Citation Nr: 0813704 Decision Date: 04/25/08 Archive Date: 05/01/08 DOCKET NO. 06-14 101 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for tubulovillous adenoma, to include as due to herbicide (Agent Orange) exposure. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Kroes, Associate Counsel INTRODUCTION The veteran served on active duty from February 1968 to February 1970. The veteran's decorations include the Vietnam Service Medal and the Combat Infantryman Badge. This appeal to the Board of Veterans' Appeals (Board) arises February 2004 and March 2006 rating decisions. In the February 2004 rating decision, the RO granted service connection for PTSD and assigned a 30 percent disability rating, effective November 26, 2003. In January 2005, the veteran filed a notice of disagreement (NOD) with the disability rating assigned for PTSD. The RO issued a statement of the case (SOC) denying a disability rating in excess of 30 percent for PTSD in February 2006. In a March 2006 rating decision, the RO denied the veteran's claim for service connection for tubulovillous adenoma (to include as due to herbicide (Agent Orange) exposure). by the February 2004 rating decision The veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in April 2006. The veteran's April 2006 VA Form 9 was also accepted as an NOD with the March 2006 rating decision that denied the veteran's claim for service connection for tubulovillous adenoma. The RO issued an SOC on the denial of service connection for tubulovillous adenoma in July 2006, and the veteran filed a substantive appeal (via a VA Form 9) in September 2006. In July 2007, the veteran testified during a hearing before a Decision Review Officer (DRO) at the RO; a transcript of that hearing is of record. The veteran had requested a hearing before a Member of the Board; however, this request was withdrawn by his representative, at the request of the veteran, in the Statement of Accredited Representative signed by the veteran's representative in November 2007. As the appeal involves a request for a higher initial rating following the grant of service connection for PTSD, the Board has characterized this matter in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disabilities). As a final preliminary matter, the Board notes that in a July 2007 statement the veteran noted that he had tinnitus that developed while he was in Vietnam. As there is no indication in the record that this matter has yet been addressed by the RO, it is not properly before the Board; hence, it is referred to the RO for appropriate action. In that same statement, the veteran also wrote that he had a high frequency hearing loss over 30 years ago, and, "acute peripheral neuropathy - noticed muscle tremors as soon as I got home - didn't go to doctor - no insurance." The veteran was previously denied service connection for muscle tremors. If the veteran wishes to file a claim for entitlement to service connection for high frequency hearing loss or attempt to reopen his claim for service connection for muscle tremors, he should do so with specificity at the RO. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. Since the November 26, 2003 effective date of the grant of service connection, the veteran's PTSD has been manifested by flashbacks, hypervigilance, excitability, some pressured speech, guilt feelings, irritability and guarding; these symptoms are indicative of no more than occupational and social impairment with 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). 3. As the veteran served in Vietnam during the Vietnam era, he is presumed to have been exposed to herbicides (to include Agent Orange). 4. Tubulovillous adenoma is not recognized by the Secretary of VA as a disease associated with exposure to herbicides (to include Agent Orange). 5 No malignant tumor was not shown in service or manifested to any degree within one year after separation from service, and there is no s no competent evidence or opinion establishing that the veteran's tubulovillous adenoma-first diagnosed many years after service-is medically related to service. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2007). 2. The criteria for service connection for tubulovillous adenoma, to include as due to herbicide (Agent Orange) exposure, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2007)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2007). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a January 2005 pre-rating letter, the RO provided notice to the veteran regarding what information and evidence was needed to substantiate the claim for service connection for tubulovillous adenoma. This letter also informed the veteran of what information and evidence must be submitted by the veteran and what information and evidence would be obtained by VA. This letter specifically informed the veteran to submit any evidence in his possession pertinent to the claim. The March 2006 RO rating decision reflects the initial adjudication of the claims after issuance of this letter. Hence, the January 2005 letter- which meets Pelegrini's content of notice requirements-also meets the VCAA's timing of notice requirement. Regarding the claim for a higher initial rating for service- connected PTSD, the Board notes that the February 2006 SOC provided notice of the criteria for a higher rating for the disability. A February 2006 post-rating letter provided notice to the veteran regarding what information and evidence was needed to substantiate the claim for a higher initial rating for PTSD, as well as what information and evidence must be submitted by the veteran, what information and evidence would be obtained by VA, and the need for the veteran to advise VA of and to submit any further evidence that is relevant to the claim. A March 2006 letter also informed the veteran how disability ratings and effective dates are assigned and the type of evidence that impacts those determinations. After issuance of each notice described above, and opportunity for the veteran to respond, the July 2006 SOC reflects readjudication of the claim. Hence, the veteran is not shown to be prejudiced by the timing of the aforementioned notice.. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also, Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a SOC or SSOC, is sufficient to cure a timing defect). With regard to the claim for a higher initial rating for service-connected PTSD, the Board also is aware of the recent decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In Vazquez-Flores, the United States Court of Appeals for Veterans Claims (Court) found that, at a minimum, adequate VCAA notice requires that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. To the extent that these requirements apply to claims for higher initial ratings, the RO, in its February and March 2006 letters, listed examples of the types of medical and lay evidence that are relevant to establishing entitlement to increased compensation. To the extent that the RO did not otherwise comply with the Vazquez-Flores notice requirements, the veteran's written statements, including his January 2005 NOD and April 2006 VA Form 9, contain extensive discussion as to the impact of the worsening of his disability on his employment and daily life, and why ratings higher than those assigned under the VA's rating schedule were warranted. Consequently, any error in this regard was "cured by actual knowledge on the part of the claimant." See Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the veteran's service treatment records, VA and private medical records and the reports of VA contracted examinations conducted in December 2005 and August 2007 and a VA Agent Orange Examination conducted in November 2002. Also of record is the transcript of the veteran's RO hearing, as well as various written statements provided by the veteran, and by his representative, on his behalf. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the veteran has been notified and made aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error and affirming that the provision of adequate notice followed by a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Higher Rating The present appeal involves the veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2007). The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the RO assigned the veteran's initial 30 percent rating for PTSD under DC 9411. However, the actual criteria for evaluating psychiatric impairment other than eating disorders are set forth in a General Rating Formula. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 30 percent rating is assigned when there is occupational and social impairment with 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, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long and short-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing or maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as school, work, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessive rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect to personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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 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. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; 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). In his November 2003 claim for service connection for PTSD, the veteran reported that not a day had gone by since August 1969 that he had not had a memory, thought or vision of something that happened during his experience as an infantryman in the central highlands of Vietnam. After PTSD symptoms were noted at the veteran's November 2003 VA Agent Orange Examination, the veteran was afforded a VA psychiatric consultation in December 2003. At that consultation, the veteran reported that he had nightmares about his experiences in Vietnam. He denied any significant mood related problems but admitted he could get angry at times if significantly provoked. He denied suicidal or homicidal ideation or behavior. It was noted that the veteran enjoyed doing upkeep on the house and the farm and enjoyed participating in a basketball league, gambling, watching sports, and working out at a local gym. At that time the veteran had been married to his wife for 27 years and had no children. Mental status examination revealed the veteran was dressed neatly and appropriately in casual clothing. His grooming and hygiene were good. He was alert and attentive and appeared his stated age. His social interaction was engaged and spontaneous. He was fully oriented. He stated his mood was usually pretty good but could be irritable when provoked. His affect was euthymic. He demonstrated good insight and judgment. His speech was of normal rate, flow, and volume. The content of his speech was well organized with no indication of disorganized thought processes, delusions, paranoia, or hallucinations. Psychological testing suggested that he suffered moderate symptoms of depression. The Axis I diagnosis was PTSD. The GAF score assigned was 70. The veteran was afforded a VA contracted psychiatric examination in December 2005. At that examination, the veteran described having anxiety and nervousness after service. He stated that there were too many conflicts and too much pressure at his job so that he could not stand it any more and took early retirement. Mental status examination revealed the veteran remained guarded, alert and hypervigilant during the interview. Otherwise, he was able to give out information in chronological order and in much detail. He showed that he easily becomes fidgety, restless, nervous, and excitable. He showed some pressure of speech, otherwise, the verbal production was logically connected. There were some guilt feelings about how enemy bodies were treated and how the military headquarters used soldiers as decoys to attract enemy to approach and then destroyed them with planes. He had not shown any visual or auditory hallucinations, and there were no signs suggestive of delusional ideas or thought disorder. He was in good touch with reality, and there were no signs suggestive of impairment of reality testing. His affect was euthymic and his mood at that point a little low. There was a sense of guilt feeling. Otherwise, his capacity for impulse control remained intact. He denied any suicidal or homicidal ideation. Cognitive functioning examination revealed that he was alert, hypervigilant most of the time, and guarded. He easily became excitable and irritable. Otherwise, he was oriented to time, place and person. He remained attentive through the interview. He showed some pressure of speech. Otherwise, there was no memory deficit for recent or remote events. He was able to abstract and generalize well. Intellectually he functioned at about average capacity. He had little insight regarding his problem and judgment was fair. The Axis I diagnosis was PTSD, combat related, chronic. The GAF scores assigned were 50 (current) and 55 (past year). The veteran was afforded another VA contracted psychiatric examination by the same examiner in August 2007. During that examination, the veteran reported having flashback memories about events in Vietnam which triggered a lot of adrenaline and excitement. He stated that at the same time these flashback memories also triggered emotions of guilt. A lot of times the flashback memories made him somewhat hypervigilant, distrustful and guarded. He reported consuming up to two six packs a day to alleviate his anxiety, but that he does not do that all the time. He had also been getting excited behind the wheel of a vehicle and experiencing trouble sleeping at night because he was tossing, turning, and very restless. His wife described that he easily becomes short and snappy with people, does not have much patience and does not trust people. He often feels restless in front of a group and wants to get out. He and his wife had been married for 30 plus years and had no children. He reportedly did not associate with his three brothers. It was noted that since he retired, the veteran stayed home puttering on his farm. Mental status examination revealed the veteran again remained highly alert, guarded and hypervigilant during the interview. He had a hard time to sit back and relax. He reportedly remained always cunning, somewhat cynical and suspicious. He was very much aware of what was around him. Any interaction with others heightened his alertness and guardedness. He tended to be suspicious and distrustful. Otherwise, he tried to be attentive and cooperative, always wanting to remain in control. Psychomotor activity showed increase. He was on the go all the time, easily becoming excitable and fidgety. His speech was pressured. Otherwise, there was no loosening of association of ideas. He easily became opinionated and did not always concur with other people. Thought processes were logically connected. There was no loosening of association of ideas and no delusional ideas or any thought disorder. Flashback memories from his combat experience generated a lot of apprehension, excitement and guilt feeling. Each time he talked about those events he had mixed feelings. He was free from any hallucinations of the five senses. His affect was euthymic; mood on an even keel. He remained guarded, hypervigilant and irritable at times. His capacity for impulse control was somewhat compromised. He easily acted out under provocation. He denied suicidal or homicidal ideation. Cognitive functioning examination revealed he was highly alert, hypervigilant, and oriented to time, place and person. His face was always flushed and he was excitable. His memory for recent and remote events was 3/3. He was capable of doing simple calculation and used adequate fund of information and vocabulary. His IQ was about average since he is a college graduate. He had little insight regarding his problems. Judgment was fair. The Axis I diagnosis was again PTSD, combat related, chronic. The GAF scores assigned were 45 (current) and 50 (past year). In this case, the competent medical evidence collectively reflects that the veteran's PTSD has been characterized, primarily, by flashbacks, hypervigilance, excitability, some pressured speech, guilt feelings, irritability and guarding. The Board finds that these symptoms more nearly approximate occupational and social impairment with 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)-the level of impairment contemplated in the currently assigned 30 percent disability rating. At no point has the veteran's PTSD symptomatology met the criteria for a rating in excess of 30 percent. As noted above, the assignment of a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long and short-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing or maintaining effective work and social relationships. Flattened affect, panic attacks, difficulty in understanding complex commands, impairment of short-and long-term memory, impaired judgment, and impaired abstract thinking are not shown by the competent medical evidence of record. In fact, the veteran's affect has routinely been described as euthymic and his judgment as fair. At his most recent VA contracted examination his memory for recent and remote events was reported as 3/3, he was capable of doing simple calculation, and he used adequate fund of information and vocabulary. There is no competent medical evidence of record in significant conflict with these findings. The veteran has had some documented symptoms of pressured speech and disturbances of motivation and mood. Specifically, at the December 2005 examination his mood was reported as "a little low." At his December 2003 psychiatric consultation he reported that his mood was usually pretty good, but that he could be irritable when provoked. At his most recent examination his affect was reported as euthymic and his mood on an even keel. While the veteran's speech has been described as pressured, his verbal production has been noted to be logically connected. Regarding establishing and maintaining effective relationships, the veteran reported that he does not associate with his brothers and that he stays home puttering on his farm. The Board finds it significant that the veteran has been married for over 30 years. The veteran has also reported some group activities, such as a basketball league. The Board finds that when considering the veteran's pressured speech, occasional mood disturbances, his ability to establish and maintain effective relationships, and all of his other PTSD symptomatology the competent medical evidence shows a disability picture more nearly approximating occupational and social impairment with 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) than occupational and social impairment with reduced reliability and productivity. See 38 C.F.R. § 4.7. The veteran's PTSD symptoms have not been shown to affect the veteran on a continuous basis and/or to limit his ability to function independently on a daily basis. The Board notes that the GAF score of 45, reflected in the August 2007 VA contracted examination report, suggests more significant impairment than is contemplated by the initial 30 percent rating. A GAF score of 41 to 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). However, the competent medical evidence of record reflects that the veteran has exhibited none of the symptoms related to PTSD identified in the DSM-IV as indicative of such a score on a continuous basis or at the most current VA examination (where he was assigned that score). At that examination the veteran denied suicidal ideation as he had in the past. No shoplifting or obsessional rituals were noted. Regarding impairment in social functioning, the veteran reported being married to his wife for over 30 years. He did report not associating with his brothers; however, he has in the past stated that he enjoys activities such as participating in a basketball league. As to occupational functioning, the veteran is currently retired. Simply put, the PTSD symptoms and level of functioning as a result of PTSD, as shown through the competent medical evidence of record, do not suggest as significant impairment as is contemplated by the GAF score of 45 assigned at the most recent VA contracted examination. Although the veteran has shown signs of pressured speech and disturbances of motivation and mood, his general functioning, routine daily behavior, and self-care have appeared essentially normal and relevant in terms of his PTSD symptoms. The aforementioned discussion makes clear that, since the effective date of the grant of service connection for the disability, the veteran's PTSD symptomatology has resulted in a disability picture that more nearly approximates the level of occupational and social impairment contemplated for a 30 percent rating under the applicable rating criteria than any more severe level of occupational and social impairment. As the criteria for the next higher, 50 percent, rating for PTSD have not been met, it logically follows that criteria for an even higher rating (70 or 100 percent) likewise have not been met. For all the foregoing reasons, the Board finds that the initial 30 percent rating assigned for PTSD represents the maximum rating assignable since the effective date of the grant of service connection for the veteran's psychiatric disability. As such, there is no basis for staged rating, pursuant to Fenderson, and the claim for a higher initial rating must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the- doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102 (2007); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a chronic disease, such as a malignant tumor, becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of such disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1111, 1112, 1113, 1137 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.307, 3.309. After a full review of the record, including the medical evidence and statements made by the veteran, the Board finds that service connection for tubulovillous adenoma is not warranted. The veteran claims that service connection is warranted pursuant to a special presumption for residuals of exposure to herbicide agents. Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all veterans who served in Vietnam during the Vietnam Era (the period beginning on January 9, 1962, and ending on May 7, 1975). 38 U.S.C.A. § 1116(f) (West 2002 & Supp.2007); 38 C.F.R. § 3.307(a)(6)(iii) (2007). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, chronic lymphocytic leukemia (CLL), Type 2 diabetes (also known as Type 2 diabetes mellitus or adult-onset diabetes), acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue carcinomas (other than osteosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Thus, a presumption of service connection arises for a Vietnam veteran (presumed exposed to Agent Orange) who develops one of the aforementioned conditions The listed diseases do not include tubulovillous adenoma; however, the veteran asserts that tubulovillous adenoma is a soft-tissue sarcoma which is included in the listed diseases. The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated With Exposure to Certain Herbicide Agents, 67 Fed. Reg. 42,600 (June 24, 2002). Note (1) to 38 C.F.R. § 3.309(e) states that the term "soft-tissue sarcoma" includes the following: adult fibrosarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, epithelioid leiomyosarcoma (malignant leiomyoblastoma), rhabdomyosarcoma, ectomesenchymoma, angiosarcoma (hemangiosarcoma and lymphangiosarcoma) proliferating (systemic) angioendotheliomatosis, malignant glomus tumor, malignant hemangiopericytoma, synovial sarcoma (malignant synovioma), malignant giant cell tumor of tendon sheath, malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas, malignant mesenchymoma, malignant granular cell tumor, alveolar soft part sarcoma, epithelioid sarcoma, clear cell sarcoma of tendons and aponeuroses, extraskeletal Ewing's sarcoma, congenital and infantile fibrosarcoma, and malignant ganglioneuroma. As the Secretary of VA has not determined that there is a positive association between tubulovillous adenoma and exposure to herbicides, presumptive service connection based upon the veteran's presumed exposure to herbicides while serving in Vietnam is not warranted. The Board also notes the record presents no other basis for a grant of service connection in this case. The United States Court of Appeals for the Federal Circuit has held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). As such, the Board must not only determine whether the veteran had a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, but also must determine whether such disability was the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). Here, as the veteran's tubulovillous adenoma may be considered a malignant tumor, the Board has also considered the legal authority governing presumptive service connection for certain chronic diseases manifested within a prescribed period (cited to above). The service medical records reflect no complaints, findings, or diagnosis of any malignant tumors or adenomas. The Board is aware that the veteran received a Combat Infantryman Badge for his service in Vietnam, and thus is a combat veteran and entitled to the application of 38 U.S.C.A. § 1154(b) (West 2002). Section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service connected. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). Rather, it aids the combat veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Id. Section 1154(b) addresses the combat veteran's ability to allege that an event occurred in service while engaging in combat. See Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996). That section, however, does not address the questions of either current disability or nexus to service, both of which competent medical evidence is generally required. Id. citing Caluza v. Brown, 7 Vet. App. 498, 507 (1995). During the veteran's RO hearing, he stated that while in Vietnam he was exposed to Agent Orange and oil dumped on the dirt roads, and that he had to drink water that could have had parasites in it. The veteran's combat status would not allow him to allege that there is a relationship between the diagnosis of tubulovillous adenoma and exposure to oil, water, and herbicides while serving in Vietnam, as that requires a medical opinion. See Caluza, 7 Vet. App. at 507; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Thus, his statements do not establish a nexus between the current disability and service. Here, there simply is no medical evidence of any malignant tumors or adenomas for many years after service. The first diagnosis of any malignant tumor or adenoma of record was in August 2000 when a private surgical pathology report shows that rectal polyps were diagnosed as tubulovillous adenoma, with foci of carcinoma in situ / intramucosal carcinoma; this was over 30 years after separation from service. Hence, there is no basis for presumptive service for a malignant tumor. See 38 U.S.C.A. § 1101, 1111, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. , The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Further, Board also points out that the record is devoid of any medical opinion evidence to support the veteran's claim that his tubulovillous adenoma was related to service, and neither he nor his representative has presented or identified any such existing evidence that would, in fact, support the claim. In addition to the medical evidence, the Board has considered the veteran's and his representative's assertions; however, none of this evidence provides a basis for allowance of the claim. As indicated above, the claim turns on the medical matter of etiology, or medical relationship, between current disability and service-a matter within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the veteran and his representative are not shown to be other than laypersons without the appropriate medical training and expertise, neither is competent to render a probative (i.e., persuasive) opinion on a medical matter. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu, 2 Vet. App. 492. See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, the lay assertions in this regard have no probative value. Under these circumstances, the Board finds that the claim for service connection for tubulovillous adenoma, to include as due to herbicide (Agent Orange) exposure, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as no competent, probative evidence supports the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ORDER An initial rating in excess of 30 percent for PTSD is denied. Service connection for tubulovillous adenoma, to include as due to herbicide (Agent Orange) exposure, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs