Citation Nr: 1521535 Decision Date: 05/20/15 Archive Date: 05/26/15 DOCKET NO. 12-15 682 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial compensable rating for bilateral hearing loss. 2. Entitlement to an initial rating in excess of 70 percent for Posttraumatic Stress Disorder (PTSD). 3. Entitlement to service connection for Hepatitis C. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Christopher Loiacono ATTORNEY FOR THE BOARD Zi-Heng Zhu, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from June 1972 to October 1973. These matters come before the Board of Veterans' Appeals (Board) from three separate rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In March 2011, the RO issued a rating decision, which, in part, granted service connection for the Veteran's claim for bilateral hearing loss and assigned a zero percent rating. In May 2011, the RO issued a separate rating decision, where it denied the Veteran's service connection claim for Hepatitis C, and granted his service connection claim for PTSD, providing a 70 percent rating from the inception of the claim. Finally, in June 2011, the RO denied the Veteran's claim for TDIU. The Veteran, through his representative, filed a notice of disagreement for all the above noted claims in November 2011, contesting the rating assigned for the granted service-connected claims of PTSD and hearing loss, and the denial of TDIU and service connection for Hepatitis C. In April 2012, the RO issued a statement of the case (SOC), which denied all appealed issues. The Veteran subsequently filed a substantive appeal (VA Form 9), and the claims are properly before the Board for appellate review. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Audiological evaluation of record reflects that the Veteran's service-connected bilateral hearing loss has been manifested by no worse than Level I hearing impairment in the right ear and no worse than Level I in the left ear. 2. The evidence of record shows that the Veteran's PTSD has been productive of severe occupational and social impairments, with deficiencies in most areas such as work, mood, thinking and relationships, due to such symptoms as depression, sleep disturbance, anxiety, flattened affect, impaired memory and focus, hypervigilance and isolation. 3. The Veteran's currently diagnosed Hepatitis C is etiologically/causally related to his active military service. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.150, 3.321, 3.385, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100 (2014). 2. The criteria for an initial rating in excess of 70 percent for his acquired psychiatric condition, to include PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.130, DC 9411. 3. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for Hepatitis C have been met. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). After the claim was received, the RO advised the claimant by letter of the elements to show entitlement to service connection for a claimed disability and informed him of his and VA's respective responsibilities in obtaining relevant records and other evidence in support of his claim. Thus, the duty to notify is satisfied. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman, 19 Vet. App. 473 (2006). VA's duty to assist under the VCAA includes helping claimants to obtain service treatment records and other pertinent records, including private medical records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, private medical records, and VA medical records. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). An adequate examination must consider the issue at hand and provide sufficient analysis for the Board to weigh that examination against others. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). However, "there is no reasons or bases requirement imposed on examiners." Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Rather, a medical opinion is adequate when it is based on consideration of the veteran's prior medical history and examinations, and the final report describes the disability in sufficient detail so that the Board's "'evaluation of the claimed disability will be a fully informed one.'"Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The Board finds that the VA examinations provided are adequate under the law. All appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2014). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. Increased Ratings - In General Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2014). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2014). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2014). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. See 38 C.F.R. § 4.2; see also Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. See Powell v. West, 13 Vet. App. 31, 34 (1999). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2 (2014). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Initial Rating - Bilateral Hearing Loss The Veteran asserts that his bilateral hearing loss is worse than that represented by his current noncompensable rating. During the pendency of this appeal, the Veteran was afforded a VA audiological examination for his hearing loss in February 2011. A review of the results of this examination, along with other relevant evidence of record reveals that the Veteran's hearing loss, at worst, does not meet the criteria for a compensable rating under VA regulations. Therefore, the Veteran's claim for a compensable rating for his service-connected bilateral hearing loss is denied, and his noncompensable rating is continued. Hearing loss is evaluated under 38 C.F.R. §§ 4.85, 4.86 (2014), Diagnostic Code 6100, Tables VI, VIA, VII of VA's rating schedule. The Rating Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. The U.S. Court of Appeals for Veterans Claims (Court) has held that the assignment of disability ratings for hearing impairment are to be derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran's service-connected hearing loss is currently assigned a noncompensable disability evaluation pursuant to 38 C.F.R. § 4.85, DC 6100. In February 2011, the Veteran was afforded a VA audiological examination. The Veteran exhibited the following puretone thresholds, in decibels: 1000Hz 2000Hz 3000Hz 4000Hz Avg. Right 10 20 30 40 25 Left 10 15 30 40 23.75 The average puretone threshold decibel loss was 25 in the right ear, and 23.75 in the left ear. Speech audiometry (Maryland CNC) revealed speech recognition ability of 96 percent in the right ear and of 100 percent in the left ear. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet.App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Applying the findings of the February 2011 VA examination to the rating criteria for hearing impairment, the Board finds that the criteria for a compensable evaluation for bilateral hearing loss have not been met. As previously noted, the Veteran's right ear manifested an average puretone threshold of 25 dB, with a 96 percent speech discrimination score, and the left ear manifested an average puretone threshold of 23.75 dB, with a 100 percent speech discrimination score in the February 2011 VA evaluation. Since the puretone tests revealed that neither ear had all four relevant categories (1000Hz, 2000Hz, 3000Hz and 4000Hz) registering above 55 dB, the Veteran's hearing acuity was measured referencing 38 C.F.R. § 4.85, Table VI. See 38 C.F.R. § 4.86(a). Under Table VI, both ears' hearing acuity was manifested by no more than Level I. The result from this examination remains below the criteria required for a compensable rating. 38 C.F.R. §§ 4.85. Table VI. Such designations equate to a noncompensable evaluation for the entire appeal period. See 38 C.F.R. § 4.85(f). As such, the probative evidence fails to demonstrate a more severe hearing loss disability than is currently contemplated by the Veteran's noncompensable disability rating. Therefore, the claim for entitlement to a compensable rating must be denied. The Board has reviewed the Veteran's VA treatment records regarding the Veteran's hearing loss. Specifically, the Board considered the January 2009 audiological examination which provided objective testing of the Veteran's hearing, providing puretone tests in the relevant categories. During that examination, the Veteran exhibited the following puretone thresholds, in decibels: 1000Hz 2000Hz 3000Hz 4000Hz Avg. Right 20 20 30 35 26.25 Left 10 10 20 30 17.5 The Board notes, however, that the results from the VA treatment record did not include a speech audiometry (Maryland CNC) testing and therefore renders the examination inadequate for VA rating purposes. See 38 C.F.R. § 4.85. However, even considering these puretone results on their own, utilizing Table VIA, the Veteran's hearing acuity in each ear still remains at a Level I, again yielding a noncompensable disability rating under VA regulations. See 38 C.F.R. § 4.85, Table VIA; see also 38 C.F.R. § 4.86(a). The Board also acknowledges that Veteran's contentions, and those of his representative, that the Veteran's condition is worse than his non-compensable rating. The Veteran, to include his representative, is competent to attest to the occurrence of lay-observable events or the presence of a disability or symptoms of a disability subject to lay observation. Jandreau, 492 F.3d 1372; see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). However, the clinical findings reported on examination are more probative than the Veteran's statements as the Veteran is not shown to have the requisite education, experience and training to determine the severity level of his service-connected bilateral hearing loss as it applies to the rating schedule. See Smith v. Derwinski, 1 Vet. App. 235, 237 (1991). The Board finds that the VA examination afforded to the Veteran more probative in establishing his specific level of hearing loss in light of the Rating Schedule. Therefore, considering the Veteran's subjective report, and weighing the probative medical evidence, the Board finds that the preponderance of all the relevant evidence is against the claim. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); 38 C.F.R. § 3.159(a)(1) and (2). In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Ratings Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's 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 Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The evidence does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the Rating Schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned noncompensable rating under the appropriate diagnostic code contemplate his level of symptomatology. Specifically, the criteria account for the Veteran's current puretone thresholds and speech recognition ability. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that, 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. See Martinak, 21 Vet. App. at 455. The February 2011 VA examiner noted that the Veteran's hearing loss was only mild and that it may cause some difficulty hearing and understanding speech. The Board finds that the Veteran's hearing difficulties are adequately contemplated by the rating schedule, as these symptoms are encompassed within the speech discrimination component of hearing loss rating. Notably, 38 C.F.R. §§ 4.85, 4.86 contemplates any functional loss due to hearing impairment. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. However, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations, or the like, for his hearing loss disability. There is no persuasive evidence in the record to indicate that the service-connected disability on appeal would, by itself, cause any impairment with employment, such as "marked interference" over and above that which is already contemplated in the assigned schedular rating. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b) (1) is not warranted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this instance, the benefit of the doubt doctrine, however, is not applicable with regard to the Veteran's claim at any time during the appeal period as the preponderance of the evidence is against a compensable rating for his service-connected bilateral hearing loss, and the claim must be denied. Initial Rating - PTSD The Veteran similarly contends that his service-connected acquired psychiatric conditions, to include PTSD and depression, are more severe than that represented by his current 70 percent rating. Specifically, the Veteran, and his representative, contends that his condition causes significant social/occupational impairments, and significant impairment to his daily living. The Veteran's condition includes isolation, sleep disturbance, depression and paranoia. However, the Board finds that the competent evidence of record reveals that the Veteran's psychiatric conditions is accurately contemplated by his current 70 percent rating, and has not arisen to the severity to cause total occupational and social impairment, as required under the next highest rating of 100 percent. Therefore, the Board finds that the Veteran's claim for a higher initial rating must be denied, and that the Veteran's initial rating of 70 percent is continued. The Veteran's PTSD is evaluated pursuant to Diagnostic Code 9411. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a general rating formula. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A rating of 100 percent is assignable 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. Id. Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The United States Court of Appeals for the Federal Circuit has acknowledged the "symptom-driven nature" of the General Rating Formula and that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit has explained that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Id. at 117. The newer DSM-V has now been officially released. However, 38 C.F.R. § 4.130 still explicitly refers instead to the DSM-IV. The regulation legally requires the Board to consider this earlier version of the DSM until such time as the regulation is changed. There is a regulation change in the works that would change the regulation to reference "the current version of the DSM." But it is unclear when that proposed change will be published. Regardless, in the meantime the Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) essentially agreed that their target date for moving to DSM-V was October 1st, coinciding with the beginning of the new fiscal year. It therefore is important to bear in mind that the regulation still explicitly refers to the DSM-IV, regardless of the fact that one may begin seeing private evidence instead referring to criteria under the succeeding DSM-V. In evaluating the evidence, the Board also considers the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally reflects that a person is functioning pretty well, and has some meaningful interpersonal relationships. Id. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals), or any serious impairment in social, occupational, or school functioning (e.g., no friends, inability to keep a job). Id. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered, but is not determinative in and of itself, of the percentage rating to be assigned. GAF scores are just one component of the Veteran's disability picture, and that it does not have a "formula" that it follows in assigning evaluations. Rather, the Board considers the Veteran's entire disability picture, including GAF scores. Under such circumstances Veterans with identical GAF scores may be assigned different evaluations based on each individual's symptomatology and level of functioning. Furthermore, the Board need not accept a GAF score as probative. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Considering the relevant evidence of record, to include, extensive VA psychiatric treatment records, lay statements, and a VA Compensation and Pension (C&P) examination, the current severity level of the Veteran's PTSD remains accurately contemplated by his 70 percent disability rating. See 38 C.F.R. § 4.130, DC 4911. The evidence shows that the Veteran's PTSD causes both occupational and social impairments, with severe symptoms such as daily sleep disturbance, anxiety, paranoia, depression and impairments in attention, focus and memory. However, there is no evidence of any symptoms such as suicidal/homicidal ideations, hallucinations or grossly inappropriate behavior or thinking. The Board finds that Veteran's disability picture does not reveal that he suffers from a total social and occupational impairment, nor is there evidence of a persistent danger of the Veteran hurting himself or others, as required by the next applicable rating. Therefore, the evidence does not warrant a higher rating of 100 percent disabling for the Veteran's psychiatric disability, and his claim for a higher rating must be denied. The Veteran was afforded a VA C&P examination for his service-connected acquired psychiatric condition in December 2010. During the examination the Veteran reported that he suffered from flashbacks, irritability, hypervigilance, problems with concentration, and sleep disturbance. The Veteran noted specifically, that he had a hard time getting along with people, and had some trouble controlling his anger. He also reported symptoms of depression such as feeling guilt, and that he had no future. Additionally, the Veteran complained of problems with concentration, memory and focus. On examination, the examiner noted that the Veteran has a difficult time with at his work. Specifically, when asked about his occupation, the Veteran expressed that he has poor relationships with his co-worker and his supervisors. The examiner noted that throughout the Veteran's employment as a maintenance person, he has had a difficult time getting along with his co-workers. Indeed, the prevailing evidence shows that the Veteran has a hard time with social situations and with other people. As the examiner further notes in his report, the Veteran feels a sense of detachment and isolation. He is not comfortable with crowds or noise, so much so that the Veteran and his wife have to go grocery shopping in the evening hours when there is no one there. The Veteran further reports that he would often rather be alone than be in social situations. Additionally, the examiner noted that the Veteran did suffer from mild memory issues and an inability to concentrate, with impaired attention and/or focus. However, the examiner did not note any symptoms of delusions or hallucinations, or signs of suicidal/homicidal ideations. Furthermore, the examiner found that the Veteran had normal judgment, appropriate thought process and good abstract thinking. The Veteran had good orientation, appropriate appearance and hygiene, and overall appropriate behavior. The December 2010 examiner finally provided an axis I diagnosis of PTSD, stating the Veteran's psychiatric symptoms caused him occupational and social impairments with deficiencies in most areas such as work, school family relations, judgement and thinking. The examiner further explained that the Veteran occasionally has trouble with daily activities, due mostly with his inability to concentrate and focus. Additionally, the examiner noted that the Veteran had few friends, did not socialize, and had few leisurely pursuits. However, the Veteran did not display any evidence of being a danger to himself or to others. Overall the examiner noted a GAF score of 44 for the Veteran's condition. The Board notes that this disability picture of the Veteran's service-connected PTSD is closer approximated by the Veteran's current 70 percent rating, and does not warrant a 100 percent rating as suggested by the Veteran. As noted above, a 100 percent rating is warranted when the Veteran's PTSD manifests with symptoms such as grossly impaired thought process, thinking and behavior, persistent delusions and hallucinations, and a manifest inability to perform the activities of daily life. See 38 C.F.R. § 4.130. Such a rating contemplates a total occupational and social impairment. The Board does not find that the medical evidence of record, to include the VA examination, describes a condition that would warrant such a rating. The Board notes that the 2010 VA examiner explicitly noted that the Veteran's PTSD caused social and occupational impairment that only resulted in deficiencies in areas such as work, thinking, school, family and judgement. As noted by the examiner, the Veteran was shown to have sound judgment, normal abstract thinking, and good orientation. The Veteran, during the examination, was noted to be appropriately dress with good personal hygiene, and reported that he could do most activities of daily living. The Veteran maintains familial relationships with his mother, children and his wife, and has at least a few friends. Finally, the Veteran has not expressed any indications of suicidal or homicidal ideations, or evidence that he is a danger to himself or to others. The Board finds that such medical evidence highly probative, as it is medically informed and apt to the inquiry at hand. Other evidence of record also supports such a finding for the Veteran's overall disability condition with regards to his PTSD. The Veteran has submitted his Social Security Administration (SSA) records regarding his application for disability through the SSA. These records include contemporaneous treatment records as well as an examination report by the SSA. A close review of these records, to include the SSA's final disability determination, shows a markedly similar disability picture as that noted by the VA examiner with regards to the Veteran's psychiatric condition. The evidence shows that the Veteran maintains familial relationships with his mother, kids, and wife, while keeping mostly to himself. The Veteran reported that he does go outside a few times a week, and goes shopping. He reported no problems with daily living, except with regards to his physical disabilities, but is able to maintain his personal hygiene and can even cook for himself. Likewise, VA treatment records preceding and subsequent to the December 2010 VA examination show similar symptomatology for the Veteran's PTSD. In fact, the VA treatment records note marked improvements in the Veteran's psychiatric condition in the years after the Veteran's VA examination. Specifically, in a June 2012 psychiatric evaluation conducted at a local VA Medical Center, the examiner noted that the Veteran slept better, was alert and oriented with improved mood. The Veteran was also noted to be doing better with is paranoia and depression. The Veteran's condition showed such marked improvement that the examiner proposed a reduction in the Veteran's medication. The Board finds that, based on all the evidence described above, the Veteran's service-connected PTSD does not warrant a 100 percent rating. While there is evidence that the Veteran has social and occupational issues and impairment due to symptoms such as irritability, isolation and detachment, the evidence of record does not show that the totality of his disability picture renders him totally impaired in those areas. Additionally, there is no evidence of record that he is a danger to himself or anyone else, and can perform his daily activities. Therefore, the Board finds that the preponderance of the evidence is against the finding that the Veteran's PTSD has risen to a severity as to warrant a 100 percent rating, and therefore the Veteran's claim for an initial rating in excess of 70 percent must be denied. Other Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the schedular criteria are adequate to rate the Veteran's service-connected PTSD. The Veteran's reported symptoms and their consequent effect are contemplated by the schedular rating criteria. His PTSD symptoms are rated based on the extent of social and occupational impairment they cause. The symptoms that are listed under the criteria applicable to DC 9411 serve as mere examples of the type and degree of the symptoms, and their effects, which would justify a particular rating, and are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). Thus, all of his symptoms are contemplated by the Rating Schedule, and were taken into consideration when assigning, herein, the 30 percent rating. Referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. As such a referral for extraschedular considerations remains unwarranted. Service Connection - Hepatitis C The Veteran claims that his diagnosed Hepatitis C was caused by incidents of his military service. The Veteran asserts that he participated in several activities during service that were high-risk factors for contracting Hepatitis C, specifically, sharing needles for intravenous drug use, having multiple sexual partners and getting a tattoo while in Singapore. The Board notes that while the evidence of record demonstrates that the Veteran's Hepatitis C was more likely than not contracted through his intravenous drug use, there is no competent evidence that the specific incident that caused the Veteran's condition was during or after his military service. Nor is there any evidence of the level of drug use the Veteran did during service as to render those actions as willful misconduct under VA regulations. Therefore, giving the Veteran the benefit of the doubt, the Board finds that his Hepatitis C is etiologically/causally related to his military service, and that his drug use during service did not amount to the level that would prohibit service connection. Accordingly, the Veteran's claim must be granted. The Board notes that the Veteran was afforded a VA C&P examination regarding the Veteran's claim for service connection for his Hepatitis C in April 2011. During the examination the Veteran initially asserted that he contracted Hepatitis C through getting a tattoo at a "sleazy" tattoo parlor in Singapore, while in service. However, the Veteran also stated that he participated in intravenous drug use of illicit drugs, where he shared needles with other people, and also had sex with various sexual partners, all during service. The April 2011 examiner, while noting these potential risk factors, concluded that the medical literature notes that the majority of people with Hepatitis C contracted it through shared needles while using illicit intravenous drugs. Therefore, the examiner concluded that it was less likely than not that the Veteran contracted his Hepatitis C as a result of his tattoo, instead it was more likely than not that it was the Veteran drug use and sharing needles that caused his condition. In the RO's May 2011 rating decision, the RO concluded that even if the Veteran contracted Hepatitis C during service through intravenous drug use, that such activity constituted willful misconduct under VA regulations, and therefore, the resulting disease or disability is not eligible for service connection. See 38 C.F.R. § 3.301(b). However, the Board notes that under 38 C.F.R. § 3.301(c)(3), the regulations stipulates that, while "progressive and frequent" drug use to the point of addiction is considered willful misconduct, that "isolated and infrequent" drug use would not constitute as willful misconduct. The Board finds that there is no evidence of record that speaks to the frequency regarding the Veteran's drug use during service. The Veteran's STR's confirms the Veteran's intravenous drug use during service, however, given the high standard of "to the point of addiction" that is required under 38 C.F.R. § 3.301(c)(3), for such action to constitute as willful misconduct, a notation in the Veteran's STR cannot be enough to justify a denial of service connection. Therefore, based on the evidence of record, and giving the Veteran the benefit of the doubt, the Board finds that his drug use during service did not constitute misconduct that precludes him from service connection. Id. The Board notes that while the VA examiner noted that the Veteran's Hepatitis C was not the result of the Veteran's tattoo, but instead was more likely than not due to his intravenous drug use, the examiner failed to provide which period of time of drug use caused his condition. The Veteran has admittedly reported that he used intravenous drugs both during his military service and for a period time after he left service. However, these distinct periods were never addressed by the examiner in his nexus opinion; the examiner simply notes that it was due to the Veteran's drug use, and sharing needles. This ambiguity as to when the Veteran contracted this condition does not rending the examiner's findings inadequate. The Board finds that to pinpoint the exact episode of drug use that caused the Veteran's Hepatitis C would involve the VA examiner to resort to mere speculation, and have no probative value in this appellate review. The Board finds that in light of this evidence and the reasons no noted above, the April 2011 VA examination is adequate in finding that the Veteran's intravenous drug use was the cause of his Hepatitis C. Consequently, applying the doctrine of benefit-of-the-doubt, the Board finds that such a condition was in-fact contracted through the Veteran's drug use during service, and the Veteran's claim for service connection must be granted. ORDER Entitlement to an initial compensable rating for service-connected bilateral hearing loss is denied. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. Entitlement to service connection for Hepatitis C is granted. REMAND The Board finds that additional evidentiary development is necessary before the Board can adjudicate the Veteran's request for TDIU. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. The Board notes that no VA opinion has been obtained by the VA with regards to the Veteran's claimed a TDIU. The record reflects that the Veteran has been unemployed since June 2010. Prior to such time, he had worked as a maintenance person for different companies. The Veteran claims that his PTSD and his other service-connected conditions are the cause of his unemployment. The Board finds that there is ample evidence in the claims file that demonstrates that the Veteran's PTSD alone may be of sufficient severity as to prevent him from obtaining gainful employment. The records show that the Veteran is currently rated 70 percent for his PTSD, which not only fulfills the threshold schedular requirement for a TDIU, but also reveals that the Veteran does suffer from impairments to his occupation. See 38 C.F.R. § 4.16(a). Indeed, as noted in the PTSD claim decided herein, the Veteran's PTSD is manifested by irritation, inability to cope with stress, untrusting of others, and an overall sense of isolation and detachment. Additionally, the Veteran has explicitly reported that the he does not get along with his co-workers or supervisors. The Board also notes that the Veteran has submitted a Psychiatric/Psychological Functional Assessment examination completed by a private treating psychologist, Dr. D.W. This brief assessment, explicitly states that the Veteran cannot obtain gainful employment because of his psychiatric condition. This evidence, however, is of little probative value since it offers no reasoning or basis for its medical assessment. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). However, it does trigger the Board's duty to obtain a proper VA opinion regarding the Veteran's service-connected disabilities and the Veteran's employability. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). The Board notes that while the Veteran's SSA records found that the Veteran's disability/ unemployability was due to his Leukemia, such finding does not preclude the fact that the disabilities that the Veteran is service-connected for cannot, alone, also be a source of his unemployment. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Therefore, a social and industrial survey/opinion is required to assess whether the Veteran's service-connected disabilities, rather alone or in concert, would render the Veteran unemployable. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a social and industrial survey for an opinion on his employability, and the effect of his service-connected disabilities on obtaining and maintaining employment. The AOJ should provide the examiner with a list of all service-connected disabilities. The examiner must include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 2. After obtaining the survey and associating it with the claims file, the RO/AMC should readjudicate the Veteran's claim for a TDIU. If the determination of the claim remain unfavorable to the Veteran, he and his representative should be furnished with a Supplemental Statement of the Case and be afforded a reasonable period of time in which to respond before the case is returned to the Board. 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 2014). ______________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs