Citation Nr: 1140627 Decision Date: 11/02/11 Archive Date: 11/16/11 DOCKET NO. 08-37 616 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial schedular rating in excess of 30 percent for posttraumatic stress disorder (PTSD), for the period from October 1, 2006 to August 10, 2009, in excess of a 50 percent schedular rating from August 11, 2009 to February 4, 2010, and in excess of 70 percent thereafter. 2. Entitlement to an initial higher rating for PTSD, on an extra-schedular basis, pursuant to 38 C.F.R. § 3.321(b) (1). 3. Entitlement to an initial schedular rating in excess of 20 percent for scarring alopecia. 4. Entitlement to an initial higher rating for scarring alopecia, on an extra-schedular basis, pursuant to 38 C.F.R. § 3.321(b) (1). 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for a right shoulder disorder (claimed as right shoulder pain), to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. 7. Entitlement to service connection for a left shoulder disorder (claimed as left shoulder pain), to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran had active military service from September 1985 to September 2006. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The initial January 2007 rating decision, in pertinent part, granted service connection for PTSD, and assigned an initial 30 percent rating, effective October 1, 2006, granted service connection for alopecia and assigned an initial noncompensable rating, effective October 1, 2006, and denied service connection for bilateral hearing loss, tinnitus of the left ear and right and left shoulder pain. The Veteran submitted her notice of disagreements with this issues in June and August 2007. In an October 2008 rating decision, the RO granted service connection for tinnitus of the left ear. As the benefit sought as to this issue was granted, there is no longer an appeal as to this matter. In December 2008, the Veteran perfected her appeal (via a VA form 9) as to the remaining issues. In a June 2010 supplemental statement of the case (SSOC), the RO continued the initial 30 percent rating for PTSD from October 1, 2006 to August 10, 2009, but granted a higher 50 percent rating, effective August 11, 2009, and a 70 percent rating from February 5, 2010 for the Veteran's service-connected PTSD. In addition, the RO assigned an initial 20 percent disability rating for scarring alopecia, effective October 1, 2006. Because the Veteran has disagreed with the initial ratings assigned following the grants of service connection for the PTSD and for scarring alopecia, the Board has characterized these issues in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Although the RO has granted higher staged ratings during the pendency of this appeal for PTSD, inasmuch as higher ratings are available during each period, and a Veteran is presumed to seek the maximum available benefit for a disability, the claims for initial higher ratings for PTSD remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues of initial higher ratings for PTSD and for scarring alopecia, each, on an extra-schedular basis, pursuant to 38 C.F.R. § 3.321(b), and the claims for service connection for right and left shoulder disorders and left ear hearing loss are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims decided herein has been accomplished. 2. From the October 1, 2006 effective date of the grant of service connection to August 10, 2009, the Veteran's PTSD was manifested, primarily, by depression, chronic sleep disturbance and insomnia, nightmares, flashbacks, irritability and anger, avoidance behaviors, exaggerated startle response, difficulty concentrating, feelings of detachment, decreased energy and interest in activities, hypervigilance, and restlessness. The Veteran was employed and denied panic attacks. These symptoms are reflective of no more than occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships is not demonstrated. 3. For the period from August 11, 2009, the Veteran's PTSD was manifested, primarily, by depression, anxiety, chronic sleep disturbance and insomnia, panic attacks, nightmares, flashbacks, irritability, anger, sadness, exaggerated startle response, difficulty concentrating, impaired memory, intrusive thoughts, feelings of detachment, decreased energy and interest in activities, hypervigilance, some hallucinations, interpersonal guardedness, avoidance of and exaggerated response to trauma related triggers, decreased interest in hobbies and social activities, feelings of detachment and estrangement from others, emotional numbing, and feelings of a foreshortened life. The Veteran discontinued working in 2009 due to an increase in her PTSD symptoms. Collectively, these symptoms are indicative of occupational and social impairment with deficiencies in most areas and the inability to establish and maintain effective relationships is not demonstrated. Symptoms of total occupational and social impairment have not been demonstrated. 4. The Veteran's current 20 percent schedular rating for scarring alopecia is the maximum schedular rating allowed under the applicable rating criteria. 5. The Veteran does not have right ear hearing loss to an extent recognized as a disability for VA purposes. CONCLUSIONS OF LAW 1. With resolution of all reasonable doubt in the Veteran's favor, the criteria for an initial 50 percent schedular rating for PTSD, but no higher, for the period from October 1, 2006 to August 10, 2009, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.130, 4.132, Diagnostic Code 9411 (2011). 2. With resolution of all reasonable doubt in the Veteran's favor, the criteria for a 70 percent schedular rating for PTSD, but no higher, for the period from August 11, 2009, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.130, 4.132, Diagnostic Code 9411 (2011). 3. The criteria for an initial schedular rating in excess of 20 percent for scarring alopecia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7830 (2011). 4. The criteria for service connection for right ear hearing loss are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353- 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, a May 2006 pre-rating letter provided notice of what was needed to substantiate the claims for service connection and provided the Veteran with notice of the disability and effective date elements pursuant to Dingess/Hartman, and the October 2008 statement of the case (SOC) set forth the criteria for higher ratings for the PTSD and for scarring alopecia (which suffices for Dingess/Hartman). In addition, after issuance of the May 2006 letter, the Veteran was afforded additional opportunities to respond before the RO readjudicated the claims in a June 2010 supplemental SOC. Hence, the Veteran is not shown to be prejudiced by the timing of VCAA-compliant notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the SOC or SSOC, is sufficient to cure a timing defect). Additionally, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters decided herein Pertinent medical evidence of record includes the Veteran's service treatment records, VA medical records, private medical records and the reports of QTC and VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran as well as by her husband and friends, on her behalf. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the appellant has been notified and made aware of the evidence needed to substantiate the claims herein decided, the avenues through which he might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the appellant or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). A. PTSD When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD has been assigned an initial 30 percent rating from the October 1, 2006 effective date of service connection to August 10, 2009, a 50 percent rating for the period from August 11, 2009 to February 4, 2010, and a 70 percent rating from the period from February 5, 2010, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Pursuant to the General Rating formula, a 30 percent rating is warranted when there is occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating 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 per 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. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. For the period from the October 1, 2006 effective date of the grant of service connection to August 10, 2009, the pertinent medical evidence includes a May 2006 QTC examination report reflecting that the Veteran complained of insomnia, depression, nightmares of running for shelter and constantly looking for somewhere to run, be safe, and to hid. The nightmares occur twice per month. She remembers hearing shots and mortar rounds every other day. She has trouble concentrating, average energy, and weight gain of 20 pounds in the last six months. The Veteran stated she has two close friends and lives with her husband and son. She does physical training three time a week, works as a manager during the day. She does housework and cooking. Hobbies include watching television. She related distantly to the examiner and other office staff. Mental status examination revealed that the Veteran was in contact with reality, she was pleasant and cooperative and her impulse control was average. Speech was normal. She reported visual flashbacks. She denied auditory hallucination. There is no evidence of delusions, persecutions, obsessions, thought control, unusual powers, feelings of helplessness, hopelessness or worthlessness or suicidal or homicidal ideation. Her affect was sad, anxious, and appropriate to content. There was no evidence of elation, anxiety, anger, suspicion, overfriendliness, fearfulness, flatness or bluntness. The Veteran was oriented times three. Her ability to concentrate and attention is diminished secondary to being in Saudi Arabia and worsened by spending time in Iraq. The diagnosis was PTSD secondary to being in military service, severe, immediate onset, and chronic. She has social problems with fee friends. A GAF score of 45 was assigned, noting that the Veteran has visual flashbacks of mortar rounds and sometimes can hear the sound. In an addendum, the QTC examiner noted that traumatic experience that led to the mental condition was nightmares of running for shelter several times a week while in Saudi Arabia. She has trouble concentrating, low energy, psychomotor retardation, was easily upset, and scared of her own shadow. The Veteran has intermittent inability to perform activities of daily living, but can perform self-care. She has difficulty understanding complex commands. She does not appear to be a threat to herself of others. Panic attacks are absent. The Veteran was noted to have responded to the traumatic event with helplessness. She has recurrent recollections, recurrent distressing dreams, feels as if the traumatic events were recurring. She makes efforts to avoid association with the trauma, makes efforts to avoid activities that arouse the event, and has a sense of a foreshortened future. She has difficulty falling of staying asleep, exaggerated startle response, and difficulty concentrating. The examiner indicated the Veteran's psychiatric symptoms cause occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and mood. A March 2007 VA mental health consultation record reflects that the Veteran is married with one child. She complained of irritability, insomnia, poor concentration, and startled response. Mental status examination revealed that her mood was anxious with congruent effect. Speech was normal. Thoughts were logical and goal-directed without evidence of thought disorder or delusion. No suicidal/homicidal ideation. No auditory/visual hallucinations. She reported her leisure/recreational activities as shopping. Depressive symptoms noted included sleep, decreased interest, decreased energy, poor concentration, decreased appetite, and restlessness. She has recurrent and intrusive distressing recollections, recurrent distressing dreams, acting or feeling as if the traumatic event were recurring, intense psychological distress at exposure to internal or external cues, and physiological reactivity on exposure to internal or external cues. She has persistent avoidance of thoughts, feelings, or conversations associated with the trauma, as well as avoidance of activities, places or people. She has an inability to recall important aspects of the trauma. She has markedly diminished interest or participation in significant activities. She has feeling of detachment or estrangement from others, has restricted range of affect, and a sense of a foreshortened future. She has persistent difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. She is easily upset and easy to cry about little things. Avoids having to make major decisions and avoids being around people. The diagnosis was PTSD and a GAF score of 45 was assigned. In a June 2007 letter, the Veteran stated that she purposely avoids situation where large crowds are gathered and loud noises. In October 2007 and November 2007 letters from the Veteran's friends, they indicated that they were surprised she retired from the military as she was on her way to becoming an E-9. She is described as attempting to prepare for worse case scenarios, reduced public interaction, and disappointment with herself in not being able to handle the type of positions she used to thrive in. The Veteran is moody, irritable, and at times does not appear words anyone is saying. One minute she may appear to be okay, the next she is crying. She has been witnessed running for cover when hearing a loud alarm and practically fight when she is startled. She often remarked how the crowds seem to be closing in on her. One friend witnessed her talking, screaming, and fighting in her sleep. As for her social life, she does not go anywhere. She avoids large crowds and events. She is noted as becoming increasingly irritable and easily aggravated. In an October 2007 letter from the Veteran's husband, he stated that when the Veteran returned from the military she was changed. She no longer wanted to socialize with anyone, was irritable and quick to anger for no apparent reason. She had frequent nightmares and never slept more than three to four hours without waking up. A VA form 21-4192 shows that the Veteran was employed full time in a clerical position until September 17, 2009 at which time the Veteran resigned. The Board has considered all the evidence of record in light of the criteria noted above, and finds that by resolving all reasonable doubt in favor of the Veteran, that her service- connected PTSD warrants an initial 50 percent disability rating from the October 1, 2006 effective date of the grant of service connection to August 10, 2009. In granting an initial 50 percent for the Veteran's PTSD for the period from October 1, 2006 to August 10, 2009, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this regard, during the period from October 1, 2006 to August 10, 2009, the Veteran's PTSD symptoms were manifested, primarily, by: depression, chronic sleep disturbance and insomnia, nightmares, flashbacks, irritability and anger, avoidance behaviors, exaggerated startle response, difficulty concentrating, feelings of detachment, decreased energy and interest in activities, hypervigilance, and restlessness. The Veteran was employed and denied panic attacks. The Board finds that this symptomatology more nearly reflects occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating. The Board emphasizes that for the period from October 1, 2006 to August 10, 2009, there simply is no medical findings of suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); or an inability to establish and maintain effective relationships or more severe symptomatology such as to warrant at least the next higher 70 percent rating. In addition to the absence of most of the symptoms listed in Diagnostic Code 9411 as characteristic of occupational and social impairment with deficiencies in most areas (criteria for a 70 percent rating), the Board also points out that none of the assigned GAF scores, alone, support the assignment of any higher rating during the period in question. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF score is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). The Board finds that collectively, the GAF scores assigned are consistent with an initial 50 percent rating. In a February 2005 VA medical record, the Veteran was assigned a GAF score of 45 in May 2006 and in March 2007. According to DSM-IV, GAF scores between 41 and 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, and inability to keep a job). In this case, the reported symptomatology is consistent with no more than moderate symptoms or moderate difficulty in social, occupational, or school functioning, in this regard, the Veteran had friends and family that she socialized with, was employed in a full time clerical position, and was not found to have suicidal ideations or obsessional rituals. Hence, a initial schedular rating in excess of 50 percent for the period from October 1, 2006 to August 10, 2009 is not warranted. For the period from August 11, 2009 to the present, the Board finds that by resolving all reasonable doubt in favor of the Veteran, that a 70 percent disability rating for her service- connected PTSD is warranted. The pertinent evidence from August 11, 2009 includes August and September 2009 Goldboro psychiatric assessments that reflect that the Veteran reported panic attacks once to three times a week/month for about 30 minutes, nightmares two to four times per week where she wakes in a panic, flashbacks two times a week, an average of four hours of sleep, waking three to four times per night and that night sweats, she startles, is hypervigilant, has intrusive thought sometimes, socializes rarely with friends and family. Her memory is impacted because she misplaces things, forgets what she is told, cannot read and gets lost driving. She described anger, sadness, and fear out of the blue, and depression, agitation, and worry about 75 percent of the time. She feels helpless and hopeless about 25 percent of the time. She always has racing and jumping thoughts and has crying spells about 50 percent of the time. As to hallucinations, she reports hearing her name called about two to five times per week to a daily occurrence, footsteps/noise in the house and shadows moving many times a day. The diagnoses were PTSD and major depression, a GAF score of 40 was assigned. In an August 2009 letter, E.W. Hoeper, M.D., stated that the Veteran was currently working as a housing clerk at Fort Bragg. She has nightmares at least three to four times per week, waking in a panic and sweats lasting one to two hours. The Veteran has flashbacks three to four times per week. She has panic attacks three times per week, lasting at least twenty minutes. She has intrusive thoughts, startles easily, is hypervigilant and cannot tolerate anyone behind her. She socializes occasionally with family and friends. Her recent memory is severely impaired, so much she cannot remember what she reads, and gets lost when traveling. Her working memory is 100 percent impaired. Anger, sadness, and fear comes upon her without her understanding why 85 percent of the time. She hears her name called daily, hears cars drive up at her residence daily, hearing noises in her house many times per day, and she sees shadows moving out of the corners of her eyes many times per day. All of these hallucinations and illusions occur when no one or nothing is there. She always feels depressed with no energy and little interest in things. She has crying spells 50 percent of the time, and she angers and agitates easily. She feels helpless and suicidal at times. Dr. Hoeper opined that the Veteran is moderately compromised in her ability to sustain social relationships and is also moderately compromised in her ability to sustain work relationships. A February 2010 VA PTSD examination report reflects that the claims file was reviewed. Since her last VA examination, she has had no remission of her symptoms. Overall, she is having an increase in her symptoms. She has generally more trouble with depression and anxiety as well as increasing difficulty with severe insomnia, even with medication. She is only getting two to three hours of sleep and awakening three to four times throughout the night. She has anger and irritability issues which also have been getting worse, and have led to her stopping work. She has decreased energy and crying spells. No suicide attempts were noted. She had panic attacks that have increased from occasional to about four times per week. She is getting therapy at the VA and also sees a private psychiatrist. While she is on medication, it is not totally relieving her symptoms. She is still showing major problems with sleep and is increasingly suffering from anxiety, depression, and panic attacks. She continues to have trauma related nightmares and flashbacks several times per week. Some weeks she has them every day and every nights. She is not working. She stopped working because of her increasing difficulty with anxiety, depression, irritability, difficulty getting along with others, difficulty handling stress, poor attention and concentration, etc. It appears at least as likely as not at the present time that the Veteran is unemployable in most full time job situations, or at best, would have major limitations in occupational reliability and productivity as a result of her PTSD and related symptoms. The only type of job that she would be reasonably expected to be able to handle would be a very quiet, isolated job with low stress and minimal interaction with others. She lives with her husband and son. She takes care of her personal activities of daily living. Sometimes she does not bother. Her motivation is very poor and sometimes gets quite scattered and loses track of what she needs to do. She rarely socializes outside the house, and if so, it is only with close family members at a quiet restaurant or a place with there is not a lot of stress. She is hypervigilant and does not want to be in places that she feels confined or crowded. She does not attend church for the same reason. For relaxation she will try to read or watch television, but usually loses track of the plot. She sometimes will go online to shop or surf the internet. She used to enjoy shopping