Citation Nr: 21042303 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-42 157 DATE: July 12, 2021 ORDER Entitlement to an initial rating for depressive disorder not otherwise specified (NOS)/cannabis abuse in remission in excess of 50 percent from October 28, 2011, is denied, a 70 percent, but not higher, rating from March 4, 2019, is granted, and a rating in excess of 70 percent from March 4, 2019, is denied. Entitlement to an initial rating in excess of 10 percent for scar, status post caesarean section surgery, is denied. Entitlement to service connection for a back disorder, diagnosed as lumbosacral strain, is granted. REMANDED Entitlement to a compensable initial evaluation for a service-connected gynecological disability from a caesarian section, secondary to childbirth, is remanded. Entitlement to service connection for non-migraine headaches is remanded. Entitlement to total disability based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. For the period beginning October 28, 2011, to March 3, 2019, the Veteran's psychiatric symptoms and overall impairment is manifested by 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 selfcare and conversation. 2. From March 4, 2019, the Veteran's psychiatric symptoms and overall impairment is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. 3. The Veteran's service-connected residual scar, located on her anterior trunk, from her status-post Caesarian section which covers an area of 13.5 cm. and 0.1 cm, though painful, is not unstable, and is well-healed. 4. Resolving all doubt in the Veteran's favor, her currently diagnosed lumbar strain disorder is related to her active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 50 percent from October 28, 2011, and in excess of 70 percent from March 4, 2019, for depressive disorder not otherwise specified (NOS)/cannabis abuse in remission have not been met; the criteria for a 70 percent, but not higher, rating from March 4, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9434. 2. The criteria for entitlement to an initial rating in excess of 10 percent for scar, status post caesarean section surgery, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.118, Diagnostic Code 7804. 3. The criteria for entitlement to service connection for lumbar strain disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 2006 to March 2007, from June 2007 to February 2008, from April 2008 to September 2008, and from December 2008 to October 2011. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), in Atlanta, Georgia. The Board notes that the issue of entitlement to a TDIU is part of a rating issue when such issue is raised by the record during the rating period. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, during the Veteran's November 2019 VA mental disorders examination for a claim currently on appeal, the Veteran reported that she was no longer working/having difficulty finding staying employed. However, her TDIU claim was originally denied by the RO in a July 2014 rating decision (and remained denied in a September 2015 rating decision) primarily because the Veteran was deemed to be fully employed at the time. Given the Veteran's updated statements about her current unemployment status, the Board finds that the Veteran's TDIU claim needs to be further developed and is therefore addressed in the remand section of this decision. Clarification of issues on appeal The Veteran initially filed claims to establish service connection for residuals of in-service childbirth, to include a caesarean section scar and pain in the area of the surgery. In the August 2013 rating decision, the Agency of Jurisdiction (AOJ) established service connection for both disabilities, assigning 10 percent and noncompensable (zero percent) initial evaluations for the caesarian section scar (Diagnostic Code 7804) and lower abdominal pain associated with childbirth (Diagnostic Code 7623), respectively. The Veteran expressed disagreement with the initial evaluations assigned for both of these disabilities, and the current appeal ensued. During the pendency of the appeal, VA's Rating Schedule was revised to the extent that Diagnostic Code 7623 was discontinued. As such, in a June 2020 Decision Review Officer (DRO) decision, the AOJ recharacterized the Veteran's service-connected disability manifested by lower abdominal pain associated with childbirth for rating purposes, determining it proper to rate the disability by analogy to a scar under Diagnostic Code 7802. This action did not impact the 10 percent evaluation assigned for the Veteran's service-connected caesarian section scar. While the Board observes the AOJ's actions in this regard, the downstream impact of such has resulted in confusion. Specifically, while the record unambiguously reflects that the Veteran's in-service childbirth resulted in one caesarian section scar, the most recent Codesheet reflects that two such scars are present, subject to service connection, and separately rated under different criteria. In an effort to more accurately reflect the Veteran's service-connected disabilities and the criteria by which each are (and should be) rated, the Board has recharacterized the Veteran's service-connected disability regarding lower abdominal pain as reflected on the title page (entitlement to service connection for a gynecological disability from a caesarian section, secondary to childbirth), which is more fully addressed below in the Remand portion of this decision. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Doing so makes clear that the Veteran has only one service-connected scar resulting from her in-service childbirth (rated 10 percent disabling) and an additional service-connected gynecological disability (rated noncompensably disabling). Increased Rating Major Depressive Disorder The Veteran's major depressive disorder is rated as 70 percent under 38 C.F.R. § 4.130, DCs 9400-9434. Psychiatric disabilities, such as major depressive disorder, are evaluated under the General Rating Formula for Mental Disorders (pertinent portions listed below). See 38 C.F.R. § 4.130, Diagnostic Code 9434. Under the General Rating Formula for Mental Disorders, a 50 percent disability 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 and maintaining effective work and social relationships. Id. A 70 percent disability 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); or inability to establish and maintain effective relationships. Id. A 100 percent disability rating requires 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; or memory loss for names of close relatives, own occupation, or own name. Id. When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating. The analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all a veteran's symptoms affecting his level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. Further, the United States Court of Appeals for the Federal Circuit has acknowledged the "symptom-driven nature" of the General Rating Formula and that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013). The Federal Circuit has explained that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Id. at 117. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to an initial rating in excess of 50 percent from October 28, 2011, and in excess of 70 percent from March 4, 2019, for depressive disorder not otherwise specified (NOS)/cannabis abuse in remission. The Veteran was granted service connection for her depressive disorder and cannabis abuse (which was deemed in remission) in an April 2013 rating decision, with an initial rating evaluation of 50 percent, effective October 28, 2011, one day following her military separation. Her 50 percent evaluation was primarily based on the findings from a December 2012 VA mental disorders examination. During this examination, the examiner confirmed the Veteran's in-service diagnoses of depressive disorder NOS and cannibis abuse (in remission). The record reflects findings from an August 2011 in-service Report of Medical Examination and an October 2012 Administrative Decision noting a postpartum depression diagnosis in April 2011 and the third positive test for tetrahydrocannabinol (THC) (July 2011). December 2012 Mental Disorders Examination During her December 2012 mental health evaluation, the Veteran reported that she started feeling depressed in service after her daughter was born; that she had gained about 140 pounds during her pregnancy and she had trouble controlling her emotions, leading to her postpartum depression diagnosis. She further reported that she was treated with Prozac, and later Zoloft; that she smoked marijuana to get out of service, and smoked it a few times right after service when she was out of Zoloft, but denied having any ongoing drug or alcohol dependency. The examiner summarized the Veteran's occupational and social impairment manifested 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 selfcare and conversation. The Veteran's mental health symptoms that were reported during this examination were depressed mood, anxiety, chronic sleep impairment, impaired judgment, disturbances in motivation mood; under "other symptoms," it was reported that she has trouble concentrating and had weight issues. However, the examiner also reported that the Veteran could manage her finances, and that she does not appear to be a threat or danger to herself and others. The Veteran filed a Notice of Disagreement (NOD) in December 2013 challenging her 50 percent initial rating evaluation, asserting that additional life stressors, such as not being able to have a career as a stylist because she is unable to obtain her cosmetologist license has kept her depressed, including being very dissatisfied with how her body looks following her Caesarian section surgery, from a scar that has not fully healed. Pertinent Treatment Records The Veteran's Mental Health Progress Notes throughout the appeal period reflect periodic consultation (sometimes, "no-shows") since her December 2012 initial VA examination and her subsequent VA examination in November 2019 (discussed below). Some of the pertinent references are cited below. December 2013 Consultation: it was reported that the Veteran was visibly distressed and tearful. She reported ongoing and "uncontrollable" anxiety/depression for the past month; that several psychosocial stressors, and past traumatic events were contributing to her emotional maladjustment; she also reported that she had stopped taking 2 of her medications for 6 months because she found them ineffective. The examiner reported that her Zoloft was restarted. August 2014 Mental Health Psychiatry General Progress Note: reflects the Veteran's report that she was quitting her job ('given notice") to go to school for a one year cosmetology and hairstyling program; that she already talked to one of her friends who is now in business with regards to joining her in the business once she finishes school. November 2014 consultation: it was observed that the Veteran was appropriately groomed; that she spoke in a spontaneous manner at a normal rate, tone, and volume; that her eye contact was appropriate; psychomotor activity was noted as normal, though her mood was slightly depressed with congruent affect. Further, that the Veteran was oriented to person, place, time and situation; thought process was logical, linear and goal directed with no difficulties in attention, concentration and memory reported or observed; insight and judgment deemed to be fair. March 2015 consultation: it was reported that the Veteran self-reported still being anxious around people and was particularly apprehensive about attending an upcoming wedding; she requested a change in her medication, which she had stopped taking, and that she was still in school and doing "fairly well." August 2015 consultation: the Veteran was reported to exhibit normal speech, depressed tearful mood, restricted affect, normal memory, fair judgment and insight and no suicidal ideation. On May 2016, the Veteran reported that nothing changed at home at that time and that she was the only one working regularly. August 2017 consultation: her clinical social worker reported the following evaluation/observation: appearance: good hygiene and grooming, appropriately dressed. Behavior: good eye contact, calm, cooperative, forthcoming with information. Speech: within normal limit (WNL) Mood: Euthymic Affect: labile; thought continuity: intact & relevant Insight/Judgment: fair impulse control: fair alertness: person, place, time. February 5, 2019 Call: It was noted that the Veteran was requesting that her call be returned as she wanted to be evaluated for renewal of her prescription for anxiety and depression. March 4, 2019, Mental Disorder Evaluation During this March 4, 2019, evaluation, the Veteran reported a significant change in her psychiatric condition. Specifically, that she was recently prescribed lorazepam with little benefit or noted symptom improvement. She also reported that she has trouble communicating with people; that she feels sad all the time; she sometimes avoids others and does not want to leave her home; she noted that she had gained weight recently due to being more sedentary and not going to the gym to workout (a normal coping skill for her); she reported experiencing crying spells several times per week (as many as three). She denied sleep disturbance; she noted fluctuating eating habits; she reported poor energy; that she interacts with her in-laws and her family, but she rarely interacts with colleagues from work; that she has also had bouts of anxiety. A notation was made that her "suicide/homicidal screening" during this evaluation was negative. November 2019 Mental Disorders Examination. The Veteran was subsequently afforded a new VA examination conducted in November 2019. During this examination, the Veteran's diagnoses were modified as Major Depressive Disorder, recurrent, severe, and Cannabis Use Disorder, Moderate in sustained remission, with the examiner citing that her prior diagnoses (depressive disorder NOS/cannabis abuse in remission) were not recognized DSM-V diagnoses. The examiner summarized the Veteran's occupational and social impairment manifest occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran's specific mental health symptoms reported during this examination were: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened effect, impaired judgment, impaired abstract thinking, difficulty in being able to establish and maintaining effective work and social relationships, disturbances in motivation mood, difficulty in adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner also reported that the Veteran reported that she has been married for 10 years, her only marriage, and that she has one child. With regard to the examiner's behavioral observations of the Veteran, he reported that the Veteran is considered to be a reliable historian; that she presented with a flat affect and depressed mood; she cried openly during the examination; she was alert and oriented; she maintained appropriate eye contact and she was appropriately dressed. At the time of the interview, it was noted that the Veteran denied suicidal ideation and homicidal ideation, plan, or intent. Based on her notable increase in the severity and frequency of her symptomology during this November 2019 examination, the Veteran's initial rating was increased from 50 percent to 70 percent. Analysis For the following reasons discussed below, the Board finds that an increased rating in excess of 50 percent prior to March 4, 2019, is not warranted. The record reflects that during the period prior to March 4, 2019, the Veteran's mental disorder manifest symptoms consistent with her current 50 percent rating. Specifically, the Veteran's record is silent for any reports of hallucinations, delusions, and grossly inappropriate behavior. The evidence of record does not show that during this period the Veteran was unable to perform activities of daily living (working, attended a one cosmetology class, interacted with her family, including her in-laws) was disoriented to time or place, or experienced memory loss. With regards to the pertinent referenced Mental Health Progress Notes reflecting the Veteran's periodic consultation and ongoing treatment for her mental disorder during the appeal of appeal, the Board finds that they demonstrate symptoms contemplated by the 50 percent rating schedule, with the exception of her March 4, 2019, evaluation. Although the Veteran quit her job, at the same time she was able to interview for a new job which she got (although she subsequently reported that she lost this job where she had worked for 3 years, in 2019, due to her mental disorder). More specifically, while the Veteran reported that she prefers to isolate herself from others, the evidence does not show that she was entirely unable to have meaningful relationships (she has been married for over 10 years to her husband) and that no cognitive problems and depression were not shown to have prevented her from functioning effectively and independently during this period. Further, the evidence does not demonstrate that her psychiatric problems precluded her ability to work during this period. In addition, there are no reports or evidence of delusions, suicidal/homicidal ideations, hallucinations, neglect of hygiene, or any other evidence that would support a higher rating than 50 percent at any time during the appeal period prior to March 4, 2019. Consequently, after a review of the record, particularly the above-referenced VA examinations and treatment records, the Board finds that the Veteran's mental disability picture remained relatively consistent throughout the appeal period until March 3, 2019, and as such, a rating in excess of 50 percent is not warranted. Effective Date of March 4, 2019 While noting that the criteria for a 70 percent initial evaluation were demonstrated at the November 6, 2019, VA examination, the Board takes exception with the effective date assigned for this increase based on the facts of this case. Specifically, as referenced above, there is evidence in the record showing that the severity of the Veteran's service-connected mental disorder had significantly worsened, discernably as early as March 4, 2019, during a VA mental health evaluation with her clinical social worker, which preceded the date of the November VA examination. In light of above, the Board will resolve all reasonable doubt in the Veteran's favor in concluding that the criteria for a 70 percent initial evaluation were closely approximated on March 4, 2019, but no earlier. For the following reasons, an increased rating in excess of 70 percent for a major depressive disorder since March 4, 2019, is not warranted. Based on the findings the Veteran's mental disorder examination conducted on November 6, 2019, the Veteran's rating was increased from 50 percent to 70 percent, and the Board has now assigned a 70 percent rating from March 4, 2019. The Board finds that a rating higher than 70 percent is not warranted because the Veteran's major depressive disorder symptoms and overall impairment do not more nearly approximate the criteria for a 100 percent rating, specifically with regards to total social impairment. As to her occupational impairment, during her November 2019 VA examination, the Veteran reported that she was unable to work, since around March 2019 ("for the past 6 months") due to her major depressive disorder. To this end, the November 2019 examiner found that the Veteran psychiatric disability manifest occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. A 100 percent rating for a psychiatric disorder requires both total occupational and social impairment; therefore, this case turns on the presence of total social impairment. The evidence of record reflects that the Veteran's major depressive disorder causes some social impairment, as she reported that she prefers social isolation and that her symptoms affect her relationships with other family, friends, and co-workers. However, the Veteran's major depressive disorder has not more nearly approximated total social impairment, as the Veteran also reported during her November 2019 VA examination, that she has been married to her husband, the father of her daughter, for 10 years, her only marriage, and they continue to live together. Her private treatment record further reflects that the Veteran had maintained a relationship with her mother whom she lived with at some point with her husband and daughter. Notably, although the Veteran's symptoms include mild memory loss, symptoms of her memory loss were not of the frequency, severity, or duration as to the level of memory loss for names of close relatives, own occupation or her own name as indicative of a 100 percent disability rating. The examiner also noted that the Veteran was alert and oriented, she maintained appropriate eye contact and she was appropriately dressed. At the time of the interview, she also denied suicidal ideation and homicidal ideation, plan or intent, and hallucinations. This has been consistent throughout the period on appeal. Given the Veteran's relationship with her husband, her child, and her mother, the Veteran's major depressive disorder symptoms do not more nearly approximate total social impairment. Therefore, because the evidence shows that the Veteran's major depressive disorder symptoms do not result in total social impairment, a 100 percent rating is not warranted. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. Entitlement to an initial rating in excess of 10 percent for scar, status post caesarean section surgery, is denied. The Board notes that based on the findings of the Veteran's November 2012 initial VA examination for the Veteran's service connection claim for complications of Caesarian section, she was granted service-connection at 10 percent evaluation for a painful scar resulting from Caesarian section, pursuant to Diagnostic Code 7804. The General Rating Formula for the skin allows for ratings under Diagnostic Code 7800, for disfigurement of the head, face, or neck, or for scars under Diagnostic Codes 7801, 7802, 7804, or 7805, depending on the predominant disability. The rating criteria for evaluating scars are set forth at 38 C.F.R. § 4.118, Diagnostic Codes (DCs) 7800-7805. DC 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful are rated at 10 percent disabling. Note (1) to DC 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, DC 7804. DC 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 7800-7804 or under an appropriate diagnostic code. During the Veteran's initial VA examination dated November 2012, the examiner reported that the Veteran had one surgical linear scar from a Caesarian section in the lower abdomen (anterior trunk region), which measured 13.5 (length) centimeters by .01 (width) centimeter. The examiner also noted that the Veteran described by the scar as painful ("somewhat tender to palpitation"), but that the scar was not unstable. Further, no disfigurement or functional impairment resulting from this scar was reported. In response, the Veteran filed a claim a Notice of Disagreement (NOD) in December 2013, seeking a higher compensable rating, asserting that her scar from her Caesarian section has not healed and this has caused her stomach to look very unattractive. Subsequent to her NOD, the Veteran was afforded another examination in November 2019 to evaluate the current condition of her scar. The findings were substantially similar to that of the VA examiner's findings during the Veteran's initial November 2012 examination. The November 2019 examiner also reported that the Veteran's incisional scar is on her lower abdomen and that there is no loss of covering over the skin, notwithstanding the Veteran's report that it is tender and sensitive. Further, this examiner also reported that the Veteran has no pertinent physical findings, complications, conditions, signs or symptoms related to her scar, and that there is no functional impact on her ability to work. See, November 2019 Scars/Disfigurement DBQ. The Board also notes that the Veteran's treatment records also reflect the existence of her Caesarian section scar but no additional or different findings with respect to the type (linear), and location (abdominal) is reported. With regards to the Veteran's claim that her stomach is unattractive as a result of her surgery, no disfigurement has been reported by any medical professional, and the Board further notes that the Veteran, as a lay person is not qualified to make such a medical finding. As such, the evidence of record reflects that a higher rating in excess of the Veteran's current 10 percent rating for the painful nature of her residual scar is currently not warranted, as there is no other medical evidence of record that contradicts the respective November 2012 and November 2019 VA examiners' findings that there is one linear residual scar resulting from the Veteran's Caesarian section surgery, which is painful, but not unstable, measuring 13.5 cm in length and 0.1 cm in width, covering 1.35 total square centimeters. The Board has also considered the other diagnostic codes for evaluating scars and has concluded that the Veteran is not entitled to separate ratings for her residual scar based on the following determination: DC 7800 pertains to scars of the head, face, or neck and is therefore not applicable to this claim, since the Veteran's scar is on her lower abdomen. DC 7801 pertains to 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.), and for which a 10 percent rating will be assigned. Note (1) indicates that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. DC 7802 pertains to 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, for which a 10 percent rating will be assigned. Note (1) indicates that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802. Since the Veteran's Caesarian scar is not as a result of a burn and is not deep and nonlinear in nature or at least 6 square inches, then, diagnostic codes 7801 and 7802 are also not applicable in this case. The Board has also examined recent changes in the criteria applicable to skin disorders, effective August 13, 2018 (See 83 Fed. Reg. 32,592 (July 13, 2018)) but notes that the amendments did not change the criteria for rating scars under Diagnostic Codes 7800 and 7804. With regards to Diagnostic Codes 7801 and 7802, the terms deep, nonlinear, and superficial, were replaced with "underlying soft tissue damage." The revisions also divided the previously referenced body parts into various zones of the body and indicated that separate evaluations may be assigned for each affected zone under Diagnostic Codes 7801 and 7802. Another noteworthy change is the creation of a General Rating Formula that applies to certain diagnostic codes, including Diagnostic Code 7806 (dermatological), and provides that the rating criteria can be met based on either: (1) the percentage of entire body/exposed areas affected OR (2) the type of therapy within the past 12-month period. As was noted previously, neither of these changes warrant any change in the Board's decision. Following a review of the record, the Board finds that a rating in excess of 10 percent for residuals scar associated with the Veteran's Caesarian surgery is not warranted under DC 7804, as the Veteran has only one scar that is painful, but not unstable. In reaching the above conclusions, 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 applicable in the current appeal. 38 U.S.C. § 5107 (b). Further, the evidence does not support additional staged ratings for any specific time period on appeal, and for no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§§ 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. §§ 3.303(b), Walker v. Shinseki 708 F.3d 1331. (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 C.F.R. §§ 3.309. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau, supra. Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Lastly, in order to deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 3. Entitlement to service connection for a back disorder, diagnosed as lumbosacral strain, is granted. The Veteran asserts that she incurred a back disability during her active duty service. For the reasons discussed below, the Board concludes that the most probative evidence of record bolsters the Veteran's contention, and thus, service connection for her claimed disability is warranted. The first element of service disability is satisfied in that the record reflects a diagnosis of lumbosacral strain disability during the appeal period. Although there were three documented in-service reports of backache/back muscle spasm and back stiffness in 2008, during the Veteran's November 2012 initial VA examination, a VA examiner acknowledged the Veteran's lumbosacral strain disability but deemed it resolved as of 2008. However, the evidence of record also reflects the Veteran's competent and credible reports of experiencing back pain that has waxed and waned since service and continuing post service to the present. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the present of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further, the Board notes that during the Veteran's subsequent VA examination in November 2019, the VA examiner acknowledged the chronic nature of the Veteran's back condition by confirming the Veteran's 2008 lumbosacral strain diagnosis, which, unlike the prior examiner, this examiner has not deemed to be resolved. The Veteran was also diagnosed with thoracic strain during the November 2019 VA examination. Given these facts, the determining factor of the Veteran's appeal is whether the most probative evidence supports that the Veteran's current back disability is related to any incident of her active duty, to include her report of in-service symptoms. The Board notes that the November 2012 VA examiner did not provide a nexus opinion, as the examiner did not find the existence of a current disability. On the other hand, the November 2019 provided an opinion to address whether the Veteran's current lumbosacral strain disability is related to her active service. The examiner made an unfavorable finding, notwithstanding the finding of a current disability, stating that "[E]ven with considering the Veteran's report of a fall while in service, there is no objective evidence of a chronic on-going condition. A nexus has not been established." However, the Board finds this aspect of the examination conducted in November 2019 inadequate because the examiner cites to a lack of objective evidence of chronicity of ongoing back pain as her basis for a negative nexus opinion, notwithstanding the Veteran's documented report of her in service symptoms and the examiner's reference to the March 2017 outpatient progress note reflecting a "[C]omplaint of right lower back pain. Reported similar back pain in 2011." Further, the Veteran's treatment records, also acknowledged in the examiner's November 2019 VA examiner's report, referenced the Veteran's statements of the waxing and waning of her continuing back pain since service: "back pain initial started at that time and resolved a few months later. Reports falling while pregnant in 2010 and back pain returned. Slipped on ice outside the hospital. Veteran states that she was seen the day after the fall. Report back pain has continued. Reports seeing a PCP for back pain after separating from the service." As such, the November 2019 examiner appears to find the Veteran's report of her ongoing back pain credible for determining that her 2008 lumbosacral strain diagnosis has not resolved, yet, discounts her report of her continuing back pain symptoms since service. Consequently, the Board finds the unfavorable aspect of the examiner's nexus opinion of low probative value. Most importantly, a closer reading of the November 2019 VA examination report reflects that the stated negative nexus is inconsistent with this VA examiner's finding that the Veteran's lumbosacral strain disability initially manifested in 2008. The importance of this statement is twofold in that: (1) it weighs against the probative value of the unfavorable nexus opinion and (2) it stands for the notion that the Veteran's current disability manifested during active duty (her period of service includes 2008) . Therefore, the Board finds that the November 2019 VA examiner's finding concerning the initial onset of the Veteran's disability fulfills the nexus element, which is further supported by the Veteran's credible reports of onset and continuity, and there is no adequate medical evidence to the contrary. In such cases, the applicable laws provide that service connection for back disability, diagnosed as lumbosacral strain, is warranted in this case. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303. Thus, the Veteran's claim is granted. REASONS FOR REMAND 1. Entitlement to a compensable initial evaluation for a service-connected gynecological disability from a caesarian section, secondary to childbirth, is remanded. As discussed in the Introduction, the noncompensable evaluation for this disability was initially assigned under former Diagnostic Code 7623 to account for the Veteran's reports of lower abdominal pain since her in-service childbirth, which included a Caesarian section. The Veteran has not been provided a gynecological or genitourinary VA examination during the pendency of the appeal to confirm the nature and manifestations of this service-connected disability. Accordingly, remand is necessary to provide the Veteran appropriate VA examinations for the purpose of evaluating this service-connected disability. 2. Entitlement to service connection for non-migraine headaches is remanded. The Board finds the November 2019 VA examination lacks substantial compliance with the Board's December 2018 remand instructions, as a complete rationale was not rendered in support of the examiner's negative nexus opinion. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, in determining the following, that Board finds the VA examiner's rationale was conclusionary, as no supporting scientific evidence was referenced to support the VA examiner's finding that the Veteran's current headache disability is not related to her military service: "[T]he cause of headaches are unknown. The Veteran was seen and treated for headaches while in service, however there is no evidence of chronicity after separation from the service. A nexus has not been established." Therefore, the Board finds that an addendum opinion is necessary before this matter can be adjudicated on its merits. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 3. Entitlement to total disability based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The Board notes that during the Veteran's November 2019 VA examination for her claims currently on appeal, the Veteran reported that she was having difficulty finding employment/staying employed. The RO has since sent the Veteran the required forms to further develop her claim for TDIU which she had initially filed in January 2014. Further, the Board also notes that this claim is inextricably intertwined with the Veteran's claims that are also being remanded in this decision. Accordingly, the Board will therefore defer any action with respect to this TDIU claim until the completion of the development noted above. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Forward the claims file to the VA examiner that conducted the November 2019 opinion to obtain an addendum opinion regarding the Veteran's claimed headache disability. If the examiner is not available, an addendum opinion should be obtained from another examiner. The need for another in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion. The claims file, including this Remand, must be reviewed, and such review should be noted in the opinion. The examiner is asked to opine on the following: Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's headaches are related to service, to include her documented in-service complaints/symptoms? The examiner must comment on the Veteran's in-service reference to headache in July 24, 2007 ("headache at right temporal area"). See, page 5 of STR (received 1/5/12). Further, the examiner must also comment on the Veteran's reports that she experienced frequent headaches that started in 2006 while stationed in Germany, noting a pain level of 5/6 (out of 10) on her frontal lobe. See, November 2012 Headaches Disability Benefits Questionnaire. If any of these documented report of headache symptoms is discounted or deemed of a different etiology to that of the Veteran's currently diagnosed headache disability, a thorough medical explanation with a supporting rationale for such, and any other opinions expressed must be provided. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this, including whether the inability is due to the absence of any specific evidence or to the limits of scientific or medical knowledge. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and severity of her service-connected gynecological disability arising from her Caesarian section. The examiner should identify any gynecological disorder that presently exists or that has existed during the appeal period and that is associated with her Caesarian during service. The examiner is asked to provide a thorough opinion, including a complete and thorough rationale, with reference to relevant evidence of record as appropriate, for all conclusions reached. 3. The RO should conduct all development necessary to re-adjudicate the Veteran's TDIU claim. 4. After completing the requested actions, and any additional action deemed warranted, the RO should readjudicate the claims remaining on appeal. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.B. King, 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.