Citation Nr: 0909812 Decision Date: 03/17/09 Archive Date: 03/26/09 DOCKET NO. 05-37 375 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Evaluation of post-traumatic stress disorder (PTSD), rated as 30 percent disabling prior to August 24, 2005. 3. Evaluation of PTSD, rated as 50 percent disabling from August 24, 2005. 4. Entitlement to a total rating based on unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from August 1974 to October 1977 and from November 1990 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Tx. The issues of entitlement to an evaluation in excess of 50 percent for PTSD and for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Right ear hearing loss is the result of acoustic trauma in service. 2. Left ear hearing loss is the result of acoustic trauma in service. 3. For the period prior to August 24, 2005 PTSD was manifested by sleep disturbance, nightmares, flashbacks, anxiety, irritability, anger management problems, avoidance, and intrusive memories. CONCLUSIONS OF LAW 1. Right ear hearing loss disability was incurred in wartime service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2008). 2. Left ear hearing loss disability was incurred in service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2008). 3. For the period prior to August 24, 2005, the criteria for a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.125, 4.123, 4.127, 4.129, 4.130, Diagnostic Code 9411 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2008). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2008); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. Any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), petition for cert. filed (U.S. March 21, 2008) (No. 07-1209). As held in Sanders, all notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non- prejudicial." Vazquez- Flores v. Peake, 22 Vet. App. at 46. Although not specifically discussed by the court, some other possible circumstances that could demonstrate that VA error did not prejudice the claimant include where the claimant has stated that he or she has no further evidence to submit, or where the record reflects that VA has obtained all relevant evidence. A letter dated in February 2004 explained the evidence necessary to substantiate a claim for service connection. The Veteran was asked to provide additional information on evidence he had previously identified. He was also asked to submit medical findings pertaining to his claimed disabilities. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining further relevant evidence. In August 2004 the Veteran was advised of the evidence necessary to support his claim of entitlement to service connection for PTSD. The evidence of record was listed and he was told how VA would assist him. In April 2008 the Veteran was asked for additional evidence concerning his employment. In June 2008 the Veteran was provided with the rating criteria for PTSD. He was also advised of the general manner in which VA determines disability ratings and effective dates. With respect to the timing of VCAA notice, the Board finds that any defect was harmless error. Although the notices were provided to the Veteran both before and after the initial adjudication, the Veteran has not been prejudiced thereby. The content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. Therefore, although the Veteran received inadequate preadjudicatory notice, and that error is presumed prejudicial, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that the preadjudicatory notice error did not affect the essential fairness of the adjudication now on appeal. As the Federal Circuit Court has stated, it is not required "that VCAA notification must always be contained in a single communication from the VA." Mayfield, supra, 444 F.3d at 1333. The Board observes that the Veteran is challenging the initial evaluation assigned following the grant of service connection for PTSD. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service- connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. The notice provided in August 2004 predated the grant of service connection. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In any event, the Veteran has also been advised of the specific diagnostic criteria pertaining to his service-connected PTSD. With respect to VA's duty to assist, the Board notes that VA examinations were conducted and treatment records have been associated with the claims file. The Board finds that such examinations were adequate, in that they were conducted by neutral, skilled providers who accurately recited the Veteran's history and provided in depth examinations of the claimed disabilities. The Veteran has not identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Service Connection for Bilateral Hearing Loss Disability Service connection may be granted for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be presumed for certain chronic disorders such as organic diseases of the nervous system that have manifested to a compensable degree of 10 percent or more within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Direct service connection may not be granted without evidence of a current disability, evidence of in-service incurrence or aggravation of a disease or injury, and evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)]. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Further, to establish service connection for hearing loss disability, the Veteran is not obliged to show that his hearing loss was present during active military service. However, if there is insufficient evidence to establish that a claimed chronic disability was present during service, the evidence must establish a nexus between his current disability and his in-service exposure to loud noise. See Godfrey v. Derwinski, 2 Vet. App. 352 (1992). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). Hearing conservation data recorded during the Veteran's service indicates that in July 1977, puretone thresholds were measured as follows on audiometric testing: HERTZ 1000 2000 3000 4000 Right 0 0 5 0 Left 0 0 10 0 In February 1981 the Veteran denied hearing loss. Audiometric testing was not conducted at that time. In August 1982, the Veteran again denied hearing loss. Puretone thresholds were as follows: HERTZ 1000 2000 3000 4000 Right 0 0 15 15 Left 10 5 15 20 The Veteran's hearing acuity was not measured in August 1983. He denied hearing loss. In September 1984, puretone thresholds were measured as follows: HERTZ 1000 2000 3000 4000 Right 0 -10 5 Error Left 5 0 0 30 The Veteran denied hearing loss in October 1984. In October 1986 the Veteran again denied hearing loss. He noted that his occupation was postal supervisor. His hearing acuity was not measured. The record does not contain a record of audiometric testing at the time of the Veteran's discharge from active service in 1991. However, he was noted to pass the whispered voice test. At that time, he denied hearing loss. On physical examination in February 1997, audiometric testing revealed the following puretone thresholds: HERTZ 1000 2000 3000 4000 Right 0 5 20 30 Left 10 5 20 50 On VA examination in August 2005, the Veteran reported very significant military noise exposure from various types of weapons. He noted that he used hearing protection most of the time, but ear protection was frequently not available during his service in the Gulf War. He indicated that he served just behind the front lines and had significant noise exposure from a combination of explosions and small arms fire. He denied any significant nonmilitary noise exposure. Audiometric testing revealed the following puretone thresholds: HERTZ 1000 2000 3000 4000 Right 5 10 25 45 Left 5 10 30 50 Speech recognition scores were 100 percent bilaterally. The examiner noted that his review of the service treatment records was negative for hearing loss, but also noted that audiometric testing was not performed on separation from service in 1991 at the conclusion of his deployment during the Gulf War. He pointed out that there was a 50 decibel threshold shift at 4000 Hz in the left ear on testing performed in February 1997. He indicated that thresholds in the right ear were normal for rating purposes on that date. He concluded that he would be unable to know one way or another what the level of hearing might have been in the Veteran's left ear a the conclusion of his deployment in 1991. He opined that, based on the available evidence, that it was at least as likely as not that left ear hearing loss was related to acoustic trauma during the Gulf War. He also opined that, since the Veteran had normal hearing thresholds in his right ear in 1997, the current right sided hearing loss was incurred subsequent to 1997 and that it was less likely than not that the right sided hearing loss was related to service. Having carefully reviewed the record, the Board has determined that service connection is warranted for hearing loss in the left ear. As discussed, there is evidence of acoustic trauma and the VA examiner concluded in his well reasoned opinion that it was at least as likely as not that the Veteran's left ear hearing loss was due to acoustic trauma during active service. Accordingly, service connection for left ear hearing loss disability is granted. The Board has also concluded that service connection is in order for the right ear hearing loss disability. In this regard, the Board acknowledges the Veteran's report of noise exposure during the Gulf War, without use of hearing protection. The Board observes that a VA examiner has opined that the Veteran's right ear hearing loss is not related to service. His opinion included consideration of in-service noise exposure, but also noted that the 1997 physical examination report revealed normal hearing thresholds. However, his interpretation of the 1997 evidence is legally incorrect. Although the appellant did not have disability in the right ear in 1997, his acuity was not normal at 4000 Hertz. See Hensley citation omitted. We shall not remand for clarification. Rather, we shall attached the same reasoning used for the opposite side on the right. Evaluation of PTSD prior to August 24, 2005 For the period prior to August 24, 2005 the Veteran's PTSD is evaluated as 30 percent disabling. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2008). The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (2008). The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether a staged rating is warranted. However, for the period in question the disability has not significantly changed and a uniform evaluation is warranted. 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. PTSD is evaluated pursuant 38 C.F.R. § 4.130 Diagnostic Code 9411, and is subject to the criteria listed under the General Rating Formula for Mental Disorders. The General Rating Formula provides a 10 percent evaluation for 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 (2008). The rating formula provides a 30 percent evaluation 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, and recent events). A 50 percent evaluation is warranted where 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 in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 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. 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 solely on the basis of social impairment. 38 C.F.R. § 4.126. In assessing the evidence of record, it is important to note that the GAF score 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 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 41- 50 is assigned where there are, "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)." Id. A score of 51-60 is assigned where there are 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, conflict with peers or co-workers). Id. A VA treatment record dated in September 2003 indicates that the Veteran appeared guarded. His mood was depressed. He denied suicidal and homicidal ideation or intent. His thoughts were logical and coherent. There was no evidence of psychotic processes. He was oriented and his memory was in tact. He had little insight into his depression. Impulse control was good. He reported that his family and friends had told him that he had changed since returning from the war, and that he was more irritable. The pertinent initial diagnoses were depressive disorder not otherwise specified and rule out PTSD. The provider assigned a GAF score of 51. In October 2003 the Veteran reported problems with sleep, decreased energy, difficulty concentrating, easy irritability, racing thoughts, need for less sleep, mood swings, and crying spells. In August 2004 the Veteran reported that his symptoms had not decreased and that he had nightmares and flashbacks. In September 2004 the Veteran described increasing pressure at work. The provider noted that the Veteran was a senior supervisor with the U.S. Postal Service. He noted that the stress had triggered parallel thoughts and emotions from the Gulf War when the Veteran felt on edge, trapped, and that the only recourse was to strike back. The Veteran agreed to a plan for his safety and others. In October 2004 the Veteran complained of disturbed sleep. He related that he was on sick leave from work due to excessive stress. On VA examination in January 2005, the examiner reviewed the Veteran's history. A comprehensive mental status examination was not reported. He noted that the Veteran presented with "the usually heard routine type of complaints" such as nightmares, flashbacks, sleep disturbances, and irritability. The examiner did not report any further information regarding the Veteran's cognitive functioning. The diagnoses were PTSD and depression. The examiner determined that the Veteran's GAF score was between 50 and 55. A January 2005 letter from the Veteran's treating VA psychologist indicates that the Veteran's recent history was most significant for increased arousal, with symptoms of anger including violent retaliation at work, exaggerated startle response, hyper vigilance, and sleep disturbance. He noted that the Veteran had reported intrusive Gulf War related memories, violent nightmares, avoidance of related stimuli and thoughts, and decreased interest and involvement in previously enjoyed activity. The psychiatrist concluded that the Veteran's current constellation of symptoms and risk for further exacerbation required a continuation of his medical authorized absence from work. An additional VA psychological examination was carried out in August 2005. The Veteran's history was reviewed. The Veteran reported that he had not worked since 2004. He stated that his current medications provided some relief of his anxiety and depression, but did not help with his sleep or anger problems. He reported middle insomnia and nightmares two times per week. He indicated that he startled easily. He denied flashbacks since he left his job. Objectively, the Veteran presented as calm, cooperative, and stable, but at times was somewhat anxious and hyperactive. He was articulate, verbal, coherent, and relevant. He exhibited good social skills. He was oriented and his affect was excited. His reasoning was good. There was no psychomotor slowing or agitation. Concentration was good. Sensorium was clear. The Veteran endorsed an inability to deal well with stress and indicated that he became anxious and avoided stressful situations. He indicated obsessional ideation, noting that he tended to become irritated and throw things away. He stated that he did not like to show emotion. He denied hallucinations. He stated that he had antagonism toward his supervisor at work. He endorsed past homicidal ideation but stated that he had not acted. The examiner concluded that the Veteran had a serious condition that affected his personal, social, and occupational functioning. He opined that it was as likely as not that the Veteran was unemployable. The diagnoses included PTSD and the examiner assigned a GAF score of 50. Having reviewed the evidence pertaining to this period, the Board has concluded that a 50 percent evaluation is warranted. In this regard, the Board notes that during the period in question, the Veteran reported sleep disturbance, flashbacks, nightmares, intrusive thoughts, startle response, avoidance, anxiety, severe irritability, anger control problems, and social isolation. The Veteran indicated that he had difficulty getting along with others, especially in the work place. This is reinforced by evidence that the Veteran was on a medically authorized absence from his work. Objectively, the record shows that the Veteran has experienced stress and conflict at work. He was noted to find less pleasure in previously pleasurable activities. He repeatedly reported anxiety and depression, as well as exaggerated startle response and avoidance. In essence, the record demonstrates hat the Veteran's symptoms prior to August 24, 2005 were remarkably similar to those found on the August 24, 2005 examination, which was the basis for the grant by the AOJ of a 50 percent evaluation. Accordingly, the Board finds that for the period prior to August 24, 2005, a 50 percent evaluation is appropriate. The Board notes that it will not address the issue of whether an evaluation higher than 50 percent is warranted at this time, as that issue is the subject of the remand below. ORDER Entitlement to service connection for right ear hearing loss disability is granted. Entitlement not service connection for left ear hearing loss is granted. Entitlement to an evaluation of 50 percent for PTSD, for the period prior to August 24, 2005 is granted, subject to the controlling regulations applicable to the award of monetary benefits. REMAND The Veteran seeks a higher evaluation for PTSD as well as total evaluation based on unemployability (TDIU). In an October 2008 statement he argued that although he was pursuing further education in a VA vocational rehabilitation program, he was uncertain whether such would result in employability. He noted that his schooling was stressful and had placed a strain on his marriage and social relationships. He also noted that he had taken many of his classes on line in order to avoid social contact and problems with being in public. He related that he had anxiety when faced with a deadline or assignment. The Board has concluded that a review of the Veteran's vocational rehabilitation file might provide valuable information regarding the Veteran's current employability status. Accordingly, it should be obtained for review. The August 2008 VA examiner concluded that the Veteran was not unemployable, but recommended against his working in a high stress environment that would require him to manage others. However, in an October 2008 letter, the Veteran's VA treating psychiatrist indicated that the Veteran's anxiety might inhibit his interview success, and that should he obtain a job, the Veteran might be at risk for a recurrence of acute anxiety and aggressive thoughts. He stated that the Veteran was vulnerable to break through anxiety and aggressive thoughts, particularly in evaluative work situations. He concluded that the Veteran's ability to obtain and maintain employment was more likely than not significantly reduced due to his continued PTSD and depressive symptoms, risk for further exacerbation, and potential for aggressive ideation in response to job stress. In light of this apparent conflict, the Board has determined that an additional VA examination should be conducted, and that such examination should include review of the Veteran's vocational rehabilitation file. In light of the above discussion, the Board has determined that additional development is necessary in this case. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file the Veteran's VA vocational rehabilitation records. 2. Schedule the Veteran for a VA examination by a psychiatrist to determine the extent of his PTSD. All appropriate testing should be carried out, to include an interview and a comprehensive mental status examination. The claims file and the Veteran's vocational rehabilitation records should be made available to the examiner for review. Upon review of the record and examination of the Veteran, the examiner should set forth all manifestations of the Veteran's PTSD and discuss the impact of such symptoms on the Veteran's social and occupational functioning. A Global Assessment of Functioning score should be assigned, and the examiner should explain the basis for such score. The examiner should specifically address whether the Veteran's PTSD and hearing loss renders him unable to obtain or maintain substantially gainful employment. A discussion of the complete rationale for all opinions expressed should be included in the examination report. 3. The AOJ must implement the grant of service connection for hearing loss and consider such disability in regard to the claim for TDIU. If upon completion of the above action the claim remains denied, the case should be returned after compliance with appellate procedure. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs