Citation Nr: 1030455 Decision Date: 08/13/10 Archive Date: 08/24/10 DOCKET NO. 07-02 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for hypertension, also claimed as secondary to service-connected disabilities. 2. Entitlement to service connection for hypertension, also claimed as secondary to service-connected disabilities. 3. Entitlement to service connection for a lumbar spine disability. 4. Entitlement to service connection for a thoracic spine disability. 5. Entitlement to service connection for a liver disorder, also claimed as secondary to service-connected disabilities. 6. Entitlement to service connection for posttraumatic stress disorder (PTSD). 7. Entitlement to service connection for a pulled groin. 8. Entitlement to service connection for diabetes mellitus, also claimed as secondary to service-connected disabilities. 9. Entitlement to service connection for glaucoma, also claimed as secondary to a service-connected disabilities. 10. Entitlement to service connection for cataracts, also claimed as secondary to service-connected disabilities. 11. Entitlement to service connection for renal insufficiency, also claimed as secondary to service-connected disabilities. 12. Entitlement to service connection for adrenal insufficiency, also claimed as secondary to service-connected disabilities. 13. Entitlement to service connection for erectile dysfunction, also claimed as secondary to service-connected disabilities. 14. Whether an October 2009 reduction from 50 percent to 30 percent for a psychiatric disability was proper. 15. Entitlement to a rating in excess of 50 percent for a psychiatric disorder. 16. Entitlement to an initial rating in excess of 10 percent for neuropathy of the right upper extremity. 17. Entitlement to an initial rating in excess of 10 percent for neuropathy of the left upper extremity. 18. Entitlement to a rating in excess of 50 percent for a cervical spine disability prior to June 28, 2007, and since October 1, 2007. 19. Entitlement to a rating in excess of 10 percent prior to October 23, 2008, and in excess of 70 percent since October 23, 2008, for residuals of a cerebral concussion. 20. Entitlement to automobile and adaptive equipment or for adaptive equipment only. 21. Entitlement to a special home adaptation. 22. Entitlement to specially adapted housing. REPRESENTATION Appellant represented by: Stetson University College of Law WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to March 1983. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that granted service connection and awarded 10 percent disability ratings for neuropathy of the upper extremities and denied the remaining claims. An August 2007 rating decision awarded a 100 percent rating for a cervical spine disability based on convalescence for the period from June 28, 2007, to September 30, 2007, after which time a disability rating of 50 percent was assigned. An October 2009 rating decision granted service connection for a spleen disorder (functional asplenia/splenosis with a history of leukocytosis), anemia, and a bilateral leg disability (myelopathy of the lower extremities), effective June 30, 2005; and awarded special monthly compensation based upon the need for the regular aid and attendance of another person, effective October 23, 2008. Accordingly, those issues are no longer before the Board. The October 2009 rating decision also granted an increased rating from 10 percent to 70 percent for a cerebral concussion with headaches, effective October 23, 2008. However, as that grant does not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In June 2007, the Veteran testified before the Board at a hearing held at the RO. In December 2007, the Board remanded the Veteran's claims for further development. Although VA did not consider whether service connection was warranted for hypertension as secondary to service-connected disabilities, including a spleen disorder, in the previous October 1996 denial, separate theories in support of a claim for a particular benefit are not equivalent to separate claims and a final denial on one theory is a final denial on all theories. Therefore, new and material evidence is necessary to reopen a claim for the same benefit asserted under a different theory. Robinson v. Mansfield, 21 Vet. App. 545 (2008); Roebuck v. Nicholson, 20 Vet. App. 307 (2006); Bingham v. Principi, 18 Vet. App. 470 (2004). In November 2009, the Veteran appears to have requested an extension of a temporary 100 percent rating based on surgical or other treatment necessitating convalescence beyond October 1, 2007 and entitlement to a TDIU rating. As those claims have been developed for appellate review, the Board refers them to the RO for appropriate action. The issues of entitlement to service connection for a lumbar and thoracic spine disability, a liver disorder, an acquired psychiatric disorder, a pulled groin, and renal and adrenal insufficiency; increased ratings for a psychiatric disorder, neuropathy of the upper extremities, a cervical spine disability, and residuals of a cerebral concussion; and entitlement to automobile and adaptive equipment or for adaptive equipment only, special home adaptation, and specially adapted housing are REMANDED to the Department of Veterans Affairs Regional Office. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran did not timely appeal an October 1996 rating decision that denied service connection for hypertension. 2. Evidence submitted since the October 1996 rating decision, when considered with previous evidence of the record, relates to an unestablished fact necessary to substantiate the Veteran's claim and raises a reasonable possibility of substantiating the claim. 3. It is as likely as not that the Veteran's hypertension is aggravated by his service-connected spleen disorder. 4. It is as likely as not that the Veteran's diabetes mellitus is aggravated by his service-connected spleen disorder. 5. It is as likely as not that the Veteran's glaucoma is aggravated by his service-connected spleen disorder. 6. It is as likely as not that the Veteran's cataracts are aggravated by his service-connected spleen disorder. 7. Since October 23, 2008, the Veteran's psychiatric disorder (adjustment disorder with anxiety and depression) has been manifested by panic attacks more than once a week, impairment of short-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. There has been no sustained improvement in the Veteran's psychiatric disorder since October 23, 2008. CONCLUSIONS OF LAW 1. The October 1996 rating decision that denied service connection for hypertension is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 3.160(d), 20.302, 20.1100, 20.1103 (2009). 2. New and material evidence has been received to reopen the claim for service connection for hypertension. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2009). 3. Service connection for hypertension is warranted because it is aggravated by the Veteran's service-connected spleen disorder. 38 U.S.C.A. §§ 1110, 1131, 1133, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310(a) (2009). 4. Service connection for diabetes mellitus is warranted because it is aggravated by the Veteran's service-connected spleen disorder. 38 U.S.C.A. §§ 1110, 1131, 1133, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310(a) (2009). 5. Service connection for glaucoma is warranted because it is aggravated by the Veteran's service-connected spleen disorder. 38 U.S.C.A. §§ 1110, 1131, 1133, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2009). 6. Service connection for cataracts is warranted because it is aggravated by the Veteran's service-connected spleen disorder. 38 U.S.C.A. §§ 1110, 1131, 1133, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2009). 7. Service connection for erectile dysfunction is warranted because it is aggravated by the Veteran's service-connected spleen disorder. 38 U.S.C.A. §§ 1110, 1131, 1133, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2009). 8. The October 2009 reduction of the rating for the Veteran's psychiatric disorder, from 50 percent to 30 percent disabling, effective October 23, 2008, was not proper. 38 U.S.C.A. §§ 1155, 5112(b)(6) (West 2002); 38 C.F.R. §§ 3.105(e), 3.344, 4.1, 4.10, 4.130, Diagnostic Code (DC) 9413 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS New and Material Evidence An October 1996 rating decision denied service connection for hypertension. Although the RO declined to reopen the claim in a July 2006 rating decision, the Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). If the Board finds that no such evidence has been offered, that is where the analysis must end. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 8 Vet. App. 1 (1995). A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.160(d), 20.302, 20.1103 (2009). Thus, the October 1996 rating decision became final because the appellant did not file a timely appeal. The claim for service connection may be reopened if new and material evidence is submitted. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed this application to reopen his claim in 2005. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate a claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2009). Only evidence presented since the last final denial on any basis will be considered, in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). At the time of the October 1996 rating decision, the evidence consisted of the Veteran's service medical records; VA and private medical reports; January 1994, January 1995, and September 1996 VA examinations; statements from the Veteran; and the Veteran's September 1995 personal hearing testimony. The RO denied the Veteran's claim based upon a September 1996 VA opinion that there was no relationship between the Veteran's hypertension and medication prescribed to treat his service-connected nervous condition. The evidence did not show that the Veteran's hypertension was incurred in or aggravated by his service or related to any service-connected disability. New evidence includes VA and private treatment records; records from the Social Security Administration; VA examinations; statements from the Veteran and his spouse in support of his claim; and June 2007 testimony before the Board. The new evidence also includes a March 2006 VA opinion that relates the Veteran's hypertension to his chronic use of corticosteroids prescribed to treat a service-connected spleen disorder. The Board finds that the evidence received since the last final decision is new and material evidence and raises a reasonable possibility of substantiating this claim because it addresses a previously unestablished fact, that the Veteran currently suffers from hypertension that is related to his service or an event or injury in service. That evidence is presumed credible for the purpose of determining whether it is material. Therefore, the Board finds that new and material evidence sufficient to reopen the claim has been received. New and material evidence having been submitted, the claim for service connection for hypertension is reopened, and the appeal is granted to that extent only. Service Connection A claimant with active service may be granted service connection for a disease or disability either incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2009). Service incurrence will be presumed for diabetes mellitus and hypertension if manifest to a degree of 10 percent or more within one year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2009). The disease entity for which service connection is sought must be chronic as opposed to merely acute and transitory in nature. 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 as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Where the fact of chronicity in service is not adequately supported then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2009). Service connection may be granted for any disease 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) (2009). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Mercado- Martinez v. West, 11 Vet. App. 415 (1998); Cuevas v. Principi, 3 Vet. App. 542 (1992). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible. Lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310 (2009). Secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Establishing service connection on a secondary basis essentially requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. §§ 3.303, 3.310 (2009). The record before the Board contains service medical records and post-service medical records, which will be addressed as pertinent. Dela Cruz v. Principi, 15 Vet. App. 143 (2001) (a discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence). Hypertension Based on a thorough review of the record, the Board finds that it is as likely as not the Veteran's hypertension is related to his active service. The Veteran claims that he has hypertension secondary to medication prescribed to treat his service-connected spleen disorder. The service medical records are void of findings, complaints, symptoms, or a diagnosis of hypertension. The Veteran was afforded a VA general medical examination in January 1995 at which time he was diagnosed with hypertension. On VA hypertension examination in September 1996, the Veteran contended that his hypertension was related to medication prescribed to treat a service-connected psychiatric disorder. However, the examiner opined that the Veteran's hypertension was not related to medications prescribed for treatment of his service-connected psychiatric disorder. On VA diabetes mellitus examination in March 2006, the Veteran was diagnosed with hypertension. The examiner opined that it is more likely than not that the Veteran's chronic steroid use contributed to and led to his frank diabetes and hypertension. The Veteran was afforded a VA general medical examination in March 2006, at which time he presented with a history of an in- service motor vehicle accident in December 1979 that resulted in a fractured cervical spine. At that time, the Veteran was found to have polysplenia. Since that time, the Veteran was hospitalized several times and treated for chronic leukocytosis and sepsis. The Veteran was given high-dose steroids on each hospitalization for rescue of his sepsis syndrome and was treated with tapering doses throughout the years. However, he was never weaned off of steroids and had a lot of end-organ damage from corticosteroid use including type II diabetes mellitus, hypertension, and chronic renal failure. At the time of the examination, the Veteran was receiving another tapering dose of steroids. The examiner indicated that the Veteran's recurrent septic episodes required multiple hospitalizations throughout the years and escalating doses of corticosteroids at a high dose that would have to be increased to maintain his blood pressure. The examiner opined that it is more likely than not that the Veteran's hypertension is secondary to his chronic corticosteroid use. After reviewing the evidence, the Board finds that there is a reasonable basis to relate the Veteran's current hypertension is related to his active service based on the medical evidence presented in this case, which establishes that it is at least as likely as not that some portion of the Veteran's hypertension is related to his service, and specifically to the steroids prescribed to treat his service-connected spleen disorder. The evidence shows that the spleen disorder has played an aggravating role in the hypertension. The medical evidence of record shows that the hypertension is as likely as not aggravated by the service-connected spleen disorder. Therefore, service connection for hypertension is granted. The Board has resolved all reasonable doubt in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. (1990). Diabetes Mellitus Based on a thorough review of the record, the Board finds that it is as likely as not the Veteran's diabetes mellitus is related to his active service. The service medical records are void of findings, complaints, symptoms, or a diagnosis of diabetes mellitus. On VA diabetes mellitus examination in March 2006, the Veteran presented with a history of diabetes mellitus since 1999. He was diagnosed with type II diabetes mellitus with erectile dysfunction, hypertension, and hyperlipidemia. The examiner opined that it is more likely than not that the Veteran's chronic steroid use has contributed to and led to his frank diabetes. On VA hemic disorders examination in March 2006, the Veteran was diagnosed with anemia of chronic disease secondary to multiple medical comorbidities such as adrenal insufficiency, recurring sepsis secondary to functional asplenia, and multiple admissions. The examiner opined that the Veteran also has diabetes mellitus due to long-term steroid use. After reviewing the evidence, the Board finds that there is a reasonable basis to relate the Veteran's current diabetes mellitus is related to his active service based on the medical evidence presented in this case, which establishes that it is at least as likely as not that some portion of the Veteran's diabetes mellitus is related to his service, and specifically to the steroids prescribed to treat his service-connected spleen disorder. The evidence shows that the spleen disorder has played an aggravating role in the diabetes mellitus. The medical evidence of record shows that the diabetes mellitus is as likely as not aggravated by the service-connected spleen disorder. Therefore, service connection for diabetes mellitus is granted. The Board has resolved all reasonable doubt in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. (1990). Glaucoma and Cataracts Based on a thorough review of the record, the Board finds that it is as likely as not the Veteran's glaucoma and cataracts are related to his active service. The service medical records are void of findings, complaints, symptoms, or a diagnosis of glaucoma or cataracts. On VA eye examination in March 2006, it was noted that the Veteran had a history of reactive arthritis for which he was prescribed prednisone pills. Over time, the Veteran developed secondary complications from steroid use for that condition, to include ocular complications. The examiner opined that the Veteran's open angle secondary type of glaucoma and cataracts are more likely than not secondary to steroid use. On VA diabetes mellitus examination in March 2006, the Veteran presented with a history of diabetes mellitus since 1999. It was noted that his last examination was two months ago during which there was no evidence of diabetic retinopathy, but there was evidence of glaucoma secondary to the Veteran's recurrent high steroid use. The examiner opined that it is more likely than not that the Veteran's chronic steroid use caused his glaucoma. On VA general medical examination in March 2006, the Veteran was receiving a tapering dose of steroids. The examiner indicated that the Veteran's recurrent septic episodes required multiple hospitalizations throughout the years and escalating doses of corticosteroids at a high dose that would have to be increased to maintain his blood pressure. The examiner opined that the Veteran's glaucoma is more likely than not secondary to his steroid use. After reviewing the evidence, the Board finds that there is a reasonable basis to relate the Veteran's current glaucoma and cataracts are related to his active service based on the medical evidence presented in this case, which establishes that it is at least as likely as not that some portion of the Veteran's glaucoma and cataracts are related to his service, and specifically to the steroids prescribed to treat his service- connected spleen disorder. The evidence shows that the spleen disorder has played an aggravating role in the glaucoma and cataracts. The medical evidence of record shows that the glaucoma and cataracts are as likely as not aggravated by the service-connected spleen disorder. Therefore, service connection for glaucoma and cataracts is granted. The Board has resolved all reasonable doubt in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. (1990). Erectile Dysfunction Based on a thorough review of the record, the Board finds that it is as likely as not the Veteran's erectile dysfunction is related to his active service. The service medical records are void of findings, complaints, symptoms, or a diagnosis of erectile dysfunction. On VA diabetes mellitus examination in March 2006, the Veteran presented with a history of diabetes mellitus since 1999. It was noted that he had a three year history of erectile dysfunction. The Veteran was diagnosed with type II diabetes mellitus with erectile dysfunction. The examiner opined that it is more likely than not that the Veteran's chronic steroid use contributed to his erectile dysfunction. After reviewing the evidence, the Board finds that there is a reasonable basis to relate the Veteran's current erectile dysfunction is related to his active service based on the medical evidence presented in this case, which establishes that it is at least as likely as not that some portion of the Veteran's erectile dysfunction is related to his service, and specifically to the steroids prescribed to treat his service-connected spleen disorder. The evidence shows that the spleen disorder has played an aggravating role in the erectile dysfunction. The medical evidence of record shows that the erectile dysfunction is as likely as not aggravated by the service-connected spleen disorder. Therefore, service connection for erectile dysfunction is granted. The Board has resolved all reasonable doubt in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. (1990). Reduction A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C.A. § 1155 (West 2002). Prior to reducing a veteran's disability rating, VA is required to comply with several general VA regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. Generally, when reduction in the rating of a service-connected disability is contemplated and the lower rating would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore. The beneficiary must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e) (2009). In the advance written notice, the beneficiary will be informed of his right for a pre-determination hearing, and if a timely request for such a hearing is received within 30 days, benefit payments shall be continued at the previously established level pending a final determination. 38 C.F.R. § 3.105(i)(1) (2009). Where there is no reduction in the amount of compensation payable to a beneficiary, 38 C.F.R. § 3.105(e) does not apply. VAOPGCPREC 71-91 (1991), 57 Fed. Reg. 2316 (1992). A May 1994 rating decision granted service connection and a 10 percent disability rating for adjustment disorder with anxiety and depression, effective March 31, 1994. A May 2004 rating decision increased the disability rating from 10 percent to 50 percent, effective May 30, 2003. An October 2009 rating decision reduced the disability rating from 50 percent to 30 percent, effective October 23, 2008. At the time of the October 2009 rating decision, the Veteran was in receipt of a combined disability rating of 100 percent. As a result of that decision, the Veteran's combined disability rating was continued at 100 percent. Since the October 2009 rating decision did not result in a reduction in the overall compensation payable to the Veteran, the provisions of 38 C.F.R. § 3.105(e) (2009) are not applicable. VAOPGCPREC 71-91 (1991); 57 Fed. Reg. 2316 (1992). In certain rating reduction cases, VA benefits recipients are to be afforded greater protections. 38 C.F.R. § 3.344(a)(b) (2009). Those regulations provide that rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. However, the provisions of 38 C.F.R. § 3.344(c) specify that those considerations are applicable for ratings which have continued for long periods at the same level (five years or more), and that they do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant a reduction in rating. Similar protections are afforded to veterans who have been awarded a total rating based on unemployability. 38 C.F.R. § 3.343 (2009). Under those criteria regarding reductions, the RO must find the following: (1) based on a review of the entire record, the examination forming the basis for the reduction is full and complete, and at least as full and complete as the examination upon which the rating was originally based; (2) the record clearly reflects a finding of material improvement; and (3) it is reasonably certain that the material improvement found will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a),(b) (2009); Kitchens v. Brown, 7 Vet. App. 320 (1995); Brown v. Brown, 5 Vet. App. 413 (1993). Ratings on account of diseases subject to temporary or episodic improvement, such as manic depressive or other psychotic reaction, will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. 38 C.F.R. § 3.344(a) (2009). The rules regarding stability of disability evaluations are specifically applicable to ratings which have continued for five years or more at the same level. 38 C.F.R. § 3.344(c) (2009). The 50 percent rating for the Veteran's psychiatric disorder was in effect from May 30, 2003 to October 23, 2008, over five years. Thus, the rules regarding stability of disability ratings are applicable. The Veteran's psychiatric disorder is one of those contemplated by 38 C.F.R. § 3.344(a), and that the rating therefore may not be reduced on the basis of any one examination, unless all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Brown v. Brown, 5 Vet. App. 413 (1993). The Board will now consider the propriety of the rating reduction. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4 (2009). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects the 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 (West 2002); 38 C.F.R. §§ 4.1, 4.10 (2009). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2009). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Under the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9413, a 30 percent disability rating for anxiety disorder with anxiety and depression is warranted for 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 short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational or 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); and disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130 (2009). On VA mental disorders examination in October 2003, the Veteran indicated that his depression had recently worsened after he lost his job and endorsed feelings of fatigue and a poor appetite. He had lost weight in the last several months secondary to his depression. The Veteran complained of anxiety and an occasional anxiety attack. He was currently receiving outpatient care, antidepressants, and anti-anxiety medication. The Veteran reported that he was compliant with his treatment, but had a history of missing appointments and some noncompliance with instructions. However, he experienced a slight decrease in his symptoms. On mental status examination, there was no impairment in the Veteran's thought processes or communication. He was alert and oriented to place, time, person, and situation. Eye contact seemed to be appropriate. There was no inappropriate behavior or evidence of panic attacks at that time. Impulse control was currently intact. Speech was spontaneous with a normal rate. However, his mood was described as "pretty down." Affect was constricted with a congruent mood. There was no suicidal or homicidal ideation, intent, or plan. Thought processes were logical and goal-directed. Long- and short-term memory appeared to be intact. The examiner opined that the Veteran met the criteria for major depressive disorder. The Veteran contended that he was no longer able to work, that his cognitive abilities had decreased, and that he no longer wanted to be around friends or family. The examiner suggested that the Veteran was unemployable due to his psychiatric disorder and co-morbid medical conditions. The Veteran was diagnosed with major depressive disorder, recurrent, moderate without psychotic features and was assigned a GAF score of 60. According to the American Psychiatric Association's Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition (DSM- IV), a Global Assessment of Functioning (GAF) score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing in school). A GAF of 41-50 indicates 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). A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or co- workers). A GAF score of 61 to 70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and having some meaningful interpersonal relationships. The Veteran was afforded a VA mental disorders examination in March 2006, at which time he was very depressed due to the worsening of various medical conditions. The Veteran's sleep was poor, but his appetite was fine. He denied any problems concentrating and denied any suicidal or homicidal ideation, intent, or plan. While the Veteran's energy level was poor, he denied any cognitive problems or psychotic symptoms. He was totally dependent on his wife for activities of daily living. On examination, the Veteran was casually attired with good eye contact and cooperative. His mood was mildly depressed with an affect of average range and intensity. The Veteran was not labile, but had appropriate thought content. He was alert and oriented times four. Thought processes were coherent, logical, and goal-directed. The Veteran did not display any flight of ideas or looseness of associations. He denied auditory or visual hallucinations, illusions, or delusions. The Veteran also denied any suicidal or homicidal ideation, intent, or plan. Insight and judgment were fair. The examiner opined that the Veteran still met the criteria for major depressive disorder and panic disorder with a depressed mood, anhedonia, problems with sleep, decreased energy, and problems with concentration at times. He did not report feelings of guilt. In terms of his anxiety symptoms, the Veteran reported that his anxiety had been under good control with antidepressant medication. The Veteran denied any cognitive or psychotic problems or suicidal or homicidal ideation, intent, or plan. The examiner opined that the Veteran was moderately socially and occupationally dysfunctional secondary to his psychiatric illness, but that he was employable from a psychiatric perspective. He was diagnosed with major depressive disorder, recurrent, mild, without psychotic features and panic disorder without agoraphobia. He was assigned a GAF score of 55. VA treatment records dated in July 2008 show that the Veteran denied any suicidal or homicidal ideations. He was diagnosed with major depressive disorder and panic disorder and assigned a GAF score of 65. However, in September 2008, on mental status examination the Veteran was casually dressed with good eye contact. Mood and affect were euthymic. The Veteran denied any suicidal or homicidal ideations and did not appear to respond to internal stimuli. Linear thought processes, insight, and judgment were adequate. He was assigned a GAF score of 55. In November 2008, the Veteran's speech was within normal limits. Mood and affect were euthymic. He denied suicidal and homicidal ideations and hallucinations. Insight and judgment were good. The Veteran was diagnosed with major depressive disorder, panic disorder, and alcohol dependence in full remission and assigned a GAF score of 60. In July 2009, the Veteran reported an increased depressed mood. However, he denied any thoughts of self-harm or harm to others. The Veteran also denied any increased anxiety, but reported difficulties surrounding medical issues. On mental status examination, he was casually dressed with adequate hygiene. The Veteran was calm with normal speech. Mood was euthymic with a constricted affect. Thought processes were linear and logical. The Veteran denied any suicidal or homicidal ideations and hallucinations. Insight and judgment were good. He was diagnosed with major depressive disorder, panic disorder, and alcohol dependence in full remission and was assigned a GAF score of 60. The Veteran was afforded a VA mental disorders examination in May 2009, at which time the examiner noted that the Veteran was found to be in full remission in November 2008 and was maintained on medication. On examination, speech was unremarkable and the Veteran was cooperative, friendly, relaxed, and attentive. His affect was blunted with an anxious mood. Thought processes and content were unremarkable. The Veteran indicated that he had obsessive and ritualistic behavior such as organization routines. However, he denied any homicidal or suicidal thoughts. Impulse control was good without any episodes of violence. While remote and recent memory was normal, immediate memory was mildly impaired. The examiner opined that there was no total occupational and social impairment due to mental disorder signs and symptoms and that those signs and symptoms did not result in deficiencies in areas such as judgment, thinking, family relations, work, mood, and school. However, there was reduced reliability and productivity due to symptoms of the Veteran's mental disorder. The examiner explained that the neuropsychiatric problems that affect memory and attention are moderate and impair the Veteran's ability to manipulate and retain information which therefore affects his ability to make decisions. Depression was fairly well controlled by medications, but panic attacks continued to manifest under stress and required the use of medications as needed. The Veteran was diagnosed with major depressive disorder; panic disorder; cognitive disorder, not otherwise specified; and alcohol dependence in full remission. He was assigned a GAF score of 59. The Board finds that the reduction of the Veteran's psychiatric disorder from 50 percent to 30 percent was improper. With the exception of a GAF score of 65 in July 2008, indicative of mild symptoms, the competent medical evidence shows that the Veteran's psychiatric disability ranged from GAF scores from 55 to 60, indicative of moderate symptoms, since May 30, 2003, the effective date of the Veteran's 50 percent disability rating. The competent medical evidence shows that the Veteran continues to experience panic attacks more than once a week, impairment of short-term memory, disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Veteran's psychiatric symptomatology has remained consistent since May 30, 2003. While a November 2008 VA treatment record and May 2009 VA examination indicate that the Veteran's major depressive disorder was in full remission, the Veteran's GAF scores were 59 and 60 indicative of moderate symptoms and the evidence of record does not demonstrate sustained improvement of the Veteran's psychiatric disorder, such that a reduction in the rating was proper. The Board finds that the competent medical evidence supports a rating of 50 percent for the Veteran's service-connected psychiatric disorder as the Veteran's overall symptomatology more nearly approximates the criteria for the 50 percent rating. Accordingly, the Board finds that a reduction in the 50 percent disability rating was not warranted and that the Veteran is entitled to a restoration of the 50 percent disability rating for his psychiatric disorder effective October 23, 2008. In sum the weight of the credible evidence demonstrates that the October 2009 reduction of the disability rating for a psychiatric disorder from 50 percent to 30 percent was not proper. Therefore, restoration of the 50 percent rating, effective October 23, 2008, is warranted. ORDER New and material evidence having been received, the claim for service connection for hypertension, is reopened. To that extent only, the claim is granted. Service connection for hypertension, aggravated by a service- connected spleen disorder, is granted. Service connection for diabetes mellitus, aggravated by a service-connected spleen disorder, is granted. Service connection for glaucoma, aggravated by a service- connected spleen disorder, is granted. Service connection for cataracts, aggravated by a service- connected spleen disorder, is granted. Service connection for erectile dysfunction, aggravated by a service-connected spleen disorder, is granted. The reduction of the rating for the Veteran's psychiatric disorder, effective October 23, 2008, was not proper; the Veteran is entitled to restoration of the 50 percent rating effective October 23, 2008. REMAND Additional development is needed prior to the disposition of the Veteran's claims. VA has a duty to assist claimants in the development of facts pertinent to claims and VA must accomplish additional development of the evidence if the record before it is inadequate. 38 U.S.C.A. § 5103A (West 2002). The Board regrets the additional delay that will result from this remand. Nevertheless, the Board is constrained by the fact that proper adjudication of the claims requires additional development. In June 2007, the Veteran was afforded a hearing before the Board with respect to the issues of entitlement to service connection for hypertension, automobile and adaptive equipment, a special home and adaptation grant, and specially adapted housing, and aid and attendance. In December 2007, the Board remanded the Veteran's remaining claims for service connection for a low back disability, a liver disorder, PTSD, a pulled groin, anemia, diabetes mellitus, glaucoma, cataracts, renal insufficiency, adrenal insufficiency, erectile dysfunction, and paralysis of the lower extremities; the ratings initially assigned for his neuropathy of the lower extremities; and the denial of his claims for an increased rating for his cervical spine disability, his psychiatric disorder, and the residuals of a cerebral concussion, for the issuance of a statement of the case. Subsequent to the November 2008 statement of the case, in his February 2009 substantive appeal, the Veteran requested a hearing before the Board. An October 2009 rating decision granted service connection for a spleen disorder (functional asplenia/splenosis with a history of leukocytosis), anemia, and a bilateral leg disability (myelopathy of the lower extremities), effective June 30, 2005; and awarded special monthly compensation based upon the need for the regular aid and attendance of another person, effective October 23, 2008. In addition, the Board has granted service connection for hypertension, diabetes mellitus, glaucoma, cataracts, and erectile dysfunction. Accordingly, those issues are no longer on appeal. However, the Veteran has not been afforded a hearing on the remaining claims on appeal. Accordingly, on remand the RO should schedule such a hearing. 38 U.S.C.A. § 7107 (West 2002); 38 C.F.R. §§ 19.75, 19.76, 20.703 (2009). With regard to the Veteran's claims of entitlement to automobile and adaptive equipment or for adaptive equipment only, to a special home adaptation, and to specially adapted housing, the Board finds that those claims are inextricably intertwined with the Veteran's pending claims for service connection and for increased ratings. Specifically, the Veteran's claims of entitlement to automobile and adaptive equipment or for adaptive equipment only, to a special home adaptation, and to specially adapted housing are inextricably intertwined with the claims for service connection and increased ratings, as the resolution of the Veteran's claims for service connection and increased ratings may have a bearing on the resolution of the claims for entitlement to automobile and adaptive equipment or for adaptive equipment only, to a special home adaptation, and to specially adapted housing. The appropriate remedy where a pending claim is inextricably intertwined with claim currently on appeal is to defer adjudication of the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). Expedited handling is requested. Schedule the Veteran for a travel board hearing in connection with his appeal to be held at the RO. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or United States Court of Appeals for Veterans Claims for development or other action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs