weekly or less often. He was found to be alert and oriented to time, place, and person at all times and there were no findings of neglect of personal appearance or hygiene. While the Veteran did report having suicidal ideation he indicated that he would not carry them out. The Veteran reported that he had never made a suicide attempt and denied current thoughts of wanting to harm himself at the time of the June 2014 VA examination. PTSD from October 29, 2014 Resolving reasonable doubt in favor of the Veteran, the Board will find that his PTSD symptoms have warranted a 70 percent disability evaluation since October 29, 2014. In this regard, the Board notes a worsening in the Veteran’s PTSD symptoms from this time point. The Veteran noted having trouble sleeping, as he slept on the floor and would wake up throughout the night and see shadows. He noted feeling like a "time bomb" and wanted to "jerk their heads off” referring to the behavioral health staff who did his VA examination. He also noted an increase in anger and wanting to move to a more secluded apartment where he was not around people. He social contact also appeared to worsen, reporting minimal interaction with his wife and no contact with his mom. He further noted having little tolerance for his wife or her son who was an addict, with no social activities. The Board finds these symptoms akin to severe symptomatology, warranting a 70 percent disability evaluation since October 29, 2014. The Board has reviewed all of the evidence of record, lay and medical, and finds that the Veteran has not met the criteria for a higher 100 percent disability rating for PTSD. See 38 C.F.R. § 4.130. The record does not indicate total occupational and social impairment, due to symptoms of such a severity as described for a 100 percent evaluation for PTSD. The examiner indicated that the Veteran has had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. These are the criteria associated with a 70 percent disability evaluation. Moreover, the Board finds that total social impairment has not been indicated as the Veteran has been able to maintain relationships with his wife and other family members. As noted above the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately, in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the veteran's psychiatric symptoms, whether listed in the applicable rating criteria or not, and had assigned a rating based on the Veteran's level of occupational and social impairment. Mauerhan v. Principi, at 444. Applying this analysis to the criteria for the 100 percent rating, it follows that the Veteran would be entitled to that rating if PTSD caused total occupational and social impairment, regardless of whether he had some, all, or none of the symptoms listed in the rating formula, and regardless of whether his symptoms were listed or not. The Board concludes that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating criteria under DC 9411 for any period. 38 C.F.R. § 4.130. The weight of the evidence shows that the Veteran has not had total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name for any period. For these reasons, the Board finds that a preponderance of the evidence is against a 100 percent schedular rating for PTSD. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Residuals of Shell Fragment Wound of the Left Shoulder with Muscle Group III Involvement The Veteran's shell fragment wound is currently evaluated under 38 C.F.R. § 4.73, Diagnostic Code 5303, for a Group III muscle disability. Muscle disabilities are rated as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56 (2019). The cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). A moderately severe muscle disability is evidenced by a 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. There should be hospitalization for a prolonged period for treatment of wound and a record of consistent complaint of cardinal signs and symptoms of muscle disability and, if present, evidence of inability to keep up with work requirements. 38 C.F.R. § 4.56(d)(4)(i),(ii). A severe muscle injury is a 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, where there was hospitalization for a prolonged period for treatment of the wound. There should be a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. 38 C.F.R. § 4.56(d)(4)(i), (ii). Moderately severe disability of muscles requires 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 the sound side, and tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56(d)(3)(iii). Severe disability of the muscles requires ragged, depressed and adherent scars, loss of deep fascia or muscle substance or soft flabby muscles in the wound area, and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56(d)(4)(iii). If present, the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies; (b) adhesion of the scar; (c) diminished muscle excitability on 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; or (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4)(iii). Diagnostic Code 5303, Muscle Group III, involves the intrinsic muscles of the shoulder girdle, including the pectoralis major I (clavicular) and the deltoid. For the non-dominant arm, a 20 percent disability rating is warranted for moderate injury. A 20 percent rating is also warranted for moderately severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5303. A maximum 30 percent rating is warranted for severe injury. Diagnostic Code 5200 rates ankylosis of the scapulohumeral joint. Where arm limitation of motion is limited to 25 degrees from the side, a 30 percent evaluation is assigned for the minor side. Limitation of motion midway between the side and shoulder level contemplates a 20 evaluation; while limitation of motion at shoulder level also contemplates a 20 percent evaluation. Under Diagnostic Code 5202, for impairment of the humerus in the major arm or minor arm a 20 percent rating is granted when there is malunion, with moderate deformity. Also under Diagnostic Code 5202, for recurrent dislocations at the scapulohumeral joint, a 20 percent rating for the major and minor arm is granted with infrequent episodes, and guarding of movement only at shoulder level; a 20 percent rating is also granted when there are frequent episodes and guarding of all arm movements. A 40 percent rating is granted for fibrous union; a 50 percent rating is granted for nonunion (false flail joint); and a 70 percent rating is granted for loss of head of (flail shoulder). Under Diagnostic Code 5203, for impairment of the clavicle or scapula, a 10 percent rating is granted for malunion or nonunion without loose movement; a 20 percent rating is granted for nonunion with loose movement or for dislocation. The Board notes that regulations regarding the musculoskeletal system changed effective February 7, 2021. The codes relating ot the shoulder changed as follows: 5201 Arm, limitation of motion of: Major Minor Flexion and/or abduction limited to 25° from side 40 30 Midway between side and shoulder level (flexion and/or abduction limited to 45°) 30 20 At shoulder level (flexion and/or abduction limited to 90°) 20 20 5202 Humerus, other impairment of: Loss of head of (flail shoulder) 80 70 Nonunion of (false flail joint) 60 50 Fibrous union of 50 40 Recurrent dislocation of at scapulohumeral joint. With frequent episodes and guarding of all arm movements 30 20 With infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90°) 20 20 Malunion of: Marked deformity 30 20 Moderate deformity 20 20 5203 Clavicle or scapula, impairment of: Dislocation of 20 20 Nonunion of: With loose movement 20 20 Without loose movement 10 10 Malunion of 10 10 Or rate on impairment of function of contiguous joint. The Veteran underwent a VA examination in June 2014. At that time, he was noted to have sustained a penetrating muscle injury. No other muscle groups were involved. Entrance and exit scars were present. There were no fascial defects or evidence of fascial defects associated with the muscle injury and the muscle injury did not affect muscle substance or function. The muscle injury caused fatigue-pain. Shoulder abduction strength was 5/5. There was no muscle atrophy. Shell fragments were found to be present in the muscle. The muscle injury did not impact the Veteran’s ability to work as he had worked as a laborer, mason layer, until 2007 when he retired. VA shoulder examination indicated that the Veteran was right arm dominant. The Veteran reported that he tried not to use the shoulder. Shoulder flexion and abduction were to 180 degrees with no pain. Range of motion remained the same with repetitive testing. Muscle strength was 5/5 with no ankylosis present. Rotator cuff testing was normal. There was no instability, dislocation, or labral pathology. The examiner stated that the Veteran's findings of arthritis in his left shoulder were less likely than not caused by or a result of the service-connected shrapnel injury to Group III muscles in the left arm because there was no evidence in the medical literature of a relation between these conditions, the injury occurred in 1969 and arthritis was just recently diagnosed in 2009, he worked as a brick layer all his life, it was commonly seen with older age and it had many causes. At the time of a September 2020 VA examination, the Veteran was noted to have entrance and exit scars indicating track of missile through one muscle group. There were no fascial defects. The injury did cause some impairment of muscle tone. It also caused weakness, a lowered threshold of fatigue, and fatigue and/or pain. Muscle strength testing was 5/5. There was no muscle atrophy. The examiner indicated that with weakness and fatigue of the left shoulder, the Veteran would not be able to do work that required a lot of lifting or work above his head. VA shoulder examination revealed that the Veteran reported episodes of worsening pain and weakness of the left shoulder and arm. The Veteran stated he could not do much physical labor because of this. Active flexion and abduction were to 130 degrees while external and internal rotation were to 90 degrees. Pain was noted on flexion and abduction. There was no additional loss with repetition. Passive range of motion was flexion to 130 degrees, abduction to 120 degrees, external rotation to 90 degrees and internal rotation to 90 degrees. There was moderate localized tenderness or pain on palpation of the joint/soft tissue in the left deltoid muscle area secondary to the muscle injury. With repeated use over time, flexion was estimated to be limited to 110 degrees with abduction to 80 degrees and external and internal rotation to 90 degrees. With flareups, flexion was estimated to be limited to 100 degrees, with abduction to 70 degrees, and external and internal rotation to 90 degrees. The Veteran was noted to have weakened movement due to the muscle injury. Muscle strength was 5/5 with no muscle atrophy. There was no ankylosis. There was no rotator cuff pathology and no shoulder instability, dislocation, or labral pathology. The examiner stated that the Veteran would not be able to do work that would require a lot of lifting or work that would need to be done above his head because of his muscle injury. The examiner opined that the Veteran had a severe disability due to the residuals of the shell fragment injury to MGIII. This severely limited his ability to abduct and flex the arm at the shoulder, as seen in the shoulder DBQ. This limitation was essentially at rest and would be markedly more noticeable if used or if during a flare. The examiner opined that Muscle Group III included the deltoid, which was the powerful abductor of the arm, and was also part of the flexing motion of the arm. Damage to this muscle would limit range of motion and cause chronic pain. Resolving reasonable doubt in favor of the Veteran, the Board finds that a 30 percent disability evaluation for residuals of a SFW to the left shoulder has been warranted throughout. While the Veteran has not been shown to have all the signs and symptoms warranted for a 30 percent disability evaluation, he has been noted to have retained shell fragment wounds in the left shoulder. Moreover, the September 2020 VA examiner specifically found that the Veteran had severe disability due to the residuals of the shell fragment injury to MGIII. The examiner noted that this severely limited his ability to abduct and flex the arm at the shoulder, as seen in the shoulder DBQ. Given the foregoing, a 30 percent disability evaluation is warranted. After a thorough review of the evidence of record, the Board concludes that an evaluation in excess of 30 percent is not warranted for the Veteran's residuals of a SFW to the left shoulder region, Muscle Group III, under Diagnostic Code 5303, as 30 percent is the highest rating available under Diagnostic Code 5303 for the nondominant arm. 38 C.F.R. § 4.73, Diagnostic Code 5303. As noted above, a maximum 30 percent rating is warranted for severe injury to Muscle Group III in the nondominant arm. An increased rating greater than 30 percent is not warranted under any of the other diagnostic codes pertaining to the muscle groups of the shoulder girdle and arm, as 30 percent is the highest rating assignable for the nondominant arm under each of those diagnostic codes. 38 C.F.R. § 4.73, Diagnostic Codes 5301-5306. The Veteran does not have complete functional impairment of his left arm, so a rating for loss of use of the arm is inappropriate for any portion of the periods under consideration. See the VA examinations (finding there was not functional impairment so severe that no effective function remains other than that which would be equally well served by an amputation with prosthesis). The Board has also considered the Veteran's left shoulder disability under the musculoskeletal diagnostic codes. However, an increased evaluation greater than 30 percent is not warranted under the shoulder and arm diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203. The currently assigned ratings based on muscle injury are higher than what the Veteran would receive if he were rated based on limitation of shoulder motion. Furthermore, there is no evidence of any left shoulder ankylosis, fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. A rating greater than 30 percent is not available under Diagnostic Codes 5201 or 5203. 38 C.F.R. § 4.71a, Diagnostic Code 5201, 5203. Accordingly, an increased evaluation is not warranted under the musculoskeletal disorder diagnostic codes under either the old or new rating criteria. Left Shoulder Scars The Veteran maintains that the symptomatology associated with his left shoulder scar is worse than that which is contemplated by his current rating and that an increased evaluation is warranted. The applicable rating criteria include Diagnostic Code 7801, which provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful warrant a 10 percent rating, while a 20 percent rating is warranted for three or four of such scars. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that 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, Diagnostic Code 7804. Diagnostic Code 7805 provides 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 diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. Effective August 13, 2018, changes were made to the rating criteria for skin disabilities (38 C.F.R. § 4.118). See 83 Fed. Reg. 32,592 (July 13, 2018). The old regulation will be considered for periods both before and after the effective date of the regulatory change. However, the revised criteria will be applied if favorable to the claim from the effective date of the regulatory change. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). To summarize, the revisions to Diagnostic Codes 7801, 7802, and 7805, pertaining to scars: (1) replace the deep/nonlinear/superficial terminology in Diagnostic Code 7801 and 7802 with "underlying soft tissue damage"; (2) streamline the body parts/areas into six zones of the body, defined as each extremity, the anterior trunk and the posterior trunk (Note 1 to DCs 7801 and 7802); and (3) indicate how to assign separate evaluations for each affected zone of the body under § 4.25 (Note 2 to DCs 7801 and 7802). At the time of a May 2013 VA examination, the Veteran was noted to have a painful left shoulder scar. Physical examination revealed an 11 cm. linear scar of the left upper extremity. There was pain and tenderness with pulling sensation with outward movement of the arm. The scar was not unstable and there was no loss of covering over the skin. At the time of a June 2014 VA examination, the Veteran was noted to have a 12.5 x 1 cm. superficial non-linear scar on the proximal aspect of the left arm. The Veteran reported having no pain in the scar area. At the time of a September 2020 VA examination, the Veteran reported that the scar was painful to the touch. Physical examination revealed a 10 cm x 1 cm scar in the left shoulder area which was tender to palpation. There was no limitation as a result of the scar. The scar was noted to not cause functional deficit. The examiner indicated that the Veteran has a 10 x 1 cm scar on his left shoulder which caused chronic pain. It was noted that the pain contributed to the limited range of motion of his left shoulder, particularly with abduction and flexion. A higher rating of 20 percent is not warranted under DC 7804, as the Veteran does not have at least 3 or more scars which are painful or unstable. See 38 C.F.R. § 4.118, DC 7804. Both the former and revised version of DC 7800 are inapplicable because that Code pertains to scars of the head, face, or neck. DC 7801 relates to scars that are deep and nonlinear (pre-2018 version) or are associated with underlying soft tissue damage (post-2018 version). DC 7802 relates to scars that are superficial and nonlinear (pre-2018 version) or are not associated with underlying soft tissue damage (post-2018 version). The Board notes that, because the surface area of the Veteran's service-connected scar was no more than 12.5 square centimeters, neither the former or revised versions of DCs 7801 or 7802 would result in a compensable rating in this case. The Board does note that the examiner indicated that the scar added to limitation of motion; however, limitation of motion is one the bases for the currently assigned disability evaluation under DC 5303. Thus, such limitation of motion is already contemplated by the underlying injury from which the scar resulted. For these reasons, no more than a 10 percent rating is warranted for the Veteran's service-connected left shoulder scar. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.