and socializing, but over the last few years, she has become increasingly isolated and dysfunctional socially. Her marriage is stressed because of her irritability, self isolation, lack of desire to socialize as a couple, etc. The Veteran is showing major impairment in social, occupational, recreational and familial adjustment. She is almost totally isolated and recently stopped working because of her increasing psychiatric symptoms. The VA examiner noted that the record does not indicate ongoing treatment in the VA system. In addition to the above, on mental status examination, the Veteran was alert and oriented. Her affect was rather flat and constricted. She had a somber, tense demeanor. There was no gross sign of a thought disorder, loosened associations, flight of ideas, hallucinations, delusions, obsessions, compulsions, or phobias other than significant social phobia and some claustrophobia. These are secondary to her PTSD. Insight and judgment appeared adequate. She denied homicidal or suicidal ideation. Her intellectual capacity appears grossly intact, but the Veteran did complain of significant problems with focusing, attention, and concentration. She continues to have an increased startle response, hypervigilance, interpersonal guardedness, avoidance of and exaggerated response to trauma related triggers, decreased interest in hobbies and social activities, feelings of detachment and estrangement from others, emotional numbing, and feelings of a foreshortened life. The diagnosis was PTSD with associated panic attacks and depression. A GAF score of 40 was assigned. She shows major impairment in both social and occupational functioning. Her current level of functioning is dependent upon continuing psychotropic medication. The Board has considered all the evidence of record in light of the criteria noted above, and finds that by resolving all reasonable doubt in favor of the Veteran, that her service- connected PTSD warrants a 70 percent disability rating from the August 11, 2009 private medical records showing symptoms that more nearly approximate the 70 percent disability rating criteria. In granting a 70 percent for the Veteran's PTSD for the period from August 11, 2009 to the present, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this regard, during the period from August 11, 2009 to the present, the Veteran's PTSD symptoms were manifested, primarily, by: depression, anxiety, chronic sleep disturbance and insomnia, panic attacks, nightmares, flashbacks, irritability, anger, sadness, exaggerated startle response, difficulty concentrating, impaired memory, intrusive thoughts, feelings of detachment, decreased energy and interest in activities, hypervigilance, some hallucinations, interpersonal guardedness, avoidance of and exaggerated response to trauma related triggers, decreased interest in hobbies and social activities, feelings of detachment and estrangement from others, emotional numbing, and feelings of a foreshortened life. The Veteran discontinued working in 2009 due to an increase in her PTSD symptoms. The Board finds that this symptomatology more nearly reflects occupational and social impairment with deficiencies in most areas, the criteria for a 70 percent disability rating. The Board also finds that the GAF scores assigned since August 11, 2009 are consistent with a 70 percent rating. In this regard, both the Veteran's private psychiatrist in an August 2009 medical record and the February 2010 VA examiner assigned a GAF score of 40. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g. depressed person avoid friends, neglects family, and is unable to work). In this case, since August 11, 2009, the extent and severity of the Veteran's actual PTSD symptoms reported and/or shown are suggestive of occupational and social impairment with deficiencies in most areas, such as work, family relationships, judgment, thinking or mood; the level of impairment contemplated in the higher, 70 percent, rating for psychiatric disabilities. The Board emphasizes, however, that for the period from August 11, 2009 to the present, the symptoms associated with the Veteran's PTSD do not meet the criteria for the maximum, 100 percent, rating. As noted above, a 100 percent rating requires total occupational and social impairment due to certain symptoms; however, the Board finds that neither the delineated symptoms nor comparable symptoms are shown to be characteristic of the Veteran's PTSD. Evidence of record does not indicate that the Veteran has exhibited persistent delusions; grossly inappropriate behavior; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Indeed, as noted throughout the record, the Veteran is married and has a son and that she socializes, even if to a limited extent, with family. Therefore, she is shown to be able to be around other people, even if to a limited degree. In addition, while the Veteran reports impaired memory, she has not been found to have any memory loss for names of close relatives, her own occupation, or her own name. Lastly, the Veteran is clearly able to perform activities of daily living, and VA records associated with the claims file do not even suggest that the Veteran fails to meet minimal personal hygiene standards. While the Veteran has been deemed unemployable, this finding, in and of itself, does not demonstrate that the schedular criteria for a 100 percent rating are met. In sum, the psychiatric symptoms shown do not support the assignment of the maximum, 100 percent, schedular rating. While the Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for an initial 50 percent schedular rating for the period from October 1, 2006 to August 10, 2009, and a 70 percent schedular rating for the period from August 11, 2009 have been met, the Board finds that the preponderance of the evidence is against the assignment of any higher schedular ratings; hence, there is no basis for further staged ratings of the Veteran's PTSD, pursuant to Fenderson. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Scarring alopecia The Board notes that the criteria for rating scars were revised, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7805). The amendments do not change the criteria set forth at Diagnostic Codes 7830 or 7831, discussed below. The Veteran is assigned an initial 20 percent rating for her service-connected scarring alopecia. Pursuant to Diagnostic Code 7830, scarring alopecia is rated 20 percent disabling when it affects more than 40 percent of the scalp. Pursuant to Diagnostic Code 7831, alopecia areata is rated 10 percent disabling when it results in loss of all body hair. These are the highest available ratings under these Diagnostic Code provisions. Based on a thorough review of the record, the Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 20 percent for scarring alopecia. Service treatment records reflects that the Veteran was diagnosed with central centrifugal scarring alopecia and that she received reimbursements for wigs. A May 2006 QTC examination report reflects that the Veteran has central centrifugal scarring alopecia and that due to this skin condition she has balding. The skin disease involves areas that are exposed to the sun, including the head. Over the past twelve months, she has received Doxycycline 100 milligrams constantly for 12 months. The functional impairment is devastating disfigurement and must wear wig or hair piece all the time. Physical examination revealed that there is alopecia areata with loss of body hair at the scalp. The skin condition located on the midline vertex to occiput has the following characteristics: there is no ulceration, exfoliation, crusting, tissue loss, induration, inflexibility, hypo or hyperpigmentation, abnormal texture or limitation of motion. The skin lesion coverage of the exposed area is 5 percent. The skin lesion coverage relative to the whole body is 1 percent. The skin lesions are not associated with systemic disease. The skin lesions do not manifest in connection with a nervous condition. The diagnosis was alopecia. The subjective factors are balding. The objective factors are alopecia areata at the scalp, midline vertex to occiput. Ravenhill dermatology records dated March and May 2007 reflect that the Veteran was seen for complaints of hair loss. She currently used Doxycycline and Clobetasol ointment. Skin examination was abnormal and revealed excessive hair loss throughout the scalp and complete clearing-loss at the frontal and apical scalp. Thinning of the hair was noted on the parital and occipital scalp. An October 2007 Wakeforest University Baptist medical center record reflects that the Veteran was evaluated for hair loss. She has occasional itching and some decreased sensation in her scalp, but no other symptoms. Physical examination revealed significant nonscarring hair loss involving the frontal and vertex of the scalp extending onto the bilateral temporal scalp in a band-like pattern. She had a negative pull test at the periphery of the alopecia. The assessment was central centrifugal scarring alopecia and although there is a component of traction alopecia at the frontal and temporal scalp as well. Total area of scalp involved is between 30 and 40 percent. Recommendation for Rogaine. A February 2010 VA skin disease examination report reflects that the claims file was reviewed. The Veteran reported she was currently taking Doxycycline 100 milligrams daily for alopecia of the scalp. The hair loss has increased over the years. Skin symptoms noted were hair loss and itching on the scalp. The examiner noted that the current treatment is daily and constant systemic treatment, that is neither a corticosteroid or immunosuppressive. The extent of hair loss involved is scalp and face only. Approximately 50 percent of the scalp shows hair loss or patches of minimal hair present, which extends from the anterior scalp to the mid scalp and along the bilateral scalp. The diagnosis was chronic alopecia, scalp. The examiner noted that the Veteran indicated she was self conscious performing her work in administration due to the hair loss and wore wigs regularly. There are no limitations/no functional impairment regarding physical or sedentary employment due to this condition. The Veteran's current 20 percent rating for scarring alopecia is the maximum schedular rating for this disability under Diagnostic Codes 7830 or 7831. There is no indication of any other complication that would warrant consideration of alternative diagnostic codes (i.e. scarring that results in tissue loss, that are deep, unstable or painful, or other skin diseases as they have not been diagnosed as related to the Veteran's service-connected scarring alopecia). Consideration of an extra-schedular rating is addressed in the REMAND section below. III. Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Specific to claims for service connection, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Initially, the Board notes that the last audiometric testing performed during service was in October 2005, which revealed pure tone decibel thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 5 0 5 LEFT 30 30 20 20 20 The October 2005 hearing audiogram chart does not show that the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz were 40 decibels or greater or that the auditory thresholds for at least three of these frequencies were 26 or greater. None of the previous audiograms in service show hearing loss. In this case, the competent evidence does not reflect the presence of bilateral hearing loss on any audiometric testing during service as defined by § 3.385. However, the absence of in-service evidence of hearing loss is not fatal to the claim, see Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In this case, however, the post-service evidence also does not reflect that the Veteran has current right ear hearing loss disability as defined by 38 C.F.R. § 3.385. A May 2006 QTC examination was performed for the Veteran's claim of service connection for bilateral hearing loss. Audiometric testing performed at that time revealed that pure tone decibel thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 0 10 5 LEFT 15 15 10 10 15 The Veteran's speech discrimination score on the Maryland CNC word list was 100 percent in the right and the left ears. The examiner found that there was no hearing loss present in the right and the left side. She concluded that there was no diagnosis because there was no pathology to render a diagnosis. A January 2007 VA audiology consultation record reflects that the Veteran complained of problems understanding speech, especially in noise. She reported exposure to excessive noise during active duty military service. Audiometric testing performed at that time revealed that pure tone decibel thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 15 15 LEFT 25 20 30 30 30 The Veteran's speech discrimination score on the Maryland CNC word list was 100 percent in the right ear and 96 percent in the left ear. The VA audiologist determined that based on audiometric examination, the Veteran's hearing was within normal limits for the right ear and a mild sensorineural hearing loss in the left ear. Based on the above findings, none of the objective evidence of record shows that the Veteran has a right ear hearing loss disability that meets the criteria set forth in 38 C.F.R. § 3.385. See Lendenmann v. Principi, 3 Vet. App. 345 (1992) (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). As indicated above, Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131. Hence, whereas here, the competent evidence establishes that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the instant appeal, the claim for service connection for right ear hearing loss must be denied because the first essential criterion for the grant of service connection - competent evidence of the disability for which service connection is sought - is not met. Therefore, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for right ear hearing loss. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. 38 U.S.C.A. § 5107(b). As such, service connection for right ear hearing loss must be denied. ORDER For the period from October 1, 2006 to August 10, 2009, an initial 50 percent schedular rating for PTSD, but no higher, is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from August 11, 2009 to the present, a 70 percent schedular rating for PTSD, but no higher, is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for right ear hearing loss is denied. REMAND Under 38 U.S.C.A. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent prior to December 31, 2011. 38 C.F.R. § 3.317(a)(1)(i). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2010); 38 C.F.R. § 3.317(a), (b). A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117(f). In this case, the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. Signs or symptoms that may be manifestations of undiagnosed illness or a chronic multi-symptom illness include headache, muscle pain, joint pain, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, and gastrointestinal signs or symptoms. 38 U.S.C.A. § 1117(g). However, the RO has adjudicated each claim in the rating decision and SOC on a direct incurrence basis only. As the Veteran is a Persian Gulf veteran who claimed service connection for symptoms listed in 38 C.F.R. § 3.317, the Board finds that the issue of service connection pursuant to 38 C.F.R. § 3.317 has been raised with regard to the claims for service connection for a right and a left shoulder disorder remaining on appeal. See EF v. Derwinski, 1 Vet. App. 324, 326 (1991) (the Board must review all issues reasonably raised from a liberal reading of all documents in the record). The RO should address this theory of entitlement in the first instance, thus warranting remand of each claim for service connection for right and left shoulder disorders. See Robinson v. Mansfield, 21 Vet. App. 545 (2007) (separate theories in support of a claim for a particular benefit are not equivalent to separate claims). The Board particularly notes that the Veteran has not been afforded a Persian Gulf War protocol examination in connection with the service connection claims for right and left shoulder disorders. Given the Veteran's Persian Gulf War service and the joint pain in the evidence of record, to include her service treatment records, the Board finds that a VA Persian Gulf War protocol examination in connection with the claims remaining on appeal is warranted. The Board notes that guidelines for disability examinations for Gulf War veterans have been issued in an Under Secretary for Health's Information Letter, dated April 28, 1998 (IL 10-98- 010). In addition, the RO/AMC should adjudicate whether the claims for initial ratings for PTSD and for scarring alopecia meet the criteria for submission for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) (2010). See Bagwell v. Brown, 9 Vet. App. 337 (1996). In order to ensure due process, the RO/AMC should provide the Veteran with a VCAA compliant notice, that addresses the issues of service connection for right and left shoulder disorders, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117, and the criteria for submission of the claims for higher ratings for PTSD and for scarring alopecia for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). Give the Veteran another opportunity to provide information and/or evidence pertinent to the claims remaining on appeal. As the VA audiogram in January 2007 shows left ear hearing loss as defined by 38 C.F.R. § 3.385; therefore, in light of the duty to assist a VA examination is warranted to determine the nature and etiology of the left ear hearing loss. Accordingly, these matters are REMANDED for the following actions: 1. The RO/AMC should send to the Veteran a VCAA compliant letter informing the Veteran of the evidence necessary to substantiate her claims for service connection for right and left shoulder disabilities, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. In addition, the letter should request that the Veteran provide sufficient information, and if necessary, authorization, to enable VA to obtain any additional evidence pertinent to the claims remaining on appeal not currently of record. The RO/AMC should also explain the requirements for establishing entitlement to a higher rating under 38 C.F.R. § 3.321(b)(1) and explain the type of evidence that is the Veteran's ultimate responsibility to submit. 2. Then, the RO/AMC should arrange for the Veteran to undergo a VA Gulf War protocol examination, by a physician, at an appropriate VA medical facility. Such examination should conform to the guidelines for conducting Gulf War examinations set forth in the Under Secretary for Health's Information Letter, dated April 28, 1998 (IL 10-98-010). The entire claims file, to include a complete copy of this REMAND, must be made available to the physician designated to examine the Veteran, and the report of the examination should include discussion of the Veteran's documented medical history and assertions. All necessary tests and studies should be accomplished (with all findings made available to the physician prior to the completion of his/her report), and all clinical findings should be reported in detail. a. The examiner should conduct a comprehensive general medical examination, and provide details about the onset, frequency, duration, and severity of orthopedic signs or symptoms pertaining to the right and the left shoulders and state what precipitates and what relieves them. b. With respect to each complaint or symptom, the examiner should specifically state whether any of the Veteran's complaints or symptoms pertaining to the right and left shoulders are attributable to a known diagnostic entity. If there is a known diagnosis that can be medically explained, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the diagnosed disability was incurred in or aggravated by service or is otherwise medically related to service, to include symptoms/assessments noted in the Veteran's service treatment records. c. The examiner should clearly set forth all examination findings, along with the rationale for the conclusions reached. 3. Then, consideration of submitting the claims for higher ratings for PTSD and for scarring alopecia to the Under Secretary for Benefits or Director of Compensation and Pension Service for an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1) should be undertaken. An extra-schedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. Exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. If the claims are submitted, documentation including the response should be in the claims folder. If not submitted, reasons why not should be spelled out as part of action in the next paragraph. 4. The Veteran should be afforded a VA audiology examination to determine: a). Whether the Veteran has a hearing loss disability of the left ear under 38 C.F.R. § 3.385, and, if so, b). Whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), less likely than not (probability less than 50 percent), that the current hearing loss disability is related to the Veteran's noise exposure in service. If, however, after a review of the record, an opinion on causation is not possible without resort to speculation, the examiner is asked to clarify whether actual causation cannot be determined because there are multiple potential causes, when one cause is not more likely than any other to cause the Veteran's current hearing loss disability and that an opinion on causation is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. The Veteran's file must be made available to the VA examiner for review. 5. Thereafter, the RO/AMC should readjudicate the Veteran's claims for service connection for a right and a left shoulder disorder, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117, the claims for higher ratings for PTSD and for scarring alopecia on a an extra-schedular basis, pursuant to 38 C.F.R. § 3.321(b) and the claim for service connection for left ear hearing loss. If any benefit sought on appeal remains denied, the Veteran should be provided with a SSOC that contains notice of all relevant actions taken on the claim. An appropriate period of time should be allowed for response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ M. Mac Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs