Citation Nr: 1213555 Decision Date: 04/13/12 Archive Date: 04/26/12 DOCKET NO. 08-06 921A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a back disorder, to include as secondary to service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee. 2. Entitlement to service connection for a neurological disorder affecting the bilateral lower extremities, claimed as sciatica of the right and left legs, to include as secondary to service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee. 3. Entitlement to service connection erectile dysfunction, to include as secondary to a neurological disorder affecting the bilateral lower extremities, claimed as sciatica of the right and left legs, and a back disorder. 4. Whether new and material evidence has been submitted to reopen a claim for service connection for a skin condition of the feet and, if so, whether service connection is now warranted. 5. Entitlement to an initial compensable rating for hemorrhoids. 6. Entitlement to a rating in excess of 10 percent for residuals of injury to the right leg (thigh) with arthritis of the right knee. 7. Entitlement to a rating in excess of 40 percent for bilateral hearing loss. 8. Entitlement to an increased initial rating for mood disorder with depressive features, rated as 10 percent disabling prior to January 11, 2010 and as 30 percent disabling as of that date. 9. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: David L. Huffman, Esq. WITNESSES AT HEARINGS ON APPEAL Appellant, wife ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from October 1961 to October 1963. He also had an unverified period of service with the U.S. Army Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision issued by the Department of Veterans Affairs Regional Office and Insurance Center (VAROIC) in Philadelphia, Pennsylvania and from rating decisions issued by the Regional Office (RO) in Newark, New Jersey, in February 2008 and April 2011. The Newark RO currently has jurisdiction of the claims. The November 2006 rating decision declined to reopen a claim for service connection for epidermophytosis of the bilateral feet, assigned a 40 percent rating for bilateral hearing loss, and recharacterized the previously service-connected residuals of injury to the right leg (thigh) as residuals of injury to the right leg (thigh) with arthritis of the right knee, continuing the 10 percent rating assigned. The February 2008 rating decision granted service connection for mood disorder with a 10 percent rating effective June 25, 2007 but denied service connection for a lumbar spine condition and sciatica of the right and left legs. The Board notes that it has recharacterized the Veteran's claims for service connection for sciatica of the right and left legs as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79 (2009). The April 2011 rating decision denied the claim for service connection for erectile dysfunction, granted service connection for hemorrhoids with a noncompensable rating effective March 3, 2010, and denied the claim for a TDIU. In an August 2010 rating decision, the Newark RO recharacterized the Veteran's mood disorder as mood disorder with depressive features and increased the rating assigned to 30 percent effective January 11, 2010. Despite the increased rating granted by the RO, the Veteran's appeal remains before the Board. Cf. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement (NOD) as to an RO decision assigning a particular rating, a subsequent decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Veteran and his wife presented testimony at a personal hearing at the RO in January 2010. The Veteran also presented testimony at a personal hearing before the undersigned Veterans Law Judge in November 2011. Transcripts from both hearings are of record. The issue of entitlement to service connection for arthritis of the bilateral legs and a claim to reopen to establish entitlement to service connection for a left hand condition affecting the nails and skin have been raised by the record and acknowledged by the Agency of Original Jurisdiction (AOJ), but have not been adjudicated. Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. The reopened claim for service connection for a skin condition of the feet, the claims for service connection for a back disorder, a neurological disorder affecting the bilateral lower extremities and erectile dysfunction, the claims for increased ratings concerning hemorrhoids, residuals of injury to the right leg (thigh) with arthritis of the right knee, and bilateral hearing loss, and the claim for entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. An unappealed November 1967 rating decision denied a claim for entitlement to service connection for epidermophytosis on the basis that the disability was first shown approximately four years following discharge and could not be considered as due to service. 2. Additional evidence received since November 1967 on the issue of service connection for a skin condition of the feet is new and material as it raises a reasonable possibility of substantiating the claim. 3. Prior to January 11, 2010, the Veteran's mood disorder with depressive features was not manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. The Veteran's mood disorder with depressive features has not been manifested by occupational and social impairment with reduced reliability and productivity since January 11, 2010. CONCLUSIONS OF LAW 1. The November 1967 rating decision that denied the claim for entitlement to service connection for epidermophytosis is final. 38 U.S.C.A. § 4005(c) (1964); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1967). 2. New and material evidence has been submitted to reopen the claim for entitlement to service connection for a skin condition of the feet. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2011). 3. The criteria for an initial rating in excess of 10 percent for mood disorder with depressive features have not been met prior to January 11, 2010. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9435 (2011). 4. The criteria for an initial rating in excess of 30 percent for mood disorder with depressive features have not been met as of January 11, 2010. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, DC 9435 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Claim to reopen The Veteran seeks to establish service connection for a skin condition of the feet. See e.g., May 2006 VA Form 119. The RO has declined to reopen the claim and continued the denial issued in a previous final decision. See November 2006 rating decision. The Board has an obligation to make an independent determination of its jurisdiction regardless of findings or actions by the RO. Barnett v. Brown, 8 Vet. App. 1 (1995), aff'd, 83 F.3d 1380 (Fed. Cir. 1996). A rating decision issued by the RO in November 1967 denied a claim for entitlement to service connection for epidermophytosis on the basis that the disability was first shown approximately four years following discharge and could not be considered as due to service. The RO notified the Veteran of this decision by letter dated in December 1967, but he did not appeal. See 38 U.S.C.A. § 4005(c) (1964); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1967). An unappealed determination of the Agency of Original Jurisdiction (AOJ) is final. 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.104(a), 3.160(d), 20.302(a). The Veteran filed a claim to reopen in May 2006, and this appeal ensues from the November 2006 rating decision issued by the VAROIC in Philadelphia, Pennsylvania, which declined to reopen the claim on the basis that no new and material evidence had been submitted. A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. 3.156. Evidence is new if it has not been previously submitted to agency decision makers. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For purposes of determining whether VA has received new and material evidence sufficient to reopen a previously-denied claim, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992); see also Madden v. Gober, 125 F.3d 1477, 1481 (1997); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b) (2011). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496. In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Evidence added to the record since the RO's November 1967 rating decision includes a February 2010 statement from R. L. C., a doctor of podiatry, who reports that he had been treating the Veteran for his skin condition since approximately 1996 and had the opportunity to review his service medical records and the available medical treatment records since the completion of his military obligation in 1967. Dr. C. reported that it was his understanding that the Veteran lived in typical military barracks-style housing with numerous other soldiers, which required use of sometimes unsanitary community bathrooms and showers. Such dormitory and barracks-style living conditions are known to promote the spread of various skin conditions. Based on his examination of the Veteran, his review of the Veteran's medical history, and his discussions with the Veteran, it was Dr. C's professional medical opinion that it is at least as likely as not that the skin and nail condition present on his feet was caused by his living conditions during his military service. This record is new, as it was not of record when the RO issued its November 1967 rating decision. It is also material, as the submission of this new evidence raises a reasonable possibility of substantiating the claim. Having found that new and material evidence has been presented, the claim for entitlement to service connection for a skin condition of the feet is reopened for review on the merits. For the reasons discussed below, additional development of the evidence is needed to decide the reopened claim. Increased rating Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Service connection was initially granted for mood disorder as secondary to the Veteran's service-connected bilateral hearing loss. A 10 percent rating was assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9435, effective June 25, 2007. See February 2008 rating decision. As noted above, the RO subsequently recharacterized the disability as mood disorder with depressive features and increased the rating to 30 percent effective January 11, 2010. The date assigned by the RO was the date on which the Veteran presented testimony that his condition had worsened. See August 2010 rating decision. Given the foregoing, the Board must determine whether the Veteran is entitled to a rating in excess of 10 percent between June 25, 2007 and January 10, 2010, and a rating in excess of 30 percent as of January 11, 2010. The Veteran contends that he is entitled to increased initial ratings for his service-connected mood disorder with depressive features. He initially asserted that his symptoms were more consistent with evaluations of 70 or 100 percent under 38 C.F.R. § 4.130 and the General Rating Formula for Mental Disorders without providing any specific symptomatology. See March 2008 NOD. The Veteran reiterated this contention, again without providing any symptomatology specific to his condition, in October 2008, August 2010 and May 2011. See statements in support of claim. The Veteran testified in January 2010 that he has depression and anxiety and is suspicious, all three of which affect his daily life. His wife corroborated that these symptoms do affect him on a day to day basis and reported that he tends to isolate himself. See January 2010 transcript. The Veteran testified in November 2011 that his disability had worsened since an April 2010 examination because little things irritate him and his wife tells him he has worsened. He denied receiving any treatment or medication for his condition. The Veteran indicated that he had been told he may need medication but he wanted to avoid it. He also testified that his other physical problems affect his mood. See November 2011 transcript. At this juncture, the Board acknowledges the Veteran's assertion that when he thinks about his military experiences, to include his disabilities, he experiences mood swings and depression. The Board also acknowledges the Veteran's description of racial tension during his period of service and the loss of a lucrative football career with the National Football League as a result of being drafted into service and injuring his right leg. See January 2010 statement in support of claim; January 2010 transcript; November 2011 transcript. To the extent that the Veteran is describing events in the past that he believes contributed to his service-connected mood disorder with depressive features, the Board finds these assertions to be moot as service connection has already been established as secondary to service-connected bilateral hearing loss. The Board will consider the Veteran's complaints of mood swings and depression as a result of such thoughts/reflections and as a result of his service-connected disabilities (to include tinnitus, hearing loss, and residuals of an injury to his right leg (thigh) with right knee arthritis) in regards to his current symptomatology. It finds these assertions, as well as all other assertions related to his mental health symptomatology, to be both competent and credible. Pursuant to the General Rating Formula for Mental Disorders, a 10 percent evaluation is warranted where the disorder is manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9435 (2011). A 30 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, 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, and recent events). Id. A 50 percent evaluation is warranted when there is 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 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 evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency 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. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV). A GAF score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is assigned where there is "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 man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF of 71 to 80 is defined as if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2011). Use of terminology such as "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The evidence in this case related to the Veteran's psychiatric disorder consists primarily of VA treatment records and several VA compensation and pension (C&P) examination reports. As noted above, however, the Veteran testified that he is not receiving treatment related to this disability; therefore, the VA treatment records are scant. The Veteran underwent a VA mental disorders VA examination in February 2008, at which time he reported being married to the same woman for 37 years and having two daughters and three grandchildren. The examiner reviewed the claims folder and noted that there were extensive notes dating back to September 2006 that indicate the Veteran was experiencing depression secondary to a knee injury. The examiner noted that he considered the Veteran to be a reliable historian. The Veteran reported that he had never received any psychiatric or psychological treatment of any kind. His primary complaints consisted of severe depression and frustration, which all appear to be secondary to his chronic medical condition. The Veteran complained of severe back and leg pain, as well as pain radiating up and down the back of his legs. He reported these pains were a result of bilateral knee problems as well as a stress fracture of his hip. The Veteran also reported hearing loss in both ears. When describing his symptoms, he made it very clear that his symptoms are all totally secondary to his medical symptoms. In pertinent part, the Veteran reported experiencing severe frustration secondary to severe mobility issues and increased limitations in overall mobility, to include needing to use a reaching device to reach for items out of grasp. The Veteran noted that his hearing loss was particularly frustrating and indicated he was not able to hear the sermon in church and described situations in which he had to ask people to consistently repeat themselves in social conversation and when using the phone. Not being able to hear what people say was frustrating to the Veteran. The examiner noted that the Veteran denied any homicidal or suicidal ideation and primarily described constant and chronic frustration and depression secondary to the severe physical symptoms and severe physical limitations he was experiencing. Mental status examination revealed that the Veteran was dressed neatly and appropriately and arrived on time for his evaluation. His attitude was cooperative, motor activity was calm, and mood was appropriate to the evaluation, becoming depressed and frustrated and irritable when he described his symptoms, but otherwise appropriate to the overall evaluation. Speech was normal and there were no impairments in perception, nor any noted impairments in thought. Thought content was appropriate and the Veteran was oriented to time, place and person and appeared to have no problems with orientation or memory. Recent and remote memory, concentration skills, ability to reason and judgment all appeared intact and there were no noted problems with impulse control. The examiner noted that, in general, the Veteran's life stressors primarily indicate his daily pain and frustration with regard to hearing loss. He described many anecdotes in which he can no longer walk or ambulate to the level that he used to and stated that coping with pain was extremely upsetting. Furthermore, talking on the phone or attending social events has become a source of conflict because he can often not hear what other people are telling him. The Veteran reportedly had a full and uninterrupted work history with no noted problems. He retired in 1998. The Veteran was experiencing a full and satisfying retirement with the exception of the limitations that his pain and physical symptoms place on him. He assisted his wife with her business, which was assisting people with relocation. The Veteran reported walking regularly, reading, socializing, going to church, and being actively involved in researching his genealogy. The examiner noted that the Veteran obviously enjoyed his hobbies of genealogy and appeared to enjoy his overall life to the extent that he can given his current medical symptoms. An Axis I diagnosis of mood disorder secondary to decreased hearing, daily pain, which can become intense at times, severe limitations in ambulation and mobility, as well as the overall physical deterioration of his body, was made. A GAF score of 72 was assigned. The examiner noted that the Veteran was able to attend social activities and was not limited in socialization. He was also enjoying his retirement, though he appeared to experience moderate to severe daily symptoms as a consequence of his daily pain, daily physical limitations, as well as his limited hearing. The Veteran was seen for a mental health consult in January 2010. The Board notes that the date on which he received treatment post-dates the effective date of the 30 percent rating. The Veteran reported progressively worsening depression coinciding with deteriorating physical ailments, hearing loss, and pain. He also reported frustration at not being able to work up to his level of education over the past 17 years, at not being able to hear well in church, and at not being able to walk as well as he would like. Appetite was intact but sleep was poor. Interest and motivation were generally intact. The Veteran denied any history of mania, hypomania, psychosis, and alcohol or substance abuse. He also denied any current suicidal or homicidal ideation, a history of suicide attempts or self injury, and a history of violence or impulse control problems. The Veteran reported considerable racism in his youth as well as in service. He indicated that he had been married for 43 years and had two children and five grandchildren. Mental status examination revealed that the Veteran's behavior was appropriate during the interview. He appeared his stated age and was appropriately groomed/dressed. He was open and fully cooperative during the interview. Eye contact was fair to good and he was alert and oriented in all three spheres. Mood was depressed with mildly constricted affect appropriate to content. Rhythms and patterns of speech were unremarkable and content of speech was clear, coherent and goal-directed. There was no evidence of tangentiality or loose associations. Sleep was characterized by early morning waking and appetite was intact. There was no current suicidal or homicidal ideation or intent, the Veteran had never made an attempt at suicide, and there was no evidence of psychotic symptoms, including auditory or visual hallucinations, paranoid ideation or ideas of reference. Insight and judgment were adequate. An Axis I diagnosis of adjustment disorder with depressed mood (secondary to hearing loss and pain) was made and a GAF score of 65 was assigned. The Veteran was seen for a mental health consult in February 2010. In pertinent part he reported being married with two children, having an antique car hobby, walking and exercising for physical activity; attending church service and participating in the neighborhood association. The Veteran also indicated that in the past month, he had been bothered by repeated disturbing memories, thoughts or images of one or more of the stressful events; and had been super-alert or watchful. He also reported feeling victimized by racism in society. The Veteran denied suicidal ideation/intent and the examiner reported a moderate level of depression. His last episode of treatment had been in 2007. The examiner reported that affect was appropriate but morose; mood was appropriate but down; and thought process and cognitive functioning were intact. The examiner reported that the Veteran had been referred for treatment of depression associated with chronic pain. He reported "mood swings" since 1974. Upon examination, these "mood swings" appear to involve moments of depression alternating with anger and irritability. The Veteran explained that he had a history of dysphoria, which he discussed with a chaplain off and on while in service. He described a history of a hematoma of the right leg and arthritis of both knees with pain rated as 8/10 on a daily basis. The Veteran reported being married and living with his wife. He related a series of painful episodes due to racial segregation and racist attitudes when he first encountered fully in basic training in South Carolina and Texas. The Veteran admitted to feelings of anger and bitterness summarized by his conclusion that even with a doctorate degree, he could not obtain the opportunities and respect he was entitled to as a citizen of this country. He stressed his perception that racism had been traumatic for him as he encounters prejudice everywhere. Mental status examination revealed that he was casually dressed with appropriate clothing, though it was a bit sloppy. He was alert and oriented to time, person and place. Eye contact was piercing and penetrating. Speech was spontaneous, productive and fluent. Manner was defensive, confrontative and antagonistic for most of the interview; however, the Veteran relaxed with time and appeared cooperative at the end. Reality testing was intact, the Veteran denied any auditory or visual hallucinations, delusions or ideas of reference; thought processes were goal oriented, coherent and relevant; and the Veteran denied any suicidal or homicidal ideation or history of the same. Mood was depressed; affect was anxious/morose; judgment was fair; insight was limited; and impulse control was good. An Axis I diagnosis of chronic adjustment disorder with depressed mood was made and a GAF score of 60 was assigned. In a February 2010 mental health risk assessment screening note, the Veteran denied any current suicidal ideation and denied any previous suicide attempts. He reported insomnia but denied, did not endorse, or did not show evidence of severe emotional distress, severe anxiety, panic symptoms, hopelessness or demoralization, obsessionality, or hallucinations. The Veteran was seen for 45 minutes in March 2010 after being referred for treatment of depression associated with his chronic pain, tinnitus, hearing loss, and multiple other medical problems. He reported mood swings that appear to consist of depression alternating with anger and irritability. The Veteran appeared alert and oriented times three and was cooperative. Reality testing was intact, mood was mildly depressed, affect was consistent with mood, and there was no evidence of suicidal or homicidal ideation. The examiner noted that they discussed depressive mood due to limitations in physical activity imposed by pain and age but that they returned almost immediately to the subject of racism and its effect on his life, which appears to be an almost obsessive concern. A GAF score of 60 was assigned. See mental health note. A subsequent March 2010 mental health treatment plan note reveals an Axis I diagnosis of adjustment disorder with depressed mood and a GAF score of 60. The Veteran underwent another VA mental disorders examination in April 2010, at which time he reported being married for 44 years with two daughters, both in their 40s. The examiner noted that the Veteran was able to drive independently to his evaluation. The examiner also noted that the Veteran's symptoms appeared to have exacerbated since his last evaluation in 2008. It was noted that the Veteran had begun psychiatric treatment since then, but was not receiving psychiatric medications. In addition to reviewing the claims folder, the Veteran provided supplementary information and was considered to be a reliable informant. In pertinent part, the Veteran reported that his depression stemmed from his physical limitations, specifically his arthritis and impaired hearing. He described his arthritis as leaving him in constant pain and reported difficulty walking. He experienced increased pain whenever he engaged in nonsedentary activities and added that the pain caused problems with sleep and interfered with intimacy. The examiner noted that the Veteran did appear to be in distress as a consequence of his orthopedic pain and appeared to exhibit legitimate depressive symptoms as a direct consequence of his ongoing degenerative arthritis and chronic pain. In addition to his depressed mood related to his chronic condition, the Veteran also exhibited depression as a consequence of his significantly impaired hearing. He found it extremely difficult to engage in social conversations and found that background noise could be extremely uncomfortable due to his impaired hearing and hearing aids. He was extremely uncomfortable in shopping malls and other areas where there is a great deal of background noise and found it most difficult to attend or go shopping because the background noise was extremely disconcerting. In addition, he had difficulty on the phone because he did not have the verbal cues to lip read, making conversation even more difficult. He appeared to exhibit a legitimate mood disorder with depressive features, which was the direct result of his impaired hearing. As a consequence, the examiner found the Veteran continued to experience mood disorder with depressive features. Mental status examination revealed a Veteran who arrived on time for his scheduled appointment. He was alert, cooperative, and appropriately dressed and groomed. Motor activity was calm, mood and affect were appropriate to content of material discussed, and speech was normal. There was no evidence of perceptual impairment and no evidence of thought disorder. Thought content was appropriate to the evaluation and the Veteran denied both suicidal and homicidal ideation. The Veteran was oriented to time, place and person and memory, and concentration, abstract reasoning, judgment, impulse control, and insight all appeared to be intact. The Veteran described a stable and adequate relationship with his wife of many years. He also got along well with his two daughters and remained in contact with his remaining siblings. The Veteran reported enjoying walking to the extent that his physical limitations allow. He also enjoyed working around the house and attended church regularly with his wife. The Veteran indicated that he tried to assist older members of his church. He maintained full independence with regard to all activities of daily living. The examiner noted that the Veteran's current symptoms of mood disorder appear to have exacerbated somewhat in the two years since he was previously examined. As a consequence of his current condition, the Veteran exhibited impaired sleep and significant depressed mood, both of which are directly attributable to his orthopedic pain and impaired hearing. An Axis I diagnosis of mood disorder with depressive features secondary to his service-connected impaired hearing and degenerative arthritis was made and a GAF score of 64 was assigned. The examiner noted that the Veteran's depression would not prevent employment and that he was competent to manage his finances independently. Current functional impairments include depressed mood with impaired sleep and the effects of his diagnosis on social and occupational functioning result in impairment with occasional decreases in work efficiency and occasional difficulty in socialization as a direct consequence of his mood swings, including depressed mood with associated impaired sleep. Overall, the Veteran's symptoms have been noted to increase since his last examination as his chronic pain increases and as his hearing deteriorates. An April 2010 mental health note reveals that the Veteran was seen for 45 minutes after being referred for treatment of depression associated with his chronic pain and deteriorating medical condition. He reported mood swings that appear to involve moments of depression alternating with anger and irritability. The Veteran appeared alert and oriented times three and was cooperative. Reality testing was intact, mood was neutral and affect was within normal limits. There was no evidence of suicidal or homicidal ideation. The examiner noted that they discussed concerns about finding an occupation because of financial considerations, which was a stressful situation. The same findings were noted the following month. See May 2010 mental health note. The evidence of record does not support the assignment of an initial rating in excess of 10 percent for mood disorder with depressive features prior to January 11, 2010. The Board notes that the only evidence available for its consideration is the February 2008 VA examination, as prior to this date, the Veteran did not report any specific symptomatology in support of his assertions that he was entitled to an increased rating. At the time of that examination, the Veteran's symptoms consisted primarily of depression, frustration and irritability. The Board acknowledges the Veteran's subjective complaints of severe depression and the fact that he had been retired since 1998. Importantly, however, he reported being married to the same woman for 37 years, assisting his wife with her business, socializing, and going to church, such that it cannot be said he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In fact, the February 2008 VA examiner specifically determined that the Veteran was not limited in socialization. In addition, there was no objective evidence of anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss. Rather, the examiner noted the absence of impairments in perception, thought, impulse control, orientation or memory, and indicated that reason and judgment appeared intact and that the Veteran denied any homicidal or suicidal ideation. Moreover, the examiner assigned a GAF score of 72, which reflects his determination that the Veteran's symptoms were transient, expectable reactions to psychosocial stressors, and represented no more than a slight impairment in social and occupational functioning. In light of the evidence discussed in the preceding paragraphs, the Board finds that the severity of the Veteran's overall disability prior to January 11, 2010 more nearly approximates the already-assigned 10 percent rating. The evidence of record also does not support the assignment of a rating in excess of 30 percent for mood disorder with depressive features as of January 11, 2010. The Veteran's subjective symptoms as of this date consist primarily of depression, anger, irritability, poor sleep, and being on alert/watchful. The Board acknowledges that the Veteran does have objective evidence of impaired affect (mildly constricted, morose, anxious, consistent with mildly depressed mood) and disturbances in mood (depressed, down, depression alternating with anger and irritability). Importantly, however, the Veteran was still married to the same woman and reported having a stable and adequate relationship with her, attended church services and tried to assist the older members of his church, participated in the neighborhood association, was able to drive independently, got along well with his daughters, and remained in contact with his siblings. As such, it cannot be said he had difficulty maintaining effective social relationships. While the Board acknowledges ongoing complaints of difficulty being out socially, these complaints were related to the problems he has with his hearing and other medical problems, not his inability or unwillingness to socialize as a result of his mental disability. It also cannot be said that the Veteran is impaired in the occupational sense. This is so because while the Board acknowledges that he remains retired, the April 2010 VA examiner determined that the Veteran's psychiatric disorder would not prevent employment. In addition, the Veteran appears to have discussed trying to find a job for economic reasons during an April 2010 mental health clinic visit. In addition, there was objective evidence of normal, unremarkable, clear, coherent goal-directed, spontaneous, productive and fluent rather than circumstantial, circumlocutory, or stereotyped speech; normal, coherent, relevant and goal-directed thought processes; intact rather than impaired memory; fair, adequate and intact rather than impaired judgment; intact rather than disturbed motivation; and limited but good insight. There was no evidence of panic attacks more than once a week; difficulty understanding complex commands; and/or impaired abstract thinking. The Board points out that the Veteran did not endorse or show evidence of severe emotional distress, severe anxiety, panic symptoms, hopelessness or demoralization, obsessionality or hallucinations at any time after January 11, 2010, and that he consistently denied any homicidal or suicidal ideation. The Board also points out that the GAF scores assigned since January 11, 2010 range from 60 to 65. See April 2010 VA examination report; VA treatment records. As noted above, a GAF of 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers) and scores between 61 and 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Board acknowledges the Veteran's testimony that depression, anxiety and suspiciousness affect his daily life, an assertion his wife corroborated. In light of the evidence discussed in the preceding paragraphs, however, it finds that the severity of the Veteran's overall disability more nearly approximates the already-assigned 30 percent rating during the period beginning January 11, 2010. The Board again notes that the RO assigned the 30 percent rating as of this date based on the Veteran's competent and credible testimony. Extraschedular consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2011). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Veteran's mood disorder with depressive features symptoms cause impairment in occupational and social functioning, but such impairment is contemplated by the rating criteria and the Board finds that the rating criteria reasonably describe the Veteran's disability. Referral for consideration of an extraschedular rating is, therefore, not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). Duties to notify and assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). With regard to claims to reopen finally disallowed claims, the VA's duties require notice of the evidence needed to reopen the claim as well as the evidence to establish the underlying benefit sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). As the issue of whether new and material evidence has been submitted to reopen the claim for service connection for a skin condition of the feet has been resolved in the Veteran's favor, any error in notice required by Kent is harmless error and analysis of whether VA has satisfied its other duties to duties to notify and assist is not in order. Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence necessary to substantiate the claim and the division of responsibilities in obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran is disagreeing with the rating assigned after service connection has been granted and an initial disability rating and effective date have been assigned. Thus the service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, to include private treatment records, afforded the Veteran appropriate examinations to determine the severity of his disability, and afforded the Veteran the opportunity to give testimony before the Board and before the RO. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. ORDER The claim for service connection for a skin condition of the feet is reopened. To this extent only, the appeal is granted. An initial rating in excess of 10 percent for mood disorder with depressive features is denied prior to January 11, 2010. An initial rating in excess of 30 percent for mood disorder with depressive features is denied as of January 11, 2010. REMAND The Board finds that additional development is needed before it can adjudicate any of the remaining claims. As an initial matter, the Veteran's reopened claim for service connection for a skin condition of the feet has not been adjudicated by the AOJ in the first instance. Consequently, due process mandates that this matter be remanded. Bernard v. Brown, 4 Vet. App. 384, 394 (1993); Hickson v. Shinseki, 23 Vet. App. 394 (2010). Pursuant to 38 C.F.R. § 3.159(c)(4) , a medical examination will be provided or a medical opinion obtained if review of the evidence of record reveals that an examination or opinion is necessary for a decision to be rendered. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). On remand, the RO/AMC should schedule the Veteran for an appropriate VA examination in conjunction with his reopened claim for service connection for a skin condition of the feet. In a January 2010 letter, Dr. C reported that the Veteran had been a patient of Park Avenue Family Foot Care since 1983. In a handwritten note at the bottom of the letter, Dr. C. indicates that he was providing the records that belonged to the previous owner, Dr. M. Review of the claims folder does not reveal that these documents were obtained. On remand, the RO/AMC must make efforts to obtain the records from the previous owner of Park Avenue Family Foot Care as referenced in Dr. C's January 2010 letter. When he filed his original claim for service connection in September 1967, the Veteran reported that he was currently a member of the reserve forces of the U.S. Army. See VA Form 21-526. Review of the claims folder, however, does not reveal that any attempt has been made to verify this reported period of service in the U.S. Army Reserves. This must be accomplished on remand and is especially important given the reopened claim for service connection for a skin condition of the feet and the claim for service connection for a back disorder. The Board notes that service connection was initially granted for an injury to the right leg in a November 1967 rating decision pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5003. The RO discussed how service records showed an injury to the right lower extremity and how a current examination showed a large bony spur in the right femur with appearance suggesting result of injury, after which an orthopedist gave a diagnosis of old healed fracture of the femur. See November 1967 rating decision (emphasis added). The disability was subsequently recharacterized as residuals of an injury to the right leg (thigh) in a February 1968 rating decision and remained that way until the issuance of the rating decision that is the subject of the current appeal. In that rating decision, the RO recharacterized the disability as residuals of injury to the right leg (thigh) with arthritis of the right knee. The diagnostic criteria used to evaluate the disability remained the same. See November 2006 rating decision. On remand, the RO/AMC must explain why it is now including arthritis of the right knee with this service-connected disability. This is especially important given the fact that the Board is referring the issue of entitlement to service connection for arthritis of the bilateral legs for adjudication by the AOJ and given the fact that any disability involving the right knee can be evaluated separately from the originally service-connected disability involving the right femur. In regards to the Veteran's service-connected right leg (thigh) disability, the Board finds that a more contemporaneous and comprehensive examination is needed. A new VA examination would also help to clarify whether the Veteran's right knee disorder is part of the service-connected right leg (thigh) disability. The Board notes that an August 2003 VA examiner indicated it was, but that the examiner who conducted an October 2006 joints examination indicated that right knee pain was likely due to lumbar radiculopathy. A more contemporaneous VA examination is also needed in conjunction with the Veteran's claim for an increased rating for hemorrhoids, as the only examination of record was conducted in conjunction with an initial claim for service connection. When a Veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the Veteran's current condition, the VA's duty to assist includes providing a new examination. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). The Veteran seeks entitlement to service connection for a neurological disorder affecting the bilateral lower extremities, claimed as sciatica of the right and left legs, to include as secondary to service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee. He was noted to have radiculopathy during an October 2006 VA joints examination and a February 2008 VA spine examination, but the examiner who conducted the January 2008 VA peripheral nerves examination reported that the Veteran did not have any significant lumbar radiculopathy or sciatica symptomatology at this point and did not provide any diagnosis related to neurological complaints. This discrepancy must be addressed on remand. In order to address it, the Board finds that a more contemporaneous VA examination should be provided. See 38 C.F.R. § 3.159(c)(4) (2011); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the Court held that, relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. This was not addressed at the time of the February 2011 VA audio examination and must be accomplished on remand. In regards to the claim for entitlement to a TDIU, no opinion has been obtained as to the combined effects of all of the Veteran's service-connected disabilities on his employability. In light of the foregoing, the claim must be remanded to obtain an opinion that addresses the effect of the Veteran's service-connected disabilities on his ability to work. Friscia v. Brown, 7 Vet. App. 294 (1994). The RO/AMC is instructed to adjudicate the referred claim for service connection for arthritis of the bilateral legs and the claim to reopen to establish entitlement to service connection for a left hand condition affecting the nails and skin prior to scheduling this examination. As the claims are being remanded for the foregoing reasons, recent VA treatment records should also be obtained. Lastly, the Veteran's claim for erectile dysfunction is inextricably intertwined with his claims for service connection for a back disorder and a neurological disorder affecting the bilateral lower extremities, claimed as sciatica of the right and left legs. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated). As such, this claim is deferred pending the above development. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2011). Accordingly, the case is REMANDED for the following action: 1. Verify the dates and types of the Veteran's service in the Army Reserves from the appropriate source(s). Complete copies of the Veteran's service treatment records, to include any clinical records, and service personnel records, should also be obtained for any Reserve service. If no records can be found, indicate whether the records do not exist and whether further efforts to obtain the records would be futile. Document all efforts made in this regard. 2. Obtain the Veteran's treatment records from the Lyons VAMC, dated since August 2011. 3. Provide an explanation as to why the Veteran's right leg disability was recharacterized as residuals of injury to the right leg (thigh) with arthritis of the right knee in the November 2006 rating decision. 4. Make efforts to obtain the records from the previous owner of Park Avenue Family Foot Care as referenced in Dr. C's January 2010 letter. 5. When the foregoing development has been completed, schedule the Veteran for a VA skin examination. The claims folder should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not (that is, a probability of 50 percent or greater) that any current skin disorder of the feet had its onset during active service or is related to any in-service disease, event, or injury. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached. 6. When the foregoing development has been completed, schedule the Veteran for an appropriate VA examination to address his claims for a back disorder and a neurological disorder affecting the bilateral lower extremities, claimed as sciatica of the right and left legs. The claims folder should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner is requested to provide an opinion as to whether the Veteran has any disorder affecting the back and neurological disorder(s) affecting the bilateral lower extremities. The examiner should also provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any currently diagnosed back or neurological disorder(s) affecting the bilateral lower extremities had its onset during active service or is related to any in-service disease, event, or injury? (b) If the answer to (a) is no, is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee caused any currently diagnosed back or neurological disorder(s) affecting the bilateral lower extremities? (c) If the answers to (a) and (b) are no, is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee aggravated (i.e., caused an increase in severity of) any currently diagnosed back or neurological disorder(s) affecting the bilateral lower extremities? The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of neurological disability (i.e., a baseline) before the onset of the aggravation. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached. 7. When the foregoing development has been completed, schedule the Veteran for an appropriate VA examination to determine the nature, extent and severity of his service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee. The claims folder should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should identify all residuals attributable to the Veteran's service-connected residuals of injury to the right leg (thigh) with arthritis of the right knee. The examiner should report the range of motion measurements for the right leg/knee, in degrees. Whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during flare- ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups or when the left shoulder and/or cervical spine are used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The examiner should state whether there is any evidence of malunion of the femur and, if so, whether it results in any knee or hip disability. The examiner is specifically asked to address whether the arthritis of the right knee is part of the original service-connected disability (residuals of injury to the right leg (thigh)) or a separate disability. A comprehensive report, including complete rationales for all conclusions reached, must be provided. 8. When the foregoing development has been completed, schedule the Veteran for an appropriate VA examination to determine the nature, extent and severity of his service-connected hemorrhoids. The claims folder should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should state whether there is evidence the Veteran's hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A comprehensive report, including complete rationales for all conclusions reached, must be provided. 9. When the foregoing development has been completed, schedule the Veteran for a VA audiological examination. The claims folder should be made available to and reviewed by the examiner. Testing should be conducted to determine the current severity of the Veteran's hearing loss and should include the use of controlled speech discrimination (Maryland CNC) and a Puretone audiometry test. The examiner should fully describe the functional effects caused by the Veteran's hearing disability in the final report. A comprehensive report, including complete rationales for all conclusions reached, must be provided. 10. After adjudicating the referred claim for service connection for arthritis of the bilateral legs and the claim to reopen to establish entitlement to service connection for a left hand condition affecting the nails and skin, schedule the Veteran for an appropriate VA examination in conjunction with his claim for entitlement to a TDIU. The claims folder should be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's service-connected disabilities (bilateral hearing loss; mood disorder with depressive features; residuals of injury to the right leg (thigh) with arthritis of the right knee; tinnitus; and hemorrhoids) either singly or taken together, render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by nonservice-connected disabilities are not to be considered. The examiner must provide a comprehensive report, including complete rationales for all conclusions reached. 11. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 12. Finally, readjudicate the issues on appeal. If any of the claims remain denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the 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 or by the U.S. 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. 2011). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs