Citation Nr: 21022853 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-15 518 DATE: April 19, 2021 ORDER Entitlement to an initial rating in excess of 70 percent for the service-connected insomnia disorder is denied. Entitlement to an initial rating in excess of 10 percent for the service-connected cesarean section (C-section) scar is denied. Entitlement to service connection for a left wrist disorder manifested by pain is denied. FINDINGS OF FACT 1. For the entire appeal period, the severity, frequency, and duration of the Veteran’s insomnia disorder symptoms do not more closely approximate total occupational and social impairment. 2. For the entire appeal period, the Veteran has had one linear C-section scar approximately 14 centimeters in length; the scar is painful but not unstable. 3. The preponderance of the probative evidence is against finding that a left wrist disorder manifested by pain began during the Veteran’s active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for an initial disability rating in excess of 70 percent for the service-connected insomnia disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9499-9413. 2. For the entire appeal period, the criteria for a disability rating in excess of 10 percent for a service-connected C-section scar have are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804. 3. The criteria for service connection for a left wrist disorder manifested by pain are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 2003 to December 2010. In October 2018, the Board of Veterans’ Appeals (Board) remanded this case for additional development. As that development has been completed, the Board will proceed with adjudication. In an August 2020 rating decision, the Regional Office (RO) granted the Veteran service connection for her right foot sprain. As this grant represents the full benefits sought on appeal, this issue is no longer before the Board. In that same rating decision, the RO also increased the initial ratings for the Veteran’s service-connected insomnia disorder from 10 to 70 percent disabling and from a noncompensable evaluation to 10 percent disabling for the service-connected C section scar. As these ratings do not represent the highest possible evaluations under the respective Diagnostic Codes, the issues of increased ratings for the service-connected insomnia disorder and the service-connected C-section scar disabilities are still on appeal at the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Insomnia Disorder The Veteran is seeking the next-higher rating of 100 percent for her service-connected insomnia disorder. This disability is analogously rated under the unspecified anxiety disorder provisions at Diagnostic Code 9499-9413, which in turn provides for a 70 percent rating where there is occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. The highest rating of 100 percent is warranted where 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 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. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health and illness. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Effective August 4, 2014, DSM-5, which eliminated the use of GAF scores, has been implemented. As the Veteran’s appeal was certified to the Board in June 2018, DSM-5 is applicable in this case. On a September 2012 VA examination for mental disorders, the Veteran reported that she was married with two children, a four-year-old son and a 10-month-old daughter. She stated that she had not worked since she left service in 2010, but that she had been attending school, where she was performing well. She also reported that she spent her spare time reading and being present with her family. The Veteran indicated that she did not participate in any significant social activities. It was noted that she developed persistent sleep problems in the military when she worked erratic hours as an air traffic controller. It was also noted that she exhibited symptoms such as difficulty falling asleep, difficulty remaining asleep, and daytime sleepiness. The examiner indicated that the Veteran’s sleep problems persist currently, with difficulty falling and remaining asleep nightly, and being tired during the day. The Veteran denied nightmares or parasomnias and any feelings of suicidal, homicidal, psychotic, manic, or hypomanic ideations. As documented on the examination report, the only symptom that applied to his insomnia disorder is chronic sleep impairment. The examiner indicated that, despite the formal diagnosis of an insomnia disorder, the symptoms associated with this disability were not severe enough either to interfere with occupational and social impairment functioning or to require continuous medication. The examiner believed that the Veteran was capable of working on a full-time basis, from a mental health perspective, and that she did not appear to pose any threat of danger or injury to self or others. On a September 2019 VA Disability Benefits Questionnaire, the Veteran reported a predominant complaint with sleep quantity and quality associated with difficulty initiating sleep, maintaining sleep, and early morning awakenings, which occurred at least three nights per week and lasted for at least three months. She reported that the sleep difficulty occurred despite having adequate opportunity to sleep. She also stated that she lived with her husband and two children, but that she was having issues with her husband, which they were trying to work out. She reported that she gets irritable and that she snaps a lot because she does not get enough sleep. She also stated that she does not socialize frequently because of her children, work, and a lack of sleep. She noted that she obtained a bachelor’s degree in 2013 and a master’s degree in 2015 and that, although she works on a full-time basis, she makes the most mistakes at work because of her sleeping and concentration issues. The examiner described a progression of the Veteran’s insomnia symptoms. Her relevant symptoms that include, depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work-like setting; and obsessional rituals which interfere with routine activities. The examiner remarked that the Veteran arrived at the examination on time. She presented as casually dressed, with fair hygiene. The Veteran was cooperative, and was oriented to person, place, time, and event. Her speech was normal in rate, tone, rhythm, and volume. The Veteran’s mood was lethargic, which was congruent with her affect. She seemed to make effort to make eye contact often. Her thought process was linear and goal directed. No problems in long-term memory or short-term recall were observed during the session. The Veteran denied experiencing any current hallucinations, or homicidal or suicidal ideation. There was no evidence of delusional thinking. The Veteran seemed open and appeared to demonstrate fair insight and judgment. The examiner concluded that the Veteran’s insomnia disorder results 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. Throughout the month of July 2020, the Veteran reported for mental health outpatient assessments. She stated that she had been separated from her husband since 2019 and was going through a divorce, which was indicated as the main source of her increased anxiety. She reported that she had been an alcoholic and was sober for nine months. She also reported that, in November 2019, she was suicidal and attempted to kill herself, when her husband called the police. The notes state that the police appeared and tased the Veteran, after which she was hospitalized for four days. The Veteran indicated that she was still fully employed. On mental status examination, the Veteran was oriented to person, place, date, and purpose. Her attitude was cooperative, and her speech rate and speech output were normal. Her mood was anxious, her affect was appropriate to content, and her thought was logical. Memory was intact. The Veteran also had good insight and judgment. There were no suicidal or homicidal ideations, or hallucinations. Given the above, the Board finds that the assessments of the severity of the Veteran’s insomnia disorder more nearly approximate the criteria for a 70 percent rating. The Veteran did not report any symptoms indicative of a 100 percent rating at any of her mental evaluations. Although she indicated that she tried to harm herself in November 2019, there is no evidence of persistent danger of hurting self or others. At the July 2020 mental status examination, she denied having suicidal or homicidal ideations, or hallucinations. The results of the VA examinations and mental status evaluations show that the Veteran’s insomnia disorder causes occupational and social impairment with deficiencies in most areas, but none of the symptoms reported at any of these evaluations indicate total occupational and social impairment. While she admitted that she made mistakes at work due to her sleep problems, there is no indication that she is not capable of performing her job. The evidence indicates that she has maintained steady employment with the same employer. Although she has reported marital problems, she appears to have a good relationship with her children. In addition, she reported to the July 2020 examiner that she went on a recent girls’ trip, which indicates that she also maintains a good relationship with her friends. Thus, she does not have total social impairment. Accordingly, the Board assigns probative value to the opinions of the VA examiners, who each found that the Veteran’s insomnia disorder has not resulted in total occupational and social impairment. Hayes v. Brown, 9 Vet. App. 67 (1996). Both VA examiners indicated that they reviewed the Veteran’s medical history. The September 2019 examiner utilized the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Although the Veteran’s insomnia disorder has resulted in significant occupational and social impairment, the severity, frequency, and duration of her symptoms do not more closely approximate total occupational and social impairment. Thus, a 100 percent rating is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Cesarean Section Scar The Veteran contends that the next-higher 20 percent rating is warranted for her C section scar because it causes her to experience stabbing pains on the left side of her pelvis on a regular basis. See April 2016 VA Form 9 Lay Statement from Veteran. She also states that she met with a VA physician who informed her that the scar was open and infected, which is apparently a frequent occurence. Id. The Veteran’s C-section scar has been evaluated under Diagnostic Code 7804, for residual scars. According to the relevant diagnostic codes, Under Diagnostic Code 7801, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. A scar in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm) warrants a 20 percent evaluation. A scar in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm) warrants a 30 percent evaluation. A scar in an area or areas of at least 144 square inches (929 sq. cm.) or greater warrants a 40 percent evaluation. Note (1): a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (1): a superficial scar is one not associated with underlying soft tissue damage. Note (2): if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Id. Under Diagnostic Code 7804, 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 evaluation. Five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (1): an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. Under Diagnostic Code 7805, any disabling effects of other scars (including linear scars), and other effects of scars rated under Diagnostic Codes 7800, 7801, 7802, and 7804 not considered in a rating provided under Diagnostic Codes 7800-7804 are to be rated under an appropriate diagnostic code. Id. A September 2012 VA examiner noted that the Veteran had a post-cesarean section scar from 2008. This scar was specified on the Veteran’s anterior trunk and extremities. The scar was neither painful nor unstable. It was linear and measured 14.5 centimeters (cm). The examiner noted that the Veteran’s C-section scar does not impact her ability to work. The Veteran was afforded another VA examination for her C-section scar in September 2019. She reported having occasional pain at the site of the scar approximately every six months. She also stated that the pain usually lasts for a few days, then resolves. The Veteran reported that she last used antibiotics in 2012 when the scar was infected. It was noted that the scar was painful but not unstable. The scar is located on the right upper extremity. Specifically, it is located on the lower mid-abdomen on the anterior trunk. It measures 14 cm by 0.2 cm, for a total area of 2.8 square cm. The scar has no underlying tissue damage. The examiner noted that the scar does not impact the Veteran’s ability to work. The Board finds that the preponderance of the evidence is against the assignment of a disability evaluation in excess of 10 percent for the Veteran’s C-section scar for the entire appeal period. As previously stated, for the next-higher 20 percent rating, the evidence must show that there are three or four unstable or painful scars, or one or more scars that are both unstable and painful. 38 C.F.R. § 4.71a, Diagnostic Code 7804. Here, the evidence shows that the Veteran only has one scar, and that the scar is painful but not unstable. Specifically, while there is evidence that the Veteran experiences pain from her C-section scar, the VA examiners indicated on the examination reports that the scar is not unstable, i.e., there is no frequent loss of covering of skin over the scar. As such, the next-higher 20 percent rating is not warranted. The Board acknowledges the Veteran’s April 2016 statement that she met with a VA physician who informed her that the scar was open and infected, and that it frequently happens. However, the Board notes that the Veteran was thoroughly evaluated in September 2019, after she made that statement, and the VA examiner did not find this to be the case. The examiner specifically indicated on the examination report that the scar was not unstable or had frequent loss of covering of skin. The Veteran also reported to the September 2019 VA examiner that her scar had not been infected since 2012. With regard to other potentially applicable diagnostic codes, Diagnostic Code 7800 is not for application because the Veteran does not have a burn scar of the head, face, or neck. Diagnostic Code 7801 is not for application because the scar is not nonlinear and does not cover an area of at least 12 square inches (77 square cm). Diagnostic Code 7802 is not for application because the scar is not nonlinear. The Board also finds that a higher rating is not warranted under Diagnostic Code 7805 and other appropriate diagnostic codes based on any other disabling or other effects. The examiners indicated that the Veteran does not have any other pertinent physical findings, complications, conditions, signs and/or symptoms such as muscle or nerve damage associated with the scar. The medical evidence also does not establish any symptoms or effects of the scar other than pain. 38 C.F.R. § 4.118. As there is no objective evidence on examination of disabling effects not considered in the rating provided under Diagnostic Code 7804, the Board finds that a higher rating is not warranted under Diagnostic Code 7805. 38 C.F.R. § 4.118. The Board is sympathetic to the Veteran’s position that a rating in excess of 10 percent is warranted for her service-connected C-section scar. However, the VA examination results, as compared to the rating criteria, do not warrant a rating in excess of 10 percent. Accordingly, based on a review of the foregoing evidence, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the Veteran’s C-section scar for the entire appeal period. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not helpful to her. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). Service Connection—Left Wrist Disability Manifested By Pain Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran contends that her left wrist pain disability is related to her military service. In a March 2011 statement, she indicated that the pain in her left wrist first started in March 2005 when she was aboard the USS Carl Vinson. She explained that, when she sought medical treatment, she was given a brace that she wore occasionally when her wrist hurt. She contends that she currently has intermittent pain in her left wrist, for which she had not been treated since leaving service. The Board acknowledges the Veteran’s contention that she experiences intermittent pain in her left wrist. Indeed, on a September 2019 VA examination, the examiner diagnosed the Veteran with subjective left wrist pain. Thus, the question for the Board is whether the Veteran’s current left wrist disability began during service or is at least as likely as not related to an in-service injury, event, or disease. In this regard, the Veteran’s service treatment records (STRs) are silent for complaints of, or treatment for, left wrist pain. While a December 2010 separation physical examination report reveals that the Veteran experienced foot pain in service, there is no indication that she had left wrist pain or that she suffered a left wrist injury. On a September 2012 VA examination report for wrist conditions, the examiner noted that the Veteran did not have a wrist condition. On examination of the left wrist, there was no objective evidence of pain or painful motion. Range of motion measurements were normal. The examiner indicated that the Veteran did not have any functional loss or functional impairment of the left wrist. Muscle strength testing results were normal. There was no ankylosis. Imaging studies of the left wrist did not reveal degenerative or traumatic arthritis. Specifically, X-ray results showed a negative left wrist. The examiner concluded that there was no diagnosis of a left wrist condition because there was no pathology to render such diagnosis. On her April 2016 VA form 9, the Veteran stated that she has frequent left wrist pain, at least three times a day. She explained that it is a sharp pain that limits her range of motion and that she takes over-the-counter medicine to alleviate the pain. She also noted that physical activity which requires stress on her wrist intensifies the pain. On a September 2019 VA examination, the Veteran reported episodic wrist pain that occurs with prolonged typing or heavy lifting. The examiner diagnosed the Veteran with subjective left wrist pain. The Veteran described functional loss or functional impairment of her left wrist as having trouble picking up her work boxes; the need to have a special pad at her computer when she types; and having to avoid lifting heavy things. On examination, range of motion measurements of the left wrist were all normal. No pain was noted on the examination. The Veteran was able to perform repetitive-use testing with at least three repetitions, with no additional loss of function or range of motion. Muscle strength testing results were normal. There was no muscle atrophy, and ankylosis was not present. The Veteran reiterated that her left wrist pain impacted her ability to do heavy lifting and prolonged typing at work. The examiner negatively opined that the Veteran’s left wrist disability was not related to her active service. The examiner reasoned that a thorough review of the Veteran’s service records did not reveal treatment or complaints for the left wrist. She noted that the Veteran’s 2010 separation examination also did not note any left wrist issues. The examiner emphasized that the Veteran’s subjective left wrist pain was less likely than not incurred in, or caused by, service. Based on the above, the Board finds that the Veteran’s current left wrist pain disability is not related to her active service. There is no medical evidence linking the current left wrist pain to active duty. No health care professional has indicated that there is any such connection. Other than her statements, the Veteran has not provided any evidence showing that her left wrist complaints are linked to active duty. Contrary to what the Veteran has stated, there is nothing in her STRs to indicate that she was seen and treated for left wrist pain in service. Although the Veteran first filed her service connection claim for her left wrist pain in March 2011, within a year of leaving service, presumptive service connection based on continuity of symptomatology cannot be established because there is no evidence showing that the Veteran has a chronic disease in her left wrist. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. While the September 2019 VA examiner diagnosed the Veteran with subjective left wrist pain, there is no diagnosis of arthritis, atrophy, or any of the chronic diseases enumerated under 38 U.S.C. § 1101. In addition, the September 2012 examiner did not assign a diagnosis for the Veteran’s left wrist. As such, presumptive service connection is not warranted. As previously stated, there is no evidence linking the Veteran’s current left wrist pain to an in-service disease, injury, or event. In sum, the Board finds there is no probative evidence linking a left wrist pain disability to active duty. There is no probative evidence of record to indicate that the Veteran currently has a chronic disease that is subject to presumptive service connection, pursuant to 38 C.F.R. § 3.309. Although the Veteran seems to indicate that she has arthritis in her left wrist, there is no evidence of this in her medical records. She has also not presented any medical evidence to corroborate her statements. Although the Veteran may believe that she has a chronic left wrist disability, manifested by pain, that is related to an in-service injury, event, or disease, she is not competent to render such diagnosis—or to provide a nexus opinion regarding this issue. This matter is of a complex medical nature, requiring knowledge of pathology and interpretation of complicated diagnostic medical testing, which the Veteran has not shown that she possesses. As such, the Board finds that the Veteran is not competent to provide an etiological opinion on this issue. Jandreau, 492 F.3d at 1377 n.4; Kahana v. Shinseki, 24. Vet. App. 428 (2011). Accordingly, for the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran’s claim of entitlement to service connection for a left wrist disorder manifested by pain. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b). The claim is therefore denied. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Trowers, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.