Citation Nr: 1042829 Decision Date: 11/15/10 Archive Date: 11/24/10 DOCKET NO. 00-02 170 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for bilateral cataracts, including as due to undiagnosed illness or environmental exposures. 2. Entitlement to an initial disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD), prior to March 3, 2003. 3. Entitlement to an initial disability rating in excess of 50 percent for service-connected PTSD, from March 3, 2003. 4. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Polly Murphy, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and T.B. ATTORNEY FOR THE BOARD M. Donohue, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1978 to April 1979 and from December 1990 to July 1991. He served in the Southwest Asia Theater from December 25, 1990 to June 22, 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal of October 2001 and September 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The PTSD Claim In an April 2001 decision, the Board granted the Veteran's claim of entitlement to service connection for PTSD. In the above- mentioned October 2001 rating decision, the RO implemented the Board's decision and assigned a 30 percent initial disability rating, effective from July 6, 1999. In an August 2008 decision, the Board denied entitlement to an initial evaluation in excess of 30 percent for the Veteran's service-connected PTSD prior to March 3, 2003, and awarded an initial staged 50 percent disability rating from March 3, 2003. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (the Court). While the matter was pending before the Court, in October 2009, the Veteran's attorney and a representative of VA's Office of General Counsel filed a Joint Motion for Remand. In the Joint Motion, the parties indicated that a remand was necessary "to allow [the Board] to provide an adequate statement of reasons or bases with regard to its consideration whether a higher initial rating for PTSD is warranted." See the Joint Motion, page 5. In an October 2009 order, the Court vacated the Board's August 2008 decision and remanded the matter for readjudication in light of the Joint Motion. The bilateral cataracts and TDIU claims The Veteran's claim of entitlement to service connection for bilateral cataracts was denied in the above-mentioned September 2005 rating decision. Entitlement to TDIU was denied by the RO in the October 2001 rating decision. In August 2008, the Board remanded these issues for additional evidentiary development. A supplemental statement of the case was issued in March 2010 by the VA Appeals Management Center (AMC), which continued to deny the Veteran's claims. The issues of entitlement to an initial disability rating in excess of 50 percent for PTSD, from March 3, 2003, and entitlement to TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. Motion for new hearing The Veteran appeared before the undersigned Veterans Law Judges in October 2005 and January 2008 and delivered sworn testimony in person, and via video conference, in Muskogee, Oklahoma. During the hearings, the Board members and the Veteran's attorney attempted to uncover whether additional treatment records were available. See the October 2005 hearing transcript, page 27; the January 2008 hearing transcript, pages 12, 47; see also Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board also notes that a prior Board hearing was held in July 2000 before an Acting Veterans Law Judge who is no longer with the Board, and a personal hearing was held before an RO hearing officer in May 1999. Both the May 1999 and July 2000 hearings addressed the then pending issue of entitlement to service connection for PTSD. In May 2010 the Veteran wrote to the Board requesting an "additional hearing be scheduled in light of the time which has lapsed since [the] previous hearing before the Board." A similar request was attached to a brief submitted by the Veteran's Attorney in June 2010. The Veteran and his attorney have not argued that the October 2005 and January 2008 hearings were in any way inadequate or provided any reasons why another hearing is necessary other than the passage of time. The record on appeal reveals no reason why another hearing should be conducted. The motion for another hearing is denied. FINDINGS OF FACT 1. There has been no demonstration by competent clinical, or competent and credible lay, evidence of record that the Veteran's bilateral posterior subcapsular cataracts are etiologically related to any incident of service, including exposure to ionizing radiation, or due to undiagnosed illness. 2. Prior to March 3, 2003, the Veteran's PTSD was manifested by anxiety, sleep impairment, panic attacks occurring less than once a week, suspiciousness, isolation, suicidal ideation, and a depressed mood productive of occupational and social impairment comparable to no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. Bilateral posterior subcapsular cataracts were not incurred in or aggravated by active service, nor may such be presumed. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2009). 2. The criteria for an initial evaluation in excess of 30 percent for PTSD, prior to March 3, 2003, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 9411 (2003). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In the interest of clarity, the Board will first discuss certain preliminary matters. The Board will then render a decision. Stegall concerns In August 2008, the Board remanded the issue of entitlement to service connection for bilateral cataracts in order to obtain a dose estimate of the Veteran's ionizing radiation exposure from the VA Under Secretary for Heath. The claims folder was then to be forward to the Under Secretary for Benefits for an opinion in accordance with 38 C.F.R. 3.311(c). The record reveals that a radiation dose estimate and an opinion (one document) were received from the VA Director, Radiation and Physical Exposures in March 2010. The VA also received an opinion from the VA Director of the Compensation and Pension service in March 2010. The Veteran's claim was then readjudicated in the March 2010 supplemental statement of the case (SSOC). Thus, the Board's remand instructions have been fully complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the VCAA. The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate claims for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). The VCAA alters the legal landscape in three distinct ways: standard of review, notice and duty to assist. The Board will now address these concepts within the context of the circumstances presented in this case. Standard of review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of 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. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2009). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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); 38 C.F.R. § 3.159(b) (2009); 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 agency of original jurisdiction (AOJ) decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, 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. Upon receipt of an application for "service connection," therefore, VA is required 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. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With respect to the Veteran's bilateral cataracts claim, VA issued VCAA notice letters to the Veteran in April 2005 and April 2007. These letters informed the Veteran of what evidence was required to substantiate his service connection claim and of his and VA's respective duties for obtaining evidence. The April 2007 letter also informed the Veteran as to the law pertaining to the assignment of a disability rating and effective date as the Court required in Dingess. As VCAA notice was not completed prior to the initial AOJ adjudication of the claim, such notice was not compliant with Pelegrini. However, since the case was readjudicated thereafter, there has been no prejudice to the Veteran in this regard. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). With respect to the Veteran's PTSD claim, as the October 2001 rating decision granted the Veteran's claim of entitlement to service connection, such claim is now substantiated. His filing of a notice of disagreement as to the initial rating assigned in that determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(3) (2009). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as will be discussed below. The November 2002 statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code for rating the Veteran's PTSD, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher initial rating for the service-connected disability at issue. In short, the record indicates that the Veteran received appropriate notice pursuant to the VCAA. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. An examination is deemed "necessary" if the record does not contain sufficient medical evidence for VA to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). The Board finds that reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claim, and that there is no reasonable possibility that further assistance would aid in substantiating it. In particular, the record contains the Veteran's service treatment records, service personnel records, VA outpatient medical records, private treatment records and records from the Social Security Administration. VA has also obtained a radiation dose estimate for the Veteran and a medical nexus opinion. The Board observes that the Veteran has not been accorded a VA compensation and pension examination with regard to his claim of entitlement to service connection for cataracts. However, the Board finds that the evidence of record contains sufficient competent medical evidence on file for VA to make a decision on the claim. See 38 C.F.R. § 3.159(c)(4) (2009); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the Board will discuss in detail in its analysis below, VA has obtained a medical nexus opinion from the Director of Radiation and Physical Exposures. This report reflects that the physician reviewed the Veteran's past medical history and rendered an appropriate opinion that was consistent with the remainder of the evidence of record. Supporting rationale was also provided for the opinion proffered. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board therefore concludes that the medical opinion is adequate for rating purposes. See 38 C.F.R. § 4.2 (2009). The Board has carefully reviewed the Veteran's statements and concludes that he has not identified further evidence not already of record. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim has been obtained. There is no indication in the file that there are additional relevant records that have not yet been obtained. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2009). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. He exercised the option of a personal hearing and was afforded such in October 2005 and January 2008. Accordingly, the Board will proceed to a decision. 1. Entitlement to service connection for bilateral cataracts, including as due to undiagnosed illness or environmental exposures. Relevant law and regulations Service connection - in general In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2009). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d) (2009). In order to establish service connection for the claimed disorder, there must be (1) competent and credible evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent and credible evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009), Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection - radiation exposure Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service connected in radiation-exposed veterans under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d). Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease. Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Under Combee, VA must not only determine whether a veteran had a disability recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability was otherwise the result of active service. In other words, the fact that the requirements of a presumptive regulation are not met does not in and of itself preclude a claimant from establishing service connection by way of proof of actual direct causation. A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. 38 C.F.R. § 3.309(d)(i), (ii) (2009). Diseases presumptively service connected for radiation-exposed veterans under the provisions of 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d)(2) are: leukemia (other than chronic lymphocytic leukemia), cancer of the thyroid, cancer of the breast, cancer of the pharynx, cancer of the esophagus, cancer of the stomach, cancer of the small intestine, cancer of the pancreas, multiple myeloma, lymphomas (except Hodgkin's disease), cancer of the bile ducts, cancer of the gall bladder, primary liver cancer (except if cirrhosis or hepatitis B is indicated), cancer of the salivary glands, cancer of the urinary tract; bronchiolo-alveolar carcinoma; cancer of the bone; cancer of the brain; cancer of the colon; cancer of the lung; and cancer of the ovary. 38 U.S.C.A. § 1112(c)(2); 38 C.F.R. § 3.309(d). If a claimant does not qualify as a "radiation-exposed veteran" under 38 C.F.R. § 3.309(d)(3) and/or does not suffer from one the presumptive conditions listed in 38 C.F.R. § 3.309(d)(2), the veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if the veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Under 38 C.F.R. § 3.311, "radiogenic disease" means a disease that may be induced by ionizing radiation and shall include the following: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) Thyroid cancer; (iii) Breast cancer; (iv) Lung cancer; (v) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of the rectum; (xxii) Lymphomas other than Hodgkin's disease; (xxiii) Prostate cancer; and (xxiv) Any other cancer. 38 C.F.R. § 3.311(b)(2). Section 3.311(b)(5) requires that colon cancer become manifest 5 years or more after exposure. 38 C.F.R. § 3.311(b)(5) (2009). Under the special development procedures in § 3.311(a), dose data will be requested from the Department of Defense in claims based upon participation in atmospheric nuclear testing, and claims based upon participation in the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. 38 C.F.R. § 3.311(a)(2) (2009). In all other claims, 38 C.F.R. § 3.311(a) requires that a request be made for any available records concerning the veteran's exposure to radiation. These records normally include but may not be limited to the veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service medical records, and other records which may contain information pertaining to the veteran's radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a)(2)(iii) (2009). Analysis The Veteran has alleged that his bilateral cataracts are due to an undiagnosed illness caused by his Persian Gulf service. See, e.g., a November 2007 VA Form 9. Despite the Veteran's contentions, cataracts is manifestly a diagnosed condition. Thus, any Persian Gulf theory of entitlement is untenable. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2009). The Veteran has also contended that his bilateral cataracts is a result of radiation exposure during military service. See, e.g., the January 2008 hearing, page 49. Specifically, he has stated that he was exposed to ionizing radiation when he transported equipment that had been destroyed by depleted uranium shells. See the October 2005 hearing transcript, page 25. The Veteran also contends that by transporting a tank which had a live, unexploded, depleted uranium round "sticking out of it", he was exposed to ionizing radiation. See the January 2008 hearing transcript, page 49. The Board will now address the three methods, discussed in detail above, through which service connection based upon radiation exposure may be granted [38 C.F.R. § 3.309(d) and § 3.311, and Combee]. (i.) Presumptive service connection - radiation exposure As noted above, in order to establish presumptive service connection under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d), the Veteran must currently have a disease listed in 38 C.F.R. § 3.309(d)(2), and have been a radiation-exposed veteran who participated in a radiation-risk activity as such terms are defined in the regulation. See 38 C.F.R. § 3.309(d)(3) (2009). The medical evidence of record establishes that the Veteran has been diagnosed with bilateral subcapsular cataracts. See a February 2005 VA treatment record. This is not one of the diseases specific to radiation exposed veterans listed under 38 C.F.R. § 3.309(d)(2). Thus, the presumptive service connection provisions contained in 38 C.F.R. § 3.309(d) are not applicable in this case. (ii) Radiogenic diseases under 38 C.F.R. § 3.311 The provisions of 38 C.F.R. § 3.311 provide for development of claims based on a contention of radiation exposure during active service and post-service development of a radiogenic disease. The provisions do not give rise to a presumption of service connection, but rather establish a procedure for handling claims brought by radiation exposed veterans. See Ramey v. Gober, 120 F.3d 1239, 1244 (Fed. Cir. 1997). Section 3.311 essentially states that, in all claims in which it is established that a radiogenic disease first became manifest after service, and it is contended that the disease resulted from radiation exposure, a dose assessment will be made. The Veteran has been diagnosed with posterior subcapsular cataracts. See a February 2005 VA treatment record. This is one of the radiogenic diseases as defined by 38 C.F.R. § 3.311. Furthermore, the Veteran was diagnosed with this disease during the prescribed period; six months or more after exposure. See 38 C.F.R. § 3.311(b)(5)(iii) (2009). Based on the presence of a radiogenic disease, a radiation dose estimate was obtained in February 2010. Writing for the Under Secretary for Health, V.A.C., M.D., the Director of Radiation and Physical Exposures, observed that the Veteran was exposed to depleted uranium from May 30, 1991 to June 19, 1991. See also the Veteran's DD-215. It was further observed that a study found that the "maximum likelihood dose threshold for Stage I posterior subcapsular cataracts [is] 35 rad with a 95% confidence interval of 19-66 rad. Even at the lower limit of this range[,] the threshold dose is well above the dose that the Veteran could have received" during service. Dr. V.A.C. explained that a study had found that a "driver of a fully loaded Mark 1 Abrams tank could receive as much as 0.3 microsieverts per hour." Dr. V.A.C. opined that if the Veteran were to drive his vehicle "for 10 hours a day for 20 days, this would give him a total maximum dose of 60 microsieverts, or 6 millirems during his time in Kuwait." Dr. V.A.C. noted that this dose estimate was "clearly several orders of magnitude below the threshold dose for cataracts" and the Veteran, as a recovery vehicle driver, "would of course receive even less exposure than tank drivers." As a result, Dr. V.A.C. stated that "in view of the above, it is our opinion that it is unlikely that the [V]eteran's [cataracts] can be attributed to occupational ionizing radiation exposure while in military service." Following this opinion, on March 2, 2010, the Director of VA Compensation and Pension Service reviewed the Veteran's claims folder and determined that "there is no reasonable possibility that the [V]eteran's posterior subcapsular cataracts were the result of exposure to ionizing radiation from depleted uranium from May 30, 1991 to June 19, 1991, in service." Thus, the provisions of 38 C.F.R. § 3.311 have been adhered to. The Veteran has provided no evidence to the contrary, nor has he suggested that other methods of determining the level of radiation exposure would be more accurate. In light of the above-mentioned opinions, service connection based on the procedural advantages of 38 C.F.R. § 3.311 is not warranted. (iii.) Direct service connection - Combee The Board is also obligated to consider service connection without reference to the radiation regulations, 38 C.F.R. §§ 3.309(d), 3.311. The Federal Circuit in Combee determined that the regulations governing presumptive service connection for radiation exposure do not preclude a veteran from establishing service connection with proof of actual direct causation. Accordingly, the Board will proceed to evaluate the Veteran's claim under the regulations governing direct service connection. See Combee, 34 F.3d at 1043-1044; see also 38 C.F.R. § 3.303(d) (2009). As has been discussed above, in order to establish service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in- service disease or injury and the current disability. See Hickson, supra. With respect to the first Hickson element, the evidence indicates that the Veteran has been diagnosed with posterior subcapsular cataracts. Hickson element (1) has therefore been met. With respect to the second Hickson element, the Board will separately address in-service injury and disease. Concerning in-service disease, the Veteran's service treatment records do not indicate, and the Veteran does not contend, that he suffered an eye disease during his military service. Concerning in-service injury, as is discussed above, the Veteran was exposed to ionizing radiation during service. No specific eye injuries, as such, were documented during the Veteran's military service. Nevertheless, based on the Veteran's exposure to ionizing radiation, Hickson element (2) has been satisfied. With respect to Hickson element (3), as noted above, Dr. V.A.C. determined that the Veteran's bilateral cataracts were not related to the radiation exposure that he experienced during service. Similarly, the director of VA's compensation and Pension service determined that "there is no reasonable possibility that the Veteran's posterior subcapsular cataracts were the result of" in-service exposure to ionizing radiation. There are no other competent nexus opinions of record. To the extent that the Veteran and his attorney contend that a medical relationship exists between his cataracts and his military service, any such statements offered in support of the Veteran's claim do not constitute competent medical evidence and cannot be accepted by the Board. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. The Board is cognizant that lay evidence may be sufficient to establish a nexus in some cases. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). However, the question of whether the Veteran's diagnosed cataracts is related to his in-service radiation exposure is a complex medical issue. In this case there is no evidence that the Veteran, or his representative, have the necessary medical training or experience to comment on such a matter. The Board therefore assigns little probative value to their statements. Accordingly, Hickson element (3) has not been met, and the Veteran's claim fails on this basis. Conclusion In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for bilateral cataracts, as Hickson element (3) has not been met. The benefit sought on appeal is accordingly denied. 2. Entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD, prior to March 3, 2003. Relevant law and regulations Disability ratings - in general Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2009). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Assignment of diagnostic code The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO, Diagnostic Code 9411. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 [PTSD] (2009). Diagnostic Code 9411 is deemed by the Board to be the most appropriate primarily because it pertains specifically to the diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders including PTSD are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. Specific rating criteria PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 relating to rating psychiatric disabilities read in pertinent part as follows: 100 percent - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 70 percent - 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 worklike setting); inability to establish and maintain effective relationships. 50 percent - 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; difficulty in establishing effective work and social relationships. 30 percent - 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2009). Global Assessment of Functioning Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect 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 has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect 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). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. The Court Order The October 2009 Joint Motion, as adopted by the Court's October 15, 2009 Order, stated that the Board's discussion as to whether an increased disability was warranted for PTSD did not address how the Veteran's "social/employment functioning was impaired by the symptoms he presented" but instead focused on the symptoms the Veteran "had, or did not have, and when he had them." It was noted that the Court has held that "the proper inquiry in determining a PTSD disability rating is the effect that the symptoms a Veteran experiences, regardless of whether they are listed in [38 C.F.R. § 4.130] have on social and occupational functioning. See the Joint Motion, page 8, citing Mauerhan v. Principi, 16 Vet. App. 463 (2002). The parties indicated that "upon remand, the Board should analyze not just the timing of the [Veteran's] symptoms and which symptoms are present; the Board should address the affect that those symptoms have on the [Veteran's] social and occupational functioning. The Board wishes to make it clear that it is aware of the Court's instructions in Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991), to the effect that a remand by the Court is not "merely for the purposes of rewriting the opinion so that it will superficially comply with the 'reasons or bases' requirement of 38 U.S.C.A. § 7104(d)(1). A remand is meant to entail a critical examination of the justification for the decision." The Board's analysis of the Veteran's claim of entitlement to service connection has been undertaken with that obligation in mind. Analysis The Veteran's service-connected PTSD is currently rated as 30 percent disabling from July 6, 1999 through March 2, 2003. For the reasons explained in greater detail below, the Board finds that a 50 percent or greater disability rating is not warranted at any time during this rating period. As has been discussed above, assignment of the next higher, 50 percent, disability rating requires 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; difficulty in establishing effective work and social relationships. VA outpatient treatment records from February 1999 describe the Veteran's affect as "appropriate." During the July 1999 VA examination, the Veteran was described as anxious, but it was noted that he would smile at times. Upon review, the record does not indicate that the Veteran's affect was described as flattened during the appeal period under consideration. In April 1999, Dr. R.E.A. indicated that that the Veteran "talked easy." His speech was described as "goal oriented with no flights of ideas but with an increased pace" in February 1999. There is no evidence that the Veteran displayed circumstantial, circumlocutory or stereotyped speech prior to March 3, 2003 and he does not appear to contend otherwise. The record also does not indicate that the Veteran had difficulty following complex commands. With respect to panic attacks, in April 1999, Dr. R.E.A. indicated that the Veteran was having "occasional" panic attacks. A September 2001 VA outpatient treatment record documents that the Veteran has not had any recent panic attacks. As noted above, panic attacks which occur once a week or less are described as a symptom congruent with the currently assigned 30 percent disability rating. In this case, the record does not demonstrate that the Veteran experienced panic attacks which occurred more than once a week prior to March 3, 2003. During the July 1999 VA examination, the Veteran complained of memory problems. Notwithstanding his complaints, the VA examiner stated that it was "obvious" that the Veteran was providing exaggerated responses and the clinical testing was not valid. As a result, the Veteran was diagnosed with "malingering memory problems." The record does not indicate that the Veteran's PTSD resulted in impairment of short- and long-term memory prior to March 3, 2003. The July 1999 VA examiner also observed that the Veteran was not providing correct answers when tested for impaired judgment. Specifically, it was noted that the Veteran's answers were not "consistent with appropriateness of judgment and [were] not valid." The Board observes that the Veteran's judgment is described as normal in VA outpatient treatment records. See a February 1999 treatment record. In April 1999, J.D.C., Ph.D. indicated that there was no evidence that the Veteran had a thought disorder. The same month, R.A., M.D., stated that the Veteran is able to perform abstract thinking. In this case there is no evidence that the Veteran had impaired abstract thinking prior to March 3, 2003. With respect to disturbances of mood and motivation, while the record indicates that the Veteran's PTSD symptomatology results in isolation and suspiciousness, there is no indication that this disability results in mood and motivation disturbances. For example, during the July 1999 VA examination, the Veteran reported that he hardly ever goes out anymore because he does not trust anyone, not because of mood disturbances or a lack of motivation. During a March 2002 VA examination, the Veteran indicated that after taking his children to school he does nothing other than watch TV all day because he is so tired; he did not indicate that he lacked the mood and motivation to do anything other than watch TV. While G.T., L.S.W., indicated that the Veteran does not participate in previously enjoyable activities, it was reported that he cannot stand to be around people and that he can't go to restaurants or malls. See the April 1999 report of J.D.C., Ph.D. In March 2001, the Veteran's mood was described as normal. He reported that he attempts to exercise once a week during the March 2002 VA examination. While the Board acknowledges that the Veteran has reported having a depressed mood, such symptomatology is accounted for in the currently assigned 30 percent disability rating. Furthermore, while the Veteran reported that he does not want to go to work every day in April 1999, such complaints are hardly consistent with symptoms of mood and motivation disturbances contemplated in the criteria for a 50 percent disability rating. During the May 1999 hearing, the Veteran testified that after returning from active duty, his relationship with his employer suffered and he was ultimately fired. See the May 1999 hearing transcript, page 18. It was reported that after five months of unemployment, the Veteran began to work again, however, after taking medical leave due to chest pains, he was fired in 1999 after excessive absences. See a July 1999 treatment record; see also the July 2000 hearing, page 62. The Veteran has testified that he did not seek other employment because he does not feel physically able to work because of his chest pains and headaches. See the July 2000 hearing transcript, page 28. It was also reported that he observed the 4th of July fireworks with his brother-in-law, T.B. See the July 2000 hearing transcript, page 39. In April 1999, the Veteran reported that he gets along well with his wife and children but reported that he is not nice to anybody. In March 2000, the Veteran indicated that his life has improved, he is getting along with his family better. In short, although the Veteran was fired from his first job after returning from service, the record does not indicate that he had difficulty establishing effective work and social relationships. In this regard the Board notes that even though he reported having confrontations, he was able to obtain and maintain another job until disabilities other than his PTSD resulted in his termination. Moreover, the July 2000 hearing transcript indicates that the Veteran has developed an effective social relationship with T.B. See the hearing transcript, pages 47-49. In short, as described above, not one of the nine symptoms described in the 50 percent rating have been demonstrated. A review of the evidence of record indicates that the Veteran's psychiatric symptomatology centers on his difficulty sleeping, depression, irritability, flashbacks, intrusive thoughts, and suspiciousness. As detailed in the law and regulations section above, these symptoms and their severity are more congruent with the Veteran's currently assigned 30 percent disability rating. In the October 2009 Joint Motion, the parties noted that the Board cited to Gonazales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir 2000) in the now-vacated August 2008 decision for the proposition that it need not discuss all the evidence of record. See the Joint Motion, page 6. However, it was noted that the "Court has been clear that where the record contains evidence favorable to the Veteran, the Board may not reject such evidence without discussing it." Id., emphasis as in the original. The parties then cited to specific pieces of evidence which were not addressed in the now-vacated August 2008 decision. Specifically, the Joint Motion cited to an April 1999 psycho-social assessment, created by G.T., L.S.W., and referenced by D.B., Ph.D. which reports that the Veteran experienced a panicky feeling when driving, and felt uncomfortable, nervous, and distrustful around people not in his immediate family. It was reported that such symptomatology caused difficulty at work as he often works alone but sometimes has to interact with others. The Board has carefully reviewed this evidence, however, the symptomatology described therein, anxiety, suspiciousness and hypervigilance, is congruent with the currently assigned 30 percent disability rating. Moreover, the Veteran's PTSD symptoms are not so severe that an increased disability rating is warranted. Furthermore, while G.T. reported that the Veteran's symptomatology has caused difficulty at work, such difficulty is contemplated by the currently assigned 30 percent disability rating. Indeed, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks is required for a 30 percent disability rating. The Joint Motion also noted an April 1999 report by J.D.C., Ph.D. which states that the Veteran "reports vegetative signs of depression, such as loss of energy and extreme social withdrawal, stating that he cannot stand to be around people." As discussed above, the Board has acknowledged that the Veteran's PTSD symptomatology includes isolation and depression. However, despite the characterization of his depression as "vegetative," and social withdrawal as "extreme," there is no indication that this has resulted in occupational and social impairment with reduced reliability and productivity. As alluded to above, the Veteran's isolation and depression do not prevent him from dropping his children off at school or prevent him from attending his numerous medical appointments. He maintained social relationships, including with his wife and children. In this case, the Board finds that the Veteran's symptoms of depression and social isolation result in no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In the October 2009 Joint Motion, the parties stated that "the proper inquiry in determining a PTSD disability rating is the effect that the symptoms a Veteran experiences, regardless of whether they are listed in [38 C.F.R. § 4.130] have on social and occupational functioning." It was noted that the Board's August 2008 decision "focused on the symptoms the [Veteran] had, or did not have, and when he had them. The Board acknowledges that its inquiry is not necessarily strictly limited to the criteria found in the VA rating schedule. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) [the criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating]. However, the Board has not identified any other aspects of the Veteran's service-connected PTSD which would enable it to conclude that the criteria for a higher rating have been approximated. As noted above, the Veteran has chosen not to seek employment based on medical issues other than his PTSD. See the July 2000 hearing transcript, page 28. The evidence of record prior to March 3, 2003 does not demonstrate any of the symptoms described in the criteria for a 50 percent disability rating. Furthermore, the symptoms the Veteran has demonstrated, are not significant enough to result in occupational and social impairment with reduced reliability and productivity. As discussed above, the Veteran has been able to develop and maintain social relationships and his service-connected PTSD did not prevent him from finding and maintaining employment. The Board also notes that in October 2002, the Veteran reported that his "level of functioning is fine." In April 1999, Dr. R.A.F. noted that he "gets along well with his wife and children." The Board additionally observes that the Veteran has been assigned a GAF scores ranging from 44 to 75 prior to March 3, 2003. While the Board notes that a GAF score between 41-50 is indicative of serious symptoms or serious impairment in social, occupational, or school functioning, as described above, the evidence of record prior to March 2003 does not contain evidence which would warrant a 50 percent disability rating. While acknowledging that it is not the lowest GAF score of record, a March 1999 VA treatment record which assigned a GAF score of 48, reported that the Veteran's PTSD was "moderate." A moderate impairment due to PTSD is consistent with the Veteran's currently assigned 30 percent disability rating. Moreover, the Board notes that a GAF score is only one factor for consideration. The Board has also considered the Veteran's entitlement to 70 and 100 percent disability ratings. The record indicates that the Veteran has demonstrated one of the symptoms described in the criteria for a 70 percent rating. He has reported suicidal ideation. See the July 1999 VA examination. While the Veteran has reported that he is irritable and has had outbursts of anger, there is no evidence that the Veteran's anger has resulted in periods of violence. There is also no evidence of record indicating the Veteran has obsessional rituals which interfere with routine activities, illogical speech or near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. Nor is there evidence of spatial disorientation, neglect of personal appearance and hygiene or an inability to establish and maintain effective relationships. Additionally, there is no indication of total occupational and social impairment as would be required for the 100 percent disability rating. There is no evidence of gross impairment to thought processes and communication or grossly inappropriate behavior. Nor is there a persistent danger of the Veteran hurting himself or others, a disorientation to time or place, memory loss for names of close relatives, own occupation or own name. In this capacity, the Board notes that the July 1999 VA examiner noted that the Veteran's orientation, attention and concentration responses were exaggerated and not valid. The record does not indicate that the Veteran is unable to perform activities of daily living due to his PTSD. With respect to persistent delusions or hallucinations, during the July 1999 VA examination, the Veteran reported having visual hallucinations. However, the examiner indicated that after further assessment, there were no other types of hallucinatory episodes other than the Veteran's flashbacks. While the Board is cognizant that G.T., L.S.W. documented that the Veteran reported seeing "the faint images of what he describes as being Iraqi soldiers" in April 1999, the evidence of record routinely describes the Veteran as not suffering from hallucinations or delusions. Since this April 1999 treatment report is the only evidence of record to indicate that the Veteran experiences hallucinations, persistent hallucinations or delusions have not been demonstrated. Thus, a review of the evidence indicates that symptomatology associated with the Veteran's PTSD, and the resulting functional and social impairment, most closely approximates the currently assigned 30 percent disability rating. An increased rating is therefore denied. Fenderson considerations In Fenderson v. West, 12 Vet. App. 119 (1999), the Court discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. As noted above, staged ratings are currently in effect for the Veteran's PTSD with a 30 percent disability rating assigned prior to March 3, 2003. In the instant case, the medical evidence shows that, throughout the rating period prior to March 3, 2003, the Veteran has not evidenced PTSD symptomatology warranting a disability rating other than the currently assigned 30 percent. The July 1999 VA examination report along with the numerous VA outpatient treatment records, private medical records and hearing transcripts, indicate the disability has remained relatively stable throughout the period. There have been no medical findings and no other evidence which would allow for the assignment of an increased disability rating at any time during the period of time here under consideration. Extraschedular considerations Under Floyd v. Brown, 9 Vet. App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. However, the Board can address the matter of referral of a disability to appropriate VA officials for such consideration. According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2009). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App, 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the initial inquiry posed by Thun, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service-connected PTSD. The medical evidence fails to demonstrate symptomatology of such an extent that application of the ratings schedule would not be appropriate. In fact, as discussed in detail above, the symptomatology of the Veteran's disability is specifically contemplated under the appropriate ratings criteria. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. Nevertheless, the Board will briefly note that the evidence in this case does not demonstrate any of the factors provided in the "governing norms" such as frequent hospitalization or marked interference with employment. See 38 C.F.R. § 3.321(b)(1). In this case, there is no indication that the Veteran has required frequent hospitalizations for his PTSD. With respect to employment, the evidence of record indicates that the Veteran is unemployed. See the July 1999 VA examination report. The Board notes that the fact that the Veteran is currently unemployed is not determinative. The ultimate question is whether the Veteran, because of his service-connected disability, is incapable of performing the physical and mental acts required by employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this case there is no medical evidence that the Veteran's PTSD would have caused marked interference with employment. See Van Hoose, supra [noting that the disability rating itself is recognition that industrial capabilities are impaired]. In addition, there is no evidence in the medical records of an exceptional or unusual clinical picture, or of any other reason why an extraschedular rating should be assigned. The Board therefore has determined that referral of the case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to service connection for bilateral cataracts, including as due to undiagnosed illness or environmental exposures, is denied. An initial evaluation in excess of 30 percent for PTSD, prior to March 3, 2003, is denied. (CONTINUED ON NEXT PAGE) REMAND 3. Entitlement to an initial disability rating in excess of 50 percent for service-connected PTSD, from March 3, 2003. 4. Entitlement to TDIU. After having carefully considered the Veteran's claims, and for reasons expressed immediately below, the Board finds that these matters must be remanded for additional evidentiary and procedural development. In the October 2009 Joint Motion, the parties stated that the Board did not address how the Veteran's "social/employment functioning was impaired by the symptoms he presented" but instead focused on the symptoms the Veteran "had, or did not have, and when he had them." It was noted that the Court has held that "the proper inquiry in determining a PTSD disability rating is the effect that the symptoms a Veteran experiences, regardless of whether they are listed in [38 C.F.R. § 4.130] have on social and occupational functioning. See the Joint Motion, page 8, citing Mauerhan v. Principi, 16Vet. App. 463 (2002). The evidence of record indicates that the Veteran has not been afforded a VA examination to determine the severity of his service-connected PTSD. While the Board observes that the Veteran was afforded a PTSD examination in July 1999, this examination was conducted in connection with his then pending claim of entitlement to service connection and is now more than a decade old. Following the October 2009 Joint Motion, the Veteran submitted a private psychiatric evaluation from D.O.B., Ph.D. Upon review, this evaluation describes psychiatric symptomatology which is not consistent with that described in the most recent VA outpatient treatment records. See VA outpatient treatment records dated September 2005 and September 2006. Indeed, in a November 2009 statement in support of claim, the Veteran's attorney, citing to the report from Dr. D.O.B., argued that the Veteran's functioning "has significantly deteriorated." Since the Veteran has alleged that his disability has increased in severity and that the evidence does not adequately address the current state of his service-connected disability, the Board finds that an additional examination is necessary. See Snuffer v. Gober, 10 Vet. App. 400 (1997) [a veteran is entitled to a new VA examination where there is evidence that the disability has worsened since the last examination]. The issue of entitlement to TDIU is inextricably intertwined with the Veteran's claim of entitlement to an increased rating for PTSD. In other words, if an increased disability rating is granted for this claim, it may impact the TDIU claim. Action on the Veteran's TDIU claim is therefore deferred. Accordingly, the case is REMANDED for the following action: 1. Review the claims file and ensure that all notification and development action required by the VCAA is completed. In particular, the RO should ensure that notification is provided regarding requirements and development procedures necessary to substantiate a claim for TDIU. 2. The RO should contact the Veteran and request he identify or submit any recent medical examination, hospitalization or treatment records pertaining to his PTSD. The RO should also request the Veteran's VA treatment records from March 2007 to the present. All attempts to locate and obtain these records should be documented in the Veteran's claims folder. In the event that such treatment records do not exist or copies cannot be obtained, this must be specifically documented in the claims folder. 3. The RO should then schedule the Veteran for an examination by an appropriate health care provider for the purpose of addressing the current severity of his service-connected PTSD. The Veteran's VA claims folder should be reviewed by the examiner. A report of the examination should be associated with the Veteran's VA claims folder. 4. After an appropriate period for response to the TDIU VCAA notice has been afforded, the RO should perform any and all additional development deemed necessary for adjudication of the TDIU claim. Such additional development must include a VA examination ascertaining whether the service-connected disabilities in combination preclude substantially gainful employment. 5. The RO should then readjudicate the Veteran's claims of entitlement to an increased disability rating for PTSD and entitlement to TDIU. If any benefit sought on appeal remains denied, the RO should provide the Veteran and his attorney with a supplemental statement of the case and allow an appropriate period of time for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). K. A. BANFIELD ROBERT E. SULLIVAN Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals __________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs