Citation Nr: 21028379 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-46 122 DATE: May 11, 2021 ORDER A rating in excess of 20 percent for cystourethritis prior to August 24, 2017, is denied. A rating in excess of 40 percent for cystourethritis from August 24, 2017, to October 24, 2018, is denied. A rating in excess of 60 percent for cystourethritis from October 25, 2018, is denied. A 30 percent rating for right wrist peripheral sensory neuropathy prior to July 28, 2017, is granted. A rating in excess of 30 percent for right wrist peripheral sensory neuropathy from July 28, 2017, to September 15, 2020, is denied. A 40 percent rating for right wrist peripheral sensory neuropathy under Diagnostic Code 8511 from September 16, 2020, is granted. A rating in excess of 10 percent for right wrist scar is denied. An initial 70 percent rating for depressive disorder with major depressive like episodes prior to November 22, 2019, is granted. A rating in excess of 70 percent for depressive disorder with major depressive like episodes from November 22, 2019, is denied. FINDINGS OF FACT 1. Prior to August 24, 2017, the cystourethritis required daytime voiding every one or two hours and awakening to void three or four times per night, without use of absorbent materials that were changed two to four times per day or of evidence of urinary retention that required intermittent or continuous catheterization. 2. From August 24, 2017, to October 24, 2018, the cystourethritis required awakening five or more times per night, without use of an appliance or absorbent materials that were changed more than four times per day. 3. From October 25, 2018, the cystourethritis requires use of an appliance. 4. The Veteran's dominant hand is his right hand. 5. For the period of appeal prior to September 16, 2020, the right wrist peripheral neuropathy more nearly approximated moderate incomplete paralysis of the musculospiral (radial) nerve. 6. For the period of appeal from September 16, 2020, the right wrist peripheral neuropathy more nearly approximates moderate incomplete paralysis of the middle radicular nerve. 7. For the entire period of appeal, the single right wrist scar is painful, stable, and does not result in functional impairment. 8. For the entire period of appeal, the depressive disorder is productive of a disability picture that more nearly approximates that of occupational and a social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for cystourethritis prior to August 24, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.115a, 4.115b, Diagnostic Code 7512. 2. The criteria for a rating in excess of 40 percent for cystourethritis from August 24, 2017, to October 24, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.115a, 4.115b, Diagnostic Code 7512. 3. The criteria for a rating in excess of 60 percent for cystourethritis from October 25, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.115a, 4.115b, Diagnostic Code 7512. 4. The criteria for a 30 rating for right wrist peripheral sensory neuropathy prior to July 28, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.124a, Diagnostic Code 8614. 5. The criteria for a rating in excess of 30 percent for right wrist peripheral sensory neuropathy from July 28, 2017, to September 15, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.124a, Diagnostic Code 8614. 6. The criteria for a 40 percent rating for right wrist peripheral sensory neuropathy from September 16, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.124a, Diagnostic Code 8511. 7. The criteria for a rating in excess of 10 percent for the right wrist scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.118, Diagnostic Code 7804. 8. For the period of appeal prior to November 22, 2019, the criteria for an initial 70 percent rating for depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.130, Diagnostic Code 9434. 9. For the period of appeal from November 22, 2019, the criteria for a rating in excess of 70 percent for depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.130, Diagnostic Code 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from July 1982 to July 1985. In November 2019, the Veteran testified at a videoconference hearing before the undersigned, and a transcript of that hearing is of record. The Board remanded the issues in February 2020 for further development, including obtaining outstanding treatment records and scheduling the Veteran for a VA examinations. VA treatment records were subsequently associated with the record, and the Veteran had a series of VA examinations in September 2020 to determine the nature and severity of the cystourethritis, right wrist condition, right wrist scar, and depressive disorder. The Veteran was sent a letter in February 2020 requesting that he submit any relevant non-VA treatment records or complete an authorization for VA to obtain said records on his behalf. In March 2020, the Veteran was notified that no response had been received, and to date, no additional private records or authorization has been submitted. The Board therefore finds there has been substantial compliance with the remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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. 1. Increased ratings for cystourethritis. The Veteran has been assigned staged ratings during the period of appeal (from June 17, 2015) for his cystourethritis under Diagnostic Code 7512. For the period of appeal prior to August 24, 2017, he was assigned a 20 percent rating; for the period from August 24, 2017, to October 24, 2018, he was assigned a 40 percent rating; and for the period from October 25, 2018, he has been assigned a 60 percent rating. Diagnostic Code 7512 rates cystitis based on voiding dysfunction under ratings of the genitourinary system dysfunctions. A 20 percent rating is assigned for voiding dysfunction that requires the wearing of absorbent materials, which must be changed less than 2 times per day. A 40 percent rating is assigned for voiding dysfunction that requires the wearing of absorbent materials, which must be changed two to four times per day. A maximum 60 percent rating is assigned for voiding dysfunction that requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115b, Diagnostic Code 7512. Under ratings of the genitourinary system for dysfunctions, genitourinary system conditions may also be rated based on urinary frequency, obstructed voiding, or urinary tract infection. For urinary frequency, a 10 percent evaluation is warranted for daytime voiding interval between two and three hours, or; awakening to void two times per night. A 20 percent evaluation is warranted for daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A maximum 40 percent evaluation is warranted for daytime voiding interval less than one hour, or; awakening to void five or more times per night. 38 C.F.R. § 4.115a, Urinary Frequency. For obstructed voiding, a noncompensable (zero percent) rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A maximum 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a, obstructed voiding. For urinary tract infection, a 10 percent rating for urinary tract infection is warranted when the disability requires long-term drug therapy, one to two hospitalizations per year, or intermittent intensive management. A 30 percent rating is warranted when there is recurrent symptomatic infection requiring drainage or frequent hospitalization (greater than two times a year) or requiring continuous intensive management. Only the predominant area of dysfunction shall be considered for rating purposes. See 38 C.F.R. § 4.115a. Period of appeal prior to August 24, 2017 In a December 2015 rating decision, the Regional Office (RO) continued a 20 percent rating for the cystourethritis under Diagnostic Code 7512 based on the symptoms of a daytime voiding interval between one and two hours, and awakening to void three to four times per night. The Board finds that a rating in excess of 20 percent is not warranted for this period of appeal. In an October 2015 VA male reproductive systems conditions examination, the Veteran was noted to have been diagnosed with chronic cystitis in service. He developed a urethral stricture in the mid-1980s, which he had not been treated for recently. He was not taking medication for the condition, had not had an orchiectomy or renal dysfunction. The condition caused urine leakage, which did not require wearing absorbent material or use of an appliance. The condition caused increased urinary frequency, including daytime voiding interval between one and two hours and nighttime awakening to void three or four times. The stricture disease required dilation one to two times per year. The Veteran did not have erectile dysfunction. VA treatment records indicate that an October 2015 urology consult, the Veteran reported having a weak stream, secondary to his urethral stricture. The urologist indicated that the Veteran had a recurrent urethral stricture. In November 2015, the Veteran had a cystoscopy, which showed meatal stenosis and a bulbous urethral stricture. In January 2016, the Veteran had a retrograde urethrogram, cystoscopy, and internal optical urethrotomy (IOU) procedure for the urethral stricture. In a May 2016 treatment record, the Veteran was noted to have a recurrent of bulbous urethral stricture, for which he had a cystoscopy. He was also noted to spray when voiding and used Depends for incontinence. A November 2016 private treatment record, which indicates that the Veteran was a new patient, notes that the Veteran had a urethral stricture and was advised to have a cystoscopy retrograde urethrogram. In May 2017, the Veteran had a retrograde urethrogram for recurrent urethral stricture at a private same-day surgery center. The Board notes that VA treatment records dated during this period of the appeal indicate that the Veteran was treated by a private urologist and it is unclear whether all of the relevant records have been associated with the claims file. However, as noted above, the Veteran was sent a letter in February 2020 requesting any relevant outstanding non-VA records, or authorizing VA to obtain said records, and in March 2020, he was sent another letter indicating that no response had been received. To date, no response or treatment records have been received. Although VA has a duty to assist the Veteran in substantiating his claims, that duty is not a one-way street. Woods v. Gober, 14 Vet. App. 214, 224 (2000); see also Hurd v. West, 13 Vet. App. 449, 452 (2000). In sum, the Board finds that for this period of appeal prior to August 24, 2017, a rating in excess of 20 percent is not warranted. A higher rating under voiding dysfunction requires the wearing of absorbent materials, which must be changed two to four times per day. Here, the Veteran indicated in the October 2015 VA examination that he did not use absorbent materials, and indicated in a May 2016 treatment record that he used Depends, but the record does not indicate how frequently he changed them. A higher rating is also not warranted under the criteria for urinary frequency, obstructed voiding, or urinary tract infection, as there is no evidence of a daytime voiding interval of less than one hour or awakening to void five or more times per night; intermittent or continuous catheterization; or recurrent symptomatic infection requiring drainage or frequent hospitalization (greater than two times a year) or requiring continuous intensive management. Period of appeal from August 24, 2017, to October 24, 2018 In an August 2017 rating decision, the RO increased the rating for cystourethritis to 40 percent, effective August 24, 2017, based on the symptom of awakening to void five or more times per night. The Board finds that a rating in excess of 40 percent is not warranted for this period of appeal. In an August 24, 2017, VA male reproductive system conditions examination, the urethral stricture was noted to have not responded to conservative management. The Veteran did not take continuous medication for the condition. He had voiding dysfunction, which required absorbent material that must be changed less than two times per day, without use of an appliance. He also had increased urinary frequency, which caused daytime voiding interval between one and two hours and nighttime awakening to void five or more times. The Veteran also had obstructed voiding, which did not cause a markedly weak stream but required periodic dilation every two to three months. He did not have erectile dysfunction or any other pertinent physical findings. In a January 2018 VA urology consult, the Veteran was noted to have been advised to have an urethroplasty; however, his doctor advised him that the urethroplasty success fate would be low because of multiple IOUs. The Veteran was again advised that a urethroplasty was the only option for definitive repair; however, the Veteran wanted another IOU under anesthesia. The Veteran was scheduled for an IOU procedure in March 2018; however, he called the procedure and indicated he did not want to reschedule. In August 2018, the Veteran reported having recurrent dysuria for one week. He was prescribed Bactrim. In a follow-up appointment, he was noted to have an IOU scheduled in October 2018. The Board finds that for this period of appeal from August 24, 2017, to October 24, 2018, a rating in excess of 40 percent is not warranted. A higher rating under voiding dysfunction requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. Here, the Veteran indicated in the August 2017 VA examination that he used absorbent material that he changed less than two times per day, and did not use an appliance. There is no rating higher than 40 percent available for urinary frequency, obstructed voiding, or urinary tract infection. Period of appeal from October 25, 2018 In an October 2020 rating decision, the RO recharacterized the disability as cystourethritis with erectile dysfunction and increased the rating to 60 percent, effective October 25, 2018, based on the symptom of requiring the use of an appliance. The Board finds that a rating in excess of 60 percent is not warranted for this period of appeal. On October 25, 2018, the Veteran had an IOU procedure at VA for recurrent urethral stricture. In a follow-up treatment record dated a few days later, he was noted to need a self-catheterization daily. The Veteran testified in the November 2019 Board hearing that there was no medication that could help his condition and he had to do a self-catheter with gel every day. He had six surgeries in the past. The Veteran was in pain and had lots of urinary tract infections, including once having two within six months. At work, he had to go to bathroom a lot and at home he was scared to go anywhere because he had to go to the bathroom so often. He used Depends at night, but it was too hard to wear them during the day because he would have to change them at work. In December 2019, the Veteran was noted to still require self-catheterization once daily. In a September 16, 2020, VA urinary tract conditions examination, the Veteran reported symptoms of incontinence and erectile dysfunction. He also had constant pain, urinary frequency, urgency, and frequent voiding. The examiner indicated that the Veteran had voiding dysfunction that caused urine leakage and required absorbent material that must be changed less than two times per day. The condition also required use of an appliance, a straight catheter. The condition also caused increased urinary frequency, including a daytime voiding interval between one and two hours and awakening at night to void five or more times. There were no signs or symptoms of obstructed voiding, history of urethral or bladder calculi, a bladder or urethral fistula, or renal dysfunction. The Veteran had a urinary tract infection (UTI) approximately twice per year. Under Diagnostic Code 7512, the maximum schedular rating available for genitourinary system dysfunctions is 60 percent. As the Veteran is in receipt of a 60 percent rating as of October 25, 2018, a higher schedular rating is not available. As no higher schedular rating is available, and the evidence does not show that any other Diagnostic Code is more appropriate for rating, an increased schedular rating is not warranted. AB v. Brown, 6 Vet. App. 35 (1993); Sabonis v. Brown, 6 Vet. App. 426 (1994). Consideration of separate ratings The Board acknowledges that the Veteran has not been granted a separate rating for erectile dysfunction. Under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. Here, the evidence shows the Veteran reported erectile dysfunction for the first time in the September 2020 VA examination. He was not found to have erectile dysfunction in the October 2015 or August 2017 VA examinations. Moreover, there is no evidence of penile deformity at any point during the period of appeal to warrant a separate 20 percent rating under Diagnostic Code 7522. Finally, the Board also notes that the Veteran is already in receipt of special monthly compensation (SMC) based on loss of use of a creative organ effective September 16, 2020, the date that the Veteran was initially noted to have erectile dysfunction due to the service-connected cystourethritis. 2. Increased ratings for the right wrist neuropathy. The Veteran has been assigned staged ratings during the period of appeal (from June 17, 2015) for his right wrist neuropathy under Diagnostic Code 8614. For the period of appeal prior to July 28, 2017, he was assigned a 20 percent rating; for the period from July 28, 2017, he has been assigned a 30 percent rating. Diagnostic Code 8614 rates neuritis of the musculospiral nerve (radial nerve) based on the criteria for paralysis of the musculospiral nerve under Diagnostic Code 8514. Under this diagnostic code, mild incomplete paralysis warrants a 20 percent rating; moderate incomplete paralysis warrants a 20 percent rating for the minor hand and a 30 percent rating for the major hand; and severe incomplete paralysis warrants a 40 percent rating for the minor hand and a 50 percent rating for the major hand. Complete paralysis warrants a 70 percent rating for the major hand and a 60 percent rating for the minor hand, and is evidenced by drop of the hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of the hand, extension and flexion of elbow weakened, the loss synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. 38 C.F.R. § 4.124a, Diagnostic Code 8514. Period of appeal prior to July 28, 2017 The Board finds that a 30 percent rating is warranted for this period of appeal. VA treatment records indicate that in August 2015, the Veteran reported having chronic right wrist pain. He said that a brace did not help, and he was not on any medication for the condition. X-rays showed a fusion of the lunate and triquetral bone, which was subsequently noted to be congenital in a July 2017 VA examination. There was no fracture or significant osteophyte formation. In September 2015, the Veteran was seen for a physical therapy consult. He was noted to have a reduced range of motion due to guarding. He was given a splint to use at nighttime. In an October 2015 VA peripheral nerves examination, the Veteran reported that he had pain in the right wrist area, as well as muscle/ligament and nerve damage. His dominant hand was his right hand. He reported symptoms of mild constant right upper extremity pain, and no intermittent pain, paresthesias and/or numbness. Muscle strength testing showed reduced strength in right elbow flexion and extension, wrist flexion and extension, and grip and pinch, showing active movement against some resistance (4/5). Results of sensory testing showed decreased sensation in the right hand/fingers. The examiner indicated that the Veteran had moderate incomplete paralysis of the right radial nerve. In March 2016, the Veteran was noted to have chronic right wrist pain and hyperesthesia. He was unable to make a full fist and was hypersensitive to touch over the volar and dorsal aspects of the hand/wrist. His pain was characterized as moderate ot severe, and he had moderate limitations in functional performance secondary to the pain and hypersensitivity. Later that month, in a pain management consult, the Veteran was noted to have right wrist pain, swelling, and hyperesthesia with a diagnosis of complex regional pain syndrome, largely refractory to desensitization occupational therapy. An April 2016 VA MRI of the right hand showed a small right wrist joint effusion with minimal fluid in the distal radioulnar joint, potential partial chronic degenerative tears, a cystic lesion concerning for a ganglion cyst, a fusion of the lunotriquetral articulation that was mostly likely congenital, and scattered subcentimeter cystic changes throughout the carpal bones. In June 2016, the Veteran was seen for a pain consult for the right wrist. He reported having right wrist pain for 30 years, which was not helped by physical or occupational therapy. He was tender to light palpation throughout the right hand and wrist and had hypersensitivity and a limited active range of motion. His symptoms were consistent with complex regional pain syndrome. In January 2017, the Veteran was advised to start four weeks of occupational therapy and to start mirror therapy to decrease right wrist pain, which he continued through June 2017. In sum, the Board finds that a higher 30 percent rating for this period of appeal is warranted under Diagnostic Code 8614 based on the finding that there was moderate incomplete paralysis of the right radial nerve. A higher 50 percent rating requires evidence of severe incomplete paralysis. Here, there is no medical evidence that the Veteran's right wrist neuropathy was severe during this period of appeal. As such, a higher 50 percent rating is not warranted. Period of appeal from July 28, 2017, to September 15, 2020 In a July 28, 2017, VA peripheral nerves conditions examination, the Veteran was noted to have a diagnosis of complex regional pain syndrome. His dominant hand was his right hand. The Veteran reported having moderate constant pain in the right upper extremity, and denied having intermittent pain, paresthesias and/or dysesthesias, or numbness. Muscle strength testing showed reduced strength in right elbow flexion and extension, and wrist flexion and extension, showing active movement against some resistance (4/5); and right hand and grip and pinch, showing active movement against gravity (3/5). Results of a sensory examination were normal, and the examiner indicated that no upper extremity nerves were affected. The examiner concluded there was "little to suggest a radial nerve injury as the cause of the right hand and wrist symptoms." If the nerve was injured at the site of the in-service laceration, there would be sensory loss only and no weakness. The Veteran's complaints exceeded the objective findings, and the likely diagnosis was complex regional pain syndrome. In an August 2017 VA integrative pain service consult, the Veteran reported having fatigue with use and constant pain. He denied having numbness. He was diagnosed with right hand/wrist pain secondary to complex regional pain syndrome. The Veteran testified in the November 2019 Board hearing that his doctor told him that he could not have wrist surgery because the condition might worsen, and therapy and medication did not improve the condition. He had hand and wrist braces, but no one was able to adequately diagnose or treat his wrist problem. The pain and swelling had gotten worse over the years and he could not open his hand all the way. His hand also fatigued quickly, and the pain traveled up his forearm. During a flare-up, his pain could be at a level ten, and when he was not using the hand, it was at a seven. In sum, the Board finds that a rating in excess of 30 percent is not warranted during this period of appeal. The July 2017 VA examiner indicated that results of a sensory examination were normal and no upper extremity nerves were affected. As noted above, a higher 50 percent rating requires evidence of severe incomplete paralysis. Here, there is no medical evidence of even mild incomplete paralysis during this period of appeal. As such, a higher 50 percent rating is not warranted. Period of appeal from September 16, 2020 In a September 16, 2020, VA peripheral nerves conditions examination, the Veteran reported symptoms of moderate constant pain, numbness, and tingling in his right upper extremity. Muscle strength testing showed reduced strength in wrist flexion and extension, and right hand and grip and pinch, showing active movement against gravity (3/5). Results of a sensory examination showed normal sensation in the right shoulder and absent sensation in the inner/outer forearm and hand/fingers. The examiner indicated that the Veteran had moderate incomplete paralysis of the radial nerve, median nerve, ulnar nerve, middle radicular group, and lower radicular group. In sum, the Board finds that a higher 40 percent rating is warranted for this period of appeal under Diagnostic Code 8511. Under this diagnostic code, for paralysis of the middle radicular group, mild incomplete paralysis warrants a 20 percent rating; moderate incomplete paralysis warrants a 30 percent rating for the minor hand and a 40 percent rating for the major hand; and severe incomplete paralysis warrants a 40 percent rating for the minor hand and a 50 percent rating for the major hand. Complete paralysis warrants a 70 percent rating for the major hand and a 60 percent rating for the minor hand, and is evidenced by adduction, abduction, and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected. 38 C.F.R. § 4.124a, Diagnostic Code 8511. Here, the September 2020 VA examiner indicated that the Veteran had moderate incomplete paralysis of the middle radicular group, indicating that a 40 percent rating under Diagnostic Code 8511 is warranted. The Board acknowledges that the VA examiner also noted that the Veteran had moderate incomplete paralysis of the radial nerve, median nerve, ulnar nerve, and lower radicular group; however, combined nerve injures of the upper extremities are rated by reference to the major involvement, or if sufficient in extent, consider radicular groups. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note following DC 8719. In other words, separate ratings may not be assigned when evaluating an upper extremity peripheral neuropathy disability. As such, a rating for moderate incomplete paralysis of the radial nerve, median nerve, ulnar nerve, and/or lower radicular group would not result in a rating in excess of 40 percent. 3. Increased rating for the right wrist scar. The right wrist scar has been assigned a 10 percent rating under Diagnostic Code 7804 for the entire period of appeal. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. 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. Note (3): Scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board finds that a rating in excess of 10 percent is not warranted at any point during the period of appeal. In an October 2015 VA scars examination, the Veteran was noted to have a scar on his right forearm from a wrist surgery he had in 1985. He denied having any treatment for it in the last 12 months. The scar was painful, stable, superficial, and nonlinear. It was 3 centimeters (cm) long and 0.5 cm wide, with an approximate total area of 1.5 square cm. The scar did not result in any limitation of function or other functional impact. There was no keloid formation or restriction of range of motion caused by the scar. There was also no elevation, depression, skin breakdown, or loss of cover. In an August 2017 VA scars examination, the Veteran reported ongoing pain with touch over the scar, but not treatment over the past 12 months. The scar was 3 cm long and 0.5 cm wide, with an approximate total area of 1.5 square cm. It was tender to palpation, superficial, nonlinear, well-healed, skin colored, flat, and without adherence to the tissue, breakdown, or loss of cover. There was no induration, inflexibility of tissue, ulceration, or inflammatory changes. The scar did not result in any limitation of function or other functional impact. The Veteran testified in the November 2019 Board hearing that he had been given a cream for his scar years ago, but it did not work, and he was not currently being treated for it. He asserted that he had pain, soreness, and stiffness of the scar. In a September 2020 VA scars examination, the Veteran's right wrist scar was noted to be painful, healed, and stable. It measured 3 cm long and 0.2 cm wide. There was no underlying tissue damage and the approximately total area was 9.2 square cm. The scar did not result in any limitation of function or impact the Veteran's ability to work. VA treatment records dated during the period of appeal consistently note a healed scar on the dorsal/radial surface of the right wrist. In sum, the Board finds that the weight of the evidence is against an evaluation in excess of 10 percent for the right wrist scar under Diagnostic Code 7804. A rating higher than 10 percent is only warranted for three or more unstable or painful scars or for scars that are both painful and unstable. In this case, the Veteran has been consistently noted to have one scar on his right wrist, and it has never been noted to be unstable at any point during the period of appeal. In evaluating the Diagnostic Codes potentially applicable to the Veteran's scar, the Board notes that Diagnostic Code 7800 does not apply because the right wrist scar is not of the head, face, or neck. Diagnostic Code 7801 does not apply because the Veteran's right wrist scar is not burn scars, nor is it deep. Diagnostic Code 7802 does not apply because the Veteran's scar does not cover an area of 144 square inches or more. Diagnostic Code 7805 does not apply because the right wrist scar does not cause any functional impairment (such as limitation of motion); rather, three VA examiners indicated that the scar was well healed and did not result in any limitation of function. 4. Increased rating for depressive disorder. The Veteran has been assigned staged ratings for his depressive disorder under Diagnostic Code 9434. For the period of appeal prior to November 22, 2019, he was assigned a 50 percent rating, and for the period from November 22, 2019, he has been assigned a 70 percent rating. The rating criteria for rating mental disorders, including major depressive disorder, reads as follows: a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. A 70 percent rating requires 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. Id. A 50 percent rating 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 judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. The Board notes that the DSM-5 states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court's holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores; however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board will not afford any GAF scores mentioned in the record any probative value in cases where the DSM-5 applies. See also Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. February 23, 2018) (finding that the Board provided an inadequate statement of its reasons or bases for relying on GAF scores in its decision when the appeal was certified after August 4, 2014, and the DSM-5 applied to the claim). In this case, the Veteran's appeal was certified to the Board in September 2017. As such, the DSM-5 applies, and the Board will not afford GAF scores any probative value. Evaluation under § 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. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit explained that the frequency, severity, and duration of the symptoms also played an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443; see also Vazquez-Claudio, 713 F.3d at 117 The Board finds that for the entire period of appeal, the Veteran's depressive disorder symptoms more closely approximate the criteria for a 70 percent rating under Diagnostic Code 9434. VA treatment records indicate that in August 2015, the Veteran sought treatment because he was feeling depressed. He denied having any previous mental health evaluation. He reported that he had attempted suicide eight years ago, but realized he did not want to die. He had occasional passive thoughts of not wanting to be here, but had not had any additional plans since the attempt. He was diagnosed with major depression secondary to his medical conditions, started on sertraline, and advised to start individual psychotherapy. In an October 2015 VA psychiatry appointment, the Veteran reported still feeling depressed, but to a lesser degree since starting medication. He denied passive death wishes and suicidal ideation. His sertraline was increased. He also had his first appointment with a social worker in October 2015, in which he was diagnosed with adjustment disorder with depressed mood. In a November 2015 VA mental disorders examination, the Veteran reported that he sought treatment for his mental health due to a marked and prolonged episode of depression consisting of depressed and sad mood with increased crying episodes, anhedonia, insomnia, decreased energy, difficulty concentrating, ruminative thinking patterns, decreased appetite, and suicidal ideation without specific plan, prepatory behaviors, attempts, or plans. The Veteran indicated that he lived with his wife of 24 years and they had a 22-year-old son. He was working toward a college degree on a part-time basis and worked for the Postal Service. He was on medical for his symptoms, and had recently had his dose increased. The examiner indicated that the Veteran's symptoms included depressed mood, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation; however, the Veteran denied having suicidal or homicidal ideation, including plan, intent, prepatory behaviors, or attempts. Insight was fair, judgment was intact, and he was capable of managing his financial affairs. The examiner concluded that the Veteran's mental health symptoms caused occupational and social impairment with reduced reliability and productivity. In January 2016, the Veteran reported that sertraline helped his mood, but was not fully effective when he was confronted with situational stressors, such as a recent urethral stricture procedure that he hoped would cure his problem but did not. In March 2016, the Veteran reported having occasional bouts of moderate anxiety related to his medical and life stressors. He relaxed by watching sports or taking the dog for a walk. In June 2016, the Veteran started transitioning from Sertraline to Duloxetine; in August 2016, he was switched back to Sertraline. In January 2017, the Veteran reported that he continued to experience intermittent bouts of depressed mood. In May 2017, he reported having occasional brief bouts of mild anxiety related to his medical health and improved control of his anger/irritability since he began treatment with increased dose of sertraline. In a July 2017 VA mental disorders examination, the Veteran reported that since the last examination, he had continued to receive psychiatric care, individual therapy, and was still on sertraline. He was still married, and he and his wife lived with their adult son. His relationship with his wife was good, relationship with his son was "so-so because his son thinks he knows everything," and his relationships with his parents were good. He had occasional contact with friends on the phone. The Veteran was still working for the Postal Service, and indicated that his job was okay, but he did not bother with his coworkers because he was short-tempered. He stopped going to school in January 2017 because he had surgery and a lot of doctor appointments in 2016. On examination, the Veteran was noted to be open and cooperative. His speech and thought processes were normal. He reported chronic suicidal ideation, with a plan to stop taking his thyroid medication, but without intent. Other symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. He was capable of managing his financial affairs. The examiner concluded that the Veteran's mental health symptoms 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. In August 2017, the Veteran reported that he was "not too good" and had been experiencing near persistent, worsening anxiety over the last month and near persistent depressed mood due to stressors including his mother's health, his own health, and finances. He relaxed by watching television. The Veteran indicated in January 2018 that he continued to have intermittent bouts of depressed mood, which he was able to get out of by reading articles to distract himself from negative thoughts. In April 2018, the Veteran denied having suicidal or homicidal ideation and was looking forward to retirement and being healthy. In January 2019, the Veteran reported feeling "alright." He had occasional bouts of mildly depressed mood, primarily related to hs medical health. The Veteran denied having passive death wishes, which had last occurred in October 2017. In an August 2019 therapy appointment, the Veteran reported recurrent depressive symptoms, including people getting on his nerves, sleeping too much, loss of motivation, self-isolation, and poor appetite. He had lost motivation to go to work, but had not missed days. In an August 2019 psychiatry appointment, the Veteran was directed to taper Sertraline, then start Fluoxetine. In October 2019, the Veteran reported feeling "not too good," with increased anger and irritability. He was instructed to discontinue fluoxetine and start paroxetine. In the November 2019 Board hearing, the Veteran testified that his symptoms had gotten worse. He had depression, anxiety, did not want to be around anyone, did not want to go to work, and thought about his problems every day. At work, his temper was bad, but as long as he stayed away from people and just dealt with his bosses, he was "pretty much alright." He continued to be seen a VA psychiatrist and social worker monthly, and his medication dosage had recently been changed. He had thoughts of harming himself, but he tried to stop them. In January 2020, the Veteran reported that he felt "alright" and that his medication made him "a little laid back." He continued to experience bouts of depressed mood, anxiety, and anger, but was more mellow and better able to tolerate provocation. In April 2020, the Veteran reported that he was still working despite the pandemic, and that although he was a little worried about his health, not much had changed for him with regard to daily activity and mental health. In May 2020, the Veteran reported that he was taking a month off work due to headaches and irritability/mood. In July 2020, the Veteran reported that he was "alright" and not as stressed out as he used to be because he was at home on vacation. In a September 2020 VA mental disorders examination, the Veteran reported symptoms of difficulties initiating and maintaining sleep, disturbances of motivation/mood, panic attacks about once per week, anxiety, depressed mood, sadness, tearfulness, anhedonia, irritability with verbal outbursts, heard voices calling his name daily, felt like someone was behind him and saw people walk by when no one was there, social isolation, chronic pain, and passive suicidal ideation without plan or intent. He continued to live with his wife of 28 years. His son had recently moved out because he was engaged. The Veteran also continued to work for the postal service, but he had called out often due to his mental health symptoms, left work due to his irritability, and had verbal altercations. The examiner indicated that the Veteran had a diagnosis of major depressive disorder, severe, with psychotic features, recurrent, which the examiner noted was a progression of his service-connected diagnosis. His symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting ot stressful circumstances, impaired impulse control, and neglect of personal appearance and hygiene. The Veteran's mental health symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. He was capable of managing his financial affairs. The Board finds that the weight of the evidence shows that although the Veteran's symptoms appear to have worsened at some point between the July 2017 VA examination and the September 2020 VA examination, they have nonetheless consistently included depressed mood, anxiety, chronic sleep impairment, self-isolation, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and at least intermittent suicidal ideation. In resolving all reasonable doubt in favor of the Veteran, the Board find that such symptoms more nearly approximate that of occupational and social impairment with deficiencies in most areas, which warrants a 70 percent rating under Diagnostic Code 9434. As such, an increased 70 percent rating is warranted for the period of appeal November 22, 2019. The Board also finds that the Veteran's symptoms have not been of such frequency and severity to result in total occupational and a social impairment to warrant a 100 percent rating under Diagnostic Code 9434. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (stating that use of the term "such as" in 38 C.F.R. § 4.130 demonstrates 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). The criteria for a 100 percent rating include symptoms such 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. In this case, the Veteran reported in the September 2020 VA examination that he heard voices calling his name and saw people walk by when no one was there, and the examiner noted that his symptoms caused neglect of personal appearance and hygiene. However, those symptoms are not of such frequency and severity to result in total occupational and a social impairment to warrant a 100 percent rating under Diagnostic Code 9434. Specifically, although the Veteran has been noted to have trouble maintaining effective social and occupational relationships, the evidence also reflects that during the period of appeal he has maintained relationships with his spouse and child; has remained employed fulltime; and has engaged in activities and positive coping strategies, including walking his dog, reading articles, and watching television. There is no doubt that the Veteran has had serious symptoms; however, a 100 percent rating requires total occupational and social impairment. As discussed above, the Veteran's symptoms do not reflect total impairment in these areas, as he has maintained a relationship with his wife and child, and has remained employed fulltime. Moreover, the 70 percent rating granted herein reflects that the Veteran's symptoms are quite severe. The Board finds that the Veteran's symptoms have not been of such a level to be akin to total occupational and social impairment. While the Veteran clearly has occupational and social impairment, the fact that he is able to retain relationships with his family maintain fulltime employment reflects he does not have total impairment. While he has several symptoms from his depressive disorder that impact his functioning, none of them are like or similar to the type, degree, or effects suggested by those listed in the criteria for total occupational and social impairment. The Board finds it significant that the symptoms suggested in such a rating reflect extremely impaired functioning by noting the symptoms are "persistent" "grossly inappropriate" and the criteria even cites symptoms such as inability to perform minimal hygiene and memory loss for one's own name. While the symptoms listed in the rating schedule are not intended to constitute an exhaustive list, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The use of the word "total" reflects the symptoms should be of such frequency or severity to entirely impair one's ability to work and have social interactions. The Veteran has significant symptoms; however, as noted above, he has never been noted to have 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. Furthermore, the November 2015 VA examiner indicated that the Veteran's symptoms caused occupational and social impairment with reduced reliability and productivity, which warrants a 50 percent rating; the July 2017 VA examiner indicated that symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, which warrants 30 percent rating; and the September 2020 examiner opined that the symptoms caused occupational and social impairment with deficiencies in most areas, which warrants a 70 percent rating. As such, the Board does not find that the Veteran's symptoms are of such frequency, severity, and duration that they result in total occupational and social impairment to warrant a higher 100 percent evaluation at any point during the period of appeal. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.