Citation Nr: 1121041 Decision Date: 05/31/11 Archive Date: 06/06/11 DOCKET NO. 03-02 168 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to January 9, 2003. REPRESENTATION Appellant represented by: Barbara Burns Harris, Esq. ATTORNEY FOR THE BOARD K. A. Kennerly, Counsel INTRODUCTION The appellant served on active duty from November 1976 to November 1996. Clarification of the Issue on Appeal The appellant filed her initial claim of entitlement to service connection for PTSD on April 10, 1998. A rating decision dated January 3, 2000, granted entitlement to service connection for PTSD, assigning a 30 percent disability rating, effective the date of claim. The appellant maintains that she submitted a Notice of Disagreement (NOD) with the assigned 30 percent disability rating, though the claims file does not contain any record of a NOD. On January 9, 2003, the appellant filed a claim for an increased disability rating for her service-connected PTSD and entitlement to TDIU. A rating decision dated July 8, 2003, increased the appellant's disability rating for her service-connected PTSD, from 30 percent to 70 percent disabling, and granted entitlement to TDIU, both effective January 9, 2003. The appellant filed a NOD with the effective date assigned to these issues and timely perfected her appeal in June 2005. The appellant participated in an Informal Conference in October 2005 at the RO. The Informal Conference Report has been associated with the appellant's claims file. In August 2006, the Board of Veterans' Appeals (Board) remanded the aforementioned issues for additional evidentiary development. In August 2007, following appropriate development, the Board denied the appellant's claims. The appellant subsequently submitted a notice of appeal (NOA) to the United States Court of Appeals for Veterans Claims (the Court), indicating her disagreement with the denial of her claims. The Court issued an October 2009 Order vacating the August 2007 Board decision and remanding the appeal for readjudication consistent with the parties' Joint Motion for Remand (JMR). The JMR stated that the appellant's claim for an increased disability rating, following her grant of service connection for PTSD in January 2000, was pending at the time of the passage of the Veterans Claims Assistance Act of 2000 (VCAA), and that it should be readjudicated under the provisions of the VCAA. Review of the evidence of record revealed that the appellant had submitted a copy of the first page of a notice letter issued to her by the RO on September 14, 2000, noting her claim for VA service-connected disability compensation benefits for PTSD. The letter further informed the appellant of the well-grounded standard of establishing a claim. The Court found that the appellant's claim for an increased disability rating was pending since the assignment of the 30 percent disability rating in January 2000. Additionally, because the criteria for providing notice, developing evidence and deciding benefits claims were fundamentally altered by the passage of the VCAA, readjudication of the appellant's claims was warranted. Based on the October 2009 JMR, the appellant's claim of entitlement to an increased disability rating for PTSD was considered pending from the January 2000 assignment of the initial 30 percent disability rating. In March 2010, the Board denied the appellant's claims of entitlement to disability ratings for PTSD in excess of 30 percent prior to January 9, 2003, and in excess of 70 percent from January 9, 2003. The Board also found that the criteria for an effective date prior to January 9, 2003, for the award of a TDIU rating had not been met. The appellant subsequently submitted a NOA to the Court, indicating her disagreement with the denial of her claim of entitlement to a disability rating in excess of 30 percent for PTSD, prior to January 9, 2003. The Court issued an October 2010 Order vacating, in part, the March 2010 Board decision and remanded the appeal for readjudication consistent with the parties' JMR. The JMR also noted that the Board should consider whether documentation of the appellant's VA in-patient treatment at the Women's Trauma Recovery Program, from August 25, 2003, to November 7, 2003, reasonably raised a claim of entitlement to a temporary total evaluation under 38 C.F.R. § 4.29. As this issue has not yet been adjudicated by the RO, it is REFERRED back for appropriate action. The appellant submitted additional medical evidence to the Board in January 2011, consisting of a private medical opinion. In correspondence attached thereto, the appellant's representative specifically waived RO review of this newly submitted evidence. See 38 C.F.R. § 20.1304 (2010). FINDINGS OF FACT 1. Prior to January 9, 2003, the appellant's PTSD was productive of some social impairment, depressed mood, anxiety, chronic sleep impairment, and nightmares, resulting in moderate impairment. 2. The competent medical evidence does not show that prior to January 9, 2003, the appellant's service-connected PTSD was so exceptional or unusual that referral for extraschedular consideration by designated authority was required. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for PTSD, prior to January 9, 2003, have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.125, 4.126, and 4.130, Diagnostic Code 9411 (2010). 2. Application of the extraschedular rating provisions prior to January 9, 2003, is not warranted in this case. 38 C.F.R. § 3.321(b) (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the appellant's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA 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. The instant claim arises from a granted claim of service connection. The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the appellant's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C. § 5103(a) (West 2002). Compliance with the first Pelegrini II element requires notice of these five elements in initial ratings cases. See Dunlop v. Nicholson, 21 Vet. App. 112 (2006). As noted above, prior to the initial January 2000 adjudication of the appellant's service connection claim of entitlement to service connection for PTSD, the VCAA had not yet been enacted. However, the notice letters issued in February 2003, March 2006 and August 2006 fully satisfied the duty to notify provisions for the appellant's PTSD claim, including notice of the degree of disability. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2010); Quartuccio, at 187. The appellant was aware that it was ultimately her responsibility to give VA any evidence pertaining to the claim. Although these letters were not sent prior to initial adjudication of the appellant's PTSD claim, this was not prejudicial to her, since she was subsequently provided adequate notice, was provided ample time to respond with additional argument and evidence, the claim was readjudicated and additional supplemental statements of the case were provided to the appellant in January 2006 and January 2007. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). The Board also concludes VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. The appellant has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The RO provided the appellant with an appropriate VA examination in February 1999. The February 1999 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Thus, the Board finds that VA has satisfied the duty to assist the appellant. In the circumstances of this case, additional efforts to assist or notify her in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). VA has satisfied its duties to inform and assist the appellant at every stage of this case. Therefore, the Board may proceed to consider the merits of the claim. II. The Merits of the Claim In January 2000, a rating decision granted the appellant's claim of entitlement to service connection for PTSD and assigned a 30 percent disability rating, effective April 10, 1998. In July 2003, a rating decision increased the appellant's disability rating from 30 percent to 70 percent disabling, effective January 9, 2003. As discussed above, the only issue presently before the Board is the time period prior to January 9, 2003. Accordingly, the Board will address whether a disability rating in excess of 30 percent should have been granted for this time period. Governing Law and Regulations 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. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. § 4.1 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. See 38 C.F.R. § 4.7 (2010). In considering the severity of a disability, it is essential to trace the medical history of the veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2 (2010); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Since the appellant appealed the initial rating assigned for her PTSD, the entire body of evidence is for equal consideration. Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The appellant's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disorders. See 38 C.F.R. § 4.130 (2010). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. The current 30 percent disability rating for the time period prior to January 9, 2003, requires: Occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions and recent events). A 50 percent disability evaluation 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 and maintaining effective work and social relationships. A 70 percent disability evaluation requires: 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 that interfere with routine activities; speech that is 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 inability to establish and maintain effective relationships. A 100 percent disability evaluation requires: Total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996) citing DSM-IV. Rating agencies are charged with the responsibility of being thoroughly familiar with DSM-IV in order to apply the general rating criteria for rating mental disorders. See 38 C.F.R. § 4.130 (2010). Analysis As explained above, based on the passage of the VCAA, the Board will consider all of the evidence of record prior to the assignment of the 70 percent disability rating on January 9, 2003. The evidence associated with the claims file prior to the January 9, 2003 assignment of the 70 percent disability rating consisted of VA outpatient treatment records, a VA examination and lay statements. VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). The medical evidence beginning in April 1998, shows a fairly consistent picture of the appellant's PTSD symptomatology. The Board is aware of the appellant's representative's argument that the March 2010 Board decision did not adequately address the severity of the appellant's symptoms prior to January 9, 2003. See JMR, October 19, 2010. In clarifying this determination, the Board notes the holding in Mittleider v. West, 11 Vet. App. 181 (1998), wherein the Court held that when it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the appellant's service-connected disability. Mittleider is distinguishable from the present case, in that the symptomatology referred to by the appellant's representative was not due to her service-connected PTSD, but rather to family and other childhood circumstances. After an exhaustive review of the evidence, the Board finds that no time did the appellant endorse occupational and social impairment with reduced reliability and productivity due to a flattened affect, circumstantial, circumlocutory, or stereotyped speech. See VA PTSD Examination Report, February 22, 1998; VAMC Treatment Records, June 9, 1999, July 14, 1999, February 16, 2000, October 19, 2001, November 26, 2001, December 17, 2001, March 19, 2002, and October 11, 2002. The evidence of record does not support a finding that the appellant suffered from difficulty understanding complex commands or impaired abstract thinking. Id. In fact, in October 2002, the appellant informed her physician that she was attending computer networking classes four times per week and had started an exercise program. See VA Treatment Record, October 11, 2002. Overall, the appellant was noted to be very bright. See VA PTSD Examination Report, February 22, 1999; VA Treatment Note, June 9, 1999. Though the appellant did indicate that she suffered from "decreased memory" in June 1999, all of the remaining VA treatment records fail to address this as a continuing concern. In fact, there was no indication of the level of severity of the appellant's alleged decreased memory in the June 1999 treatment note. See June 9, 1999. Further, there was no evidence to indicate that the appellant was only able to retain highly learned material, or that she forgot to complete tasks. There is also no evidence in the claims file to support a finding that the appellant suffered from impaired judgment. In addition to the fact that all of the medical evidence found the appellant to be oriented in all spheres with normal speech and appropriate behavior, the appellant herself stated that she moved back to St. Louis, Missouri, to care for her ailing mother. See VA Treatment Record, October 19, 2001. With respect to panic attacks, the appellant's counsel argues that the February 1998 VA PTSD examination report documents the occurrence of such, specifically referring to the appellant's anxiety associated with her visits to VA for medical treatment. See VA PTSD Examination Report, February 22, 1998. The Board affords the appellant the full benefit of the doubt, and concedes that she experienced panic attacks at that time. However, the relevant medical evidence does not indicate that she continued to suffer from panic attacks after her February 1998 VA examination. In fact, as noted above, the appellant continued to seek psychiatric treatment from VA and did not voice complaints of panic attacks again. The Board certainly concedes that the appellant suffered from disturbances of motivation and mood. On nearly every visit to VA, the appellant was tearful when discussing her problems. A February 2000 VA psychiatric treatment note revealed the appellant's complaints of depression and anxiety. The appellant recounted that while in service, she was the victim of stalking and death threats by a fellow soldier who, in an intoxicated state, confessed to her that he had committed murder. The appellant stated that she was a witness against this man during his trial and he was ultimately convicted. At the time of the examination, the appellant stated that she was very frightened because the man she testified against was being released that month and he had previously threatened to kill her upon his release. As a result, she suffered from nightmares and intrusive thoughts of this man finding and harming her. She was assigned a GAF score of 35. See VA Treatment Record, February 16, 2000. It is also clear that the appellant has difficulty establishing and maintaining effective social relationships. The appellant has repeatedly stated that she is distrustful of men and is concerned about entering into a relationship, due to her experiences in service. See VA PTSD Examination Report, February 22, 1998; VAMC Treatment Records, June 9, 1999, July 14, 1999, February 16, 2000, October 19, 2001, November 26, 2001, December 17, 2001, March 19, 2002, and October 11, 2002. Although the appellant noted having some passive suicidal ideation in February 1999, she stated that she did not believe in suicide and would not harm herself. Her memory, insight and judgment for this time period have, for the most part, been fair to normal. Id. Further, a VA treatment note dated in April 2000 indicated that the appellant was doing very well on her medication and was enjoying the women's group she was participating in and had opened up some. See VA Treatment Record, April 2, 2000. The Board notes that a significant portion of the appellant's symptomatology for the appeal period is not associated with her service-connected PTSD. In June 1999, the appellant endorsed feelings of depression, decreased memory, decreased concentration, and sleep impairment, as well as some suicidal ideation, but no plan. At that time, she recounted her experiences of paternal molestation and feelings of hopelessness associated therewith. The appellant stated that she experienced intrusive thoughts, flashbacks, and nightmares associated with her childhood molestation. She also indicated that she was angry with herself for continuing to think about these experiences. The appellant was assigned a GAF score of 35. See VA Treatment Record, June 9, 1999. As noted in a January 2003 VA treatment note, the appellant also experienced three significant losses in 2002. The appellant's mother, with whom the appellant had been living and caring for, died in March 2002 of breast cancer. During that same time, the appellant herself was treated for what she believed at the time to be breast cancer. In September 2002, the appellant's grandfather died, and in November 2002, the appellant's aunt died. Though the Board certainly empathizes with the appellant regarding her horrific childhood experiences and the loss of her family members, her complaints of depression, anxiety, hopelessness, intrusive thoughts, flashbacks, and nightmares in 1999 and 2002 are clearly related to events other than those, which occurred during her military service. See Mittleider, supra. The appellant's GAF scores for this time period ranged from 35 to 55. A GAF score of 31 to 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 at school)." A GAF score of 41 to 50 shows "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)." 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). See DSM-IV at 44-47. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See VAOPGCPREC 10-95. In the present case, the appellant's GAF scores vary significantly. Ultimately, however, the Board does not find that the lower GAF scores are consistent with the other symptoms demonstrated by the appellant. The Board concedes that the appellant demonstrated significant symptomatology in June 1999, when she was assigned a GAF score of 35. As discussed above, however, the evidence of record indicates that this symptomatology was associated with the appellant's childhood trauma, and not her service-connected PTSD. In February 2000, however, it is clear that the assignment of a GAF score of 35 was based on the level of fear the appellant experienced due to the release of the convicted murderer against whom she testified. See VA Treatment Record, February 16, 2000. While this is demonstrative of the appellant's symptomatology at that time, the remaining evidence of record does not support a finding that these symptoms continued. In fact, the evidence indicates that the appellant's symptoms began to improve prior to January 9, 2003. As such, the Board finds that the previously assigned GAF scores of 35 do not accurately reflect the severity of the appellant's PTSD. Rather, a GAF score of 55, reflecting more moderate symptoms or moderate difficulty in social or occupational functioning (e.g., few friends) is deemed appropriate. The Board notes that the appellant submitted a private medical opinion in February 2011. In her psychiatric assessment, Dr. Trina M. Powell, Psy.D., upon reviewing the appellant's medical records dated February 1999 through October 2001, noted that "[a]lthough the GAF scores were different, due to subjective and objective analysis by the examiners, the veteran's symptomatology in the examinations was, for the most part, the same." Dr. Powell also commented that the Board's March 2010 determination, that the appellant's PTSD was mild to moderate, was inaccurate due to the appellant's behavior during her October 1998 VA gynecology examination. See Private Treatment Record, February 4, 2011. The Board does not find this opinion to be persuasive. Whether a physician provides a basis for her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, Dr. Powell based her conclusion [that the appellant's symptomatology more nearly approximated a GAF score of 35] upon a 1998 examination report that did not specifically address PTSD. In fact, there is no mention of the appellant's medical treatment after 2001. Further, Dr. Powell failed to address the facts that the appellant was molested during her childhood and that she was living with the stress of her mother's terminal breast cancer. Dr. Powell also did not meet the appellant in person to perform her examination, but rather spoke to the appellant over the telephone. The fact that the conclusions set forth in the examination report are unsupported and conclusory, nor are they based on a complete review of the evidence, and an in-person examination of the appellant, leaves the Board with no choice but to find this medical examination report to be of little probative value. The Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Here, the Board finds the VA treatment records for the appellate period to be the most persuasive. These records were made contemporaneous with the appellant's symptoms and the examiners had first-hand knowledge of her treatment. Dr. Powell's assessment is conclusory, fails to address all of the evidence in the appeal period, and was rendered in hindsight. Accordingly, the Board finds the contemporaneous VA examination report and VA treatment records to be the most persuasive. Despite the fact that the appellant has demonstrated some of the criteria indicated for a 50 percent disability rating, the frequency, severity, and duration of these symptoms is not sufficient to warrant a higher disability rating. The Board concludes her overall level of disability more nearly approximates that consistent with a 30 percent rating during this appeal period. As the preponderance of the evidence is against the appellant's claim, the benefit-of-the-doubt rule does not apply, and the appellant's claim of entitlement to an initial disability evaluation in excess of 30 percent for PTSD, prior to January 9, 2003, must be denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2010). III. Extraschedular Consideration Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted 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), Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111, 115 (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 VA 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. Neither the appellant nor her representative expressly raised the matter of entitlement to an extraschedular rating. The appellant's contentions have been limited to those discussed above, i.e., that her disability is more severe than is reflected by the currently assigned rating. See Brannon v. West, 12 Vet. App. 32 (1998) [while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant]. Moreover, the appellant and her representative have not identified any factors which may be considered to be exceptional or unusual with respect to the service-connected PTSD and the Board has been similarly unsuccessful. The record does not show that the appellant has required frequent hospitalizations for her service-connected disability. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. In short, the evidence does not support the proposition that the appellant's PTSD presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2010). ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD, prior to January 9, 2003, is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs