Citation Nr: 1121341 Decision Date: 06/02/11 Archive Date: 06/09/11 DOCKET NO. 08-07 393 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to November 25, 2008 and in excess of 50 percent from November 25, 2008. 2. Entitlement to an initial disability rating in excess of 10 percent for service-connected unstable temporomandibular joint prior to January 26, 2009 and in excess of 20 percent from January 26, 2009. 3. Entitlement to an initial compensable disability rating for service-connected headaches. 4. Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for a back disorder and, if so, whether service connection is warranted. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Calvin Hansen, Attorney at Law ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran had active service from December 1951 to September 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the January 2008, July 2008, February 2010, and September 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran initially requested a video conference hearing in connection with his appeal. However, in a December 2010 VA Form 9, the Veteran indicated that he did not want a hearing. Furthermore, the January 2011 statement from the Veteran specifically noted that he did not want a hearing and requested that his case be sent to the Board as soon as possible. Therefore, the Veteran's hearing request is withdrawn. The record reveals that the Veteran was afforded a local hearing before a Decision Review Officer (DRO) on July 29, 2010. The transcript is associated with the claims file. The September 2010 rating decision denied the Veteran's petition to reopen the claim of entitlement to service connection for a back disorder. The Veteran presented a timely notice of disagreement and the RO issued a statement of the case (SOC) in January 2011. In a January 2011 statement, the Veteran withdrew his request for a hearing and requested that his case be sent to the Board for adjudication. The Veteran did not specifically mention the denial of his petition to reopen the claim of entitlement to service connection for a back disorder. However, the RO construed the statement as a timely appeal and certified the issue of whether new and material evidence has been presented to reopen a claim of entitlement to service connection for a back disorder to the Board. In light of these actions on the part of VA, the Board will construe the Veteran's statement, received in January 2011, as having been a timely substantive appeal with respect to the September 2010 rating decision. Cf. Percy v. Shinseki, 23 Vet. App. 37, 46 (2009) (holding that, where the issue was treated by VA as if it were timely perfected for more than five years before the untimeliness was raised by the Board in the first instance, any issue concerning the timely filing of the substantive appeal was waived by VA). The record reveals that the Veteran submitted additional evidence directly to the Board following the most recent supplemental statements of the case. However, after a review of the claims file, the Board finds that the submitted evidence is duplicative and identical copies of evidence that has already been considered by the RO. Therefore, a waiver of initial consideration by the agency of original jurisdiction is not necessary. See 38 C.F.R. § 20.1304 (2010). The Board does note that the Veteran submitted a short statement attesting to his service in Korea and that his period of service was not appropriately defined by the RO. However, the DD Form 214 clearly shows that the Veteran had service in Korea. Thus, the Board finds that the Veteran's statement is not evidence relevant to the issues at hand and, therefore, a waiver is not required. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. Prior to November 25, 2008, the evidence of record shows that the Veteran's PTSD symptomatology has resulted in depressed mood, anxiety, irritability, hyperstartle response, some memory loss, and sleep impairment. However, the evidence does not show that the symptomatology associated with the Veteran's service-connected PTSD more closely approximates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; 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; difficulty in establishing and maintaining effective work and social relationships. 3. From November 25, 2008, the evidence of record shows that the Veteran's PTSD symptomatology has resulted in depression, irritability, flashbacks, hyperstartle response, hypervigilance, disturbances of mood, difficulty concentrating, and some memory loss, but does not show that the symptomatology associated with the Veteran's service-connected PTSD more closely approximates occupational and social impairment with deficiencies in most areas due to such symptoms as: suicidal ideation, illogical speech, neglect of personal appearance and hygiene, impaired impulse control, spatial disorientation, or inability to establish and maintain effective relationships. 4. Prior to January 26, 2009, the Veteran's unstable temporomandibular joint has resulted in inter-incisal range of motion greater than 30 mm. 5. From January 26, 2009, the Veteran's unstable temporomandibular joint has resulted in inter-incisal range of motion greater than 20 mm. 6. The most persuasive evidence of record shows that the Veteran's headaches are not prostrating. 7. The October 2007 rating decision is final. 8. Some of the evidence submitted subsequent to the October 2007 rating decision is new to the claims file and raises a reasonable possibility of substantiating the claim. 9. The evidence of record is in equipoise as to whether the Veteran's back disorder was incurred in active service. CONCLUSIONS OF LAW 1. Prior to November 25, 2008, the criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.130, Diagnostic Code 9411 (2010). 2. From November 25, 2008, the criteria for an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.130, Diagnostic Code 9411 (2010). 3. Prior to January 26, 2009, the criteria for an initial disability rating in excess of 10 percent for unstable temporomandibular joint have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.150, Diagnostic Code 9905 (2010). 4. From January 26, 2009, the criteria for an initial disability rating in excess of 20 percent for unstable temporomandibular joint have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.21, 4.40, 4.45, 4.150, Diagnostic Code 9905 (2010). 5. The criteria for an initial compensable disability rating for headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code 8100 (2010). 6. The October 2007 rating decision is final. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 20.1103 (2010). 7. Some of the evidence received subsequent to the October 2007 rating decision is new and material and the claim of entitlement to service connection for a back disorder is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 8. Resolving the benefit of the doubt in favor of the Veteran, a back disorder, diagnosed as moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1, was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). As the claim for service connection for a back disorder, the decision is favorable to the Veteran and, therefore, there is no need to review whether VA's statutory duties to notify and assist are fully satisfied as any error would be non-prejudicial. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, in this case, the Veteran is challenging the initial disability ratings assigned following the grants of service connection for PTSD, headaches, and unstable temporomandibular joint. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied. Finally, the duty to assist the Veteran also has been satisfied in this case. The service treatment records as well as VA treatment records and private treatment records are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claims. VA is not on notice of any evidence needed to decide the claims which has not been obtained. Moreover, in addition to obtaining all relevant medical records, VA afforded the Veteran VA examinations in December 2007, September 2007, July 2008, January 2009, August 2009, December 2009, and May 2010 with respect to his claims. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are more than adequate as the examiners performed physical examinations and mental status examinations, considered the Veteran's statements, and the examiners provided the medical information addressing the rating criteria with respect to the Veteran's service-connected disabilities on appeal. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claims and did in fact participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. LAW AND ANALYSIS Disability Ratings 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. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Fenderson v. West, 12 Vet. App. 119 (1999). Initial disability rating in excess of 30 percent for PTSD prior to November 25, 2008 The Veteran has been rated as 30 percent disabling for his service-connected PTSD prior to November 25, 2008 under Diagnostic Code 9411. A 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is contemplated for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed 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 is contemplated for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is contemplated for 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. The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. 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 of Mental Disorders, Fourth Edition (DSM-IV), p. 32). GAF scores ranging between 61 and 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). Initially, the Board observes that the Veteran has been diagnosed with adjustment disorder with depression by his private psychiatrist. However, several VA examiners, including the May 2010 VA examiner, have specifically noted that the Veteran's depression is part and parcel to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). Thus, in light of the conflicting evidence, the Board will consider all psychiatric symptoms when adjudicating the claim of entitlement to a higher initial disability rating for PTSD. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial disability rating in excess of 30 percent for PTSD prior to November 25, 2008. The medical evidence associated with the record includes VA examination reports, VA treatment records, and VA examination reports. In this case, the Veteran does not meet most, if any of the specifically enumerated criteria for disability rating in excess of 30 percent. Specifically, as to the 50 percent criteria, the evidence does not show that the Veteran has flattened affect; circumstantial, circumlocutory, or stereo-typed 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. First, the Board notes that the December 2007 and July 2008 VA examination reports noted that the Veteran had a slight restriction of affect. However, the Veteran was not noted to have a flat affect. Nevertheless, as detailed below, the Veteran's overall disability picture more closely approximates the assigned disability rating of 30 percent prior to November 25, 2008. The medical evidence does not reflect any circumstantial, circumlocutory, or stereo-typed speech. The July 2008 VA examination report noted that the Veteran's speech was unremarkable and spontaneous. The Board notes that the Veteran has reported that he has experienced panic attacks. However, the December 2007 VA examination report noted that the Veteran did not report any panic attacks. Furthermore, the VA examination reports show that the Veteran's judgment is fine and the Veteran's thought processes were unremarkable. The evidence also does not show difficulty in understanding complex commands. Furthermore, although the Veteran has reported some memory loss, the December 2007 and July 2008 VA examiners noted that the Veteran had normal hearing. In addition, the evidence, prior to November 25, 2008, does reflect that the Veteran had some social impairment. However, the July 2008 VA examination noted that the Veteran was married and spent time with his children. In fact, the Veteran stated during the July 2008 examination that two of his children came back for the 4th of July and that he was blessed because they were a very close family. Nonetheless, in reviewing all of the Veteran's symptoms and overall findings, the Board finds that the Veteran's disability more closely approximates the criteria for a 30 percent disability rating prior to November 25, 2008. In addition, the Board finds that the evidence does not warrant an initial disability rating of 70 percent. Although the Veteran had shown some social and occupational impairment, the overall medical evidence of record does not show that the Veteran has deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Although the records show that the Veteran experiences social isolation, severe depression, impaired concentration, the overall medical evidence of record shows that the Veteran does not meet the majority of symptoms listed for a 70 percent disability rating. The Veteran has not exhibited obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene or an inability to establish and maintain effective relationships. Thus, the Board finds that the overall disability picture is more akin to the criteria for the 30 percent disability rating. See Diagnostic Code 9411. The Board further observes that the next higher disability rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology approximates a 100 percent disability rating. In this regard, there is no evidence that he has gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation as to time or place, or memory loss for names of close relatives, own occupation, or own name. In this case, the Veteran has been assigned GAF scores ranging from 67-70. GAF scores ranging between 61 and 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. The Board finds that the documented GAF scores accurately depict the Veteran's level of disability. The Board also finds it probative that the Veteran has not demonstrated the majority of the symptoms listed in the rating criteria for a 50 percent disability rating or higher under Diagnostic Code 9411. The Board is aware that the symptoms listed under the higher disability ratings and in the GAF scale are essentially examples and that the Veteran need not demonstrate those exact symptoms to warrant a higher disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the preponderance of the evidence, including the clinical findings, shows that the Veteran's PTSD symptoms more nearly approximate the criteria for a 30 percent disability rating. In reaching this conclusion, the Board acknowledges the Veteran's belief that his PTSD symptoms are more severe than the current disability rating reflects. The Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, the Board finds that the medical evidence of record is more persuasive with respect to whether the Veteran's PTSD warrants a higher disability rating in accordance with the schedular criteria. The VA examiners noted the Veteran's reported symptoms and performed mental status examinations which show that the Veteran's disability does not warrant an initial disability rating in excess of 30 percent prior to November 25, 2008. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet App 492 (1992); see Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 30 percent for PTSD prior to November 25, 2008. Thus, the benefit of the doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Initial disability rating in excess of 50 percent for PTSD from November 25, 2008 In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial disability rating in excess of 50 percent for his service-connected PTSD from November 25, 2008. The medical evidence of record consists of VA treatment records, private treatment records, and VA examination reports conducted in January 2009, August 2009, and May 2010. The evidence shows that the Veteran's service-connected PTSD symptoms have resulted in nightmares, flashbacks, irritability, hyperstartle response, hypervigilance, disturbances of mood, and difficulty concentrating. The foregoing symptoms are contemplated by the currently assigned disability rating of 50 percent. The Board notes that the overall symptomatology associated with the Veteran's PTSD does not more closely approximate the schedular criteria required for the next higher 70 percent disability rating. The medical evidence does not show that the Veteran has experienced symptoms such as suicidal ideation; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. The medical evidence does not reveal any evidence of spatial disorientation. The VA examination reports and treatment records consistently show that the Veteran is oriented to person, place, and time. Furthermore, although the record shows that the Veteran suffers from depression, there is no indication that his depression affects his ability to function independently. In addition, although one record noted problems with impulse control, the January 2009 VA examiner noted that the extent of impulse control was good and that there were no episodes of violence. The August 2009 examiner noted that the Veteran's extent of impulse control was good, but that there had been episodes of violence. The May 2010 VA examiner noted that the Veteran's impulse control was good and there were no episodes of violence. Thus, the overall evidence shows that the Veteran's impulse control is good. The medical evidence also shows that the Veteran has been adequately groomed. Indeed, the May 2010 VA examination report noted that the Veteran was clean, neatly groomed, and appropriately dressed. The medical evidence of record also shows that the Veteran has consistently denied suicidal ideation. See January 2009 VA examination report, August 2009 VA examination report, May 2010 VA examination report. There is also no evidence of any obsessional behavior. The Board recognizes that the Veteran has been noted to have some mild psychomotor agitation. See November 2009 VA treatment record. However, the overall medical evidence of record consistently shows that the Veteran's speech is clear, spontaneous, and that his psychomotor activity is unremarkable. See VA examination reports. Finally, the evidence does reflect that the Veteran generally has depression everyday. The Veteran's private psychiatrist stated that the Veteran has low energy and his general depression is seen most of the day almost everyday. However, the Board finds that the Veteran's symptoms are more accurately associated with his current 50 percent disability rating. Finally, the evidence indicates that the Veteran may have difficulty in adapting to stressful circumstances (including work or worklike setting). However, in reviewing the overall medical evidence, the Board finds that the Veteran's disability most closely approximates the assigned 50 percent disability rating. In fact, the May 2010 VA examiner noted that the present level of PTSD would likely cause reduced reliability and productivity, the August 2009 VA examiner explained that the Veteran's PTSD would only create an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, and the January 2009 VA examiner noted that there would only be an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. To warrant a disability rating of 70 percent, there must be occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In this case, the Board finds that the Veteran's disability does not warrant a higher disability rating of 70 percent. In regard to family and social life, the record shows that the Veteran tries to avoid most people. The November 2008 private psychiatric evaluation shows that the Veteran does not have any real interpersonal contact. He stated that he did care for his wife, but had been absent from any libidinous desire for at least twenty years. He stated that he has no interest in service clubs but he does attend mass, but that he did not want to see too many people. He stated that he lives mostly as a recluse. The November 3, 2009 VA treatment record also noted that the Veteran had significant social isolation and only reported some minimal contact with his wife. However, the August 2009 VA examination report noted that the Veteran fixes the kneelers at church and has good friends from his church, but that he was not one to attend coffee with others. He also stated that he will be in Omaha and Lincoln more often to see his children. The May 2010 VA examination report shows that the Veteran has been married for 54 years and is close with his family, but that he avoids most people. In reviewing the record, it is clear that the Veteran has social impairment; however, it does not establish that the Veteran has an inability to maintain or establish relationships. In reviewing the overall evidence of record, the Board finds that the Veteran's social impairment is taken into account by the currently assigned 50 percent disability rating. As for evidence regarding work relationships, the record shows that the Veteran stated that he quit his last job in part because he could not deal with people, but also because he could not hear when speaking on the phone due to his hearing loss. However, the Board finds that the Veteran's difficulties with work are taken into account by the 50 percent disability rating. As noted above, the most recent VA examiner opined that the Veteran's PTSD would only caused reduced reliability and productivity in a work setting. As such, the Board finds that the Veteran's symptoms are more accurately associated with the 50 percent disability rating. In light of the above, the Board finds that the evidence does not warrant an initial disability rating in excess of 50 percent from November 25, 2008. Although the Veteran had shown social and occupational impairment to include social isolation, possible difficulty in adapting to stressful circumstances, and continuous depression, the overall symptomatology experienced by the Veteran is more akin to the criteria for the 50 percent disability rating. See Diagnostic Code 9411. The Board recognizes that the Veteran's private psychiatrist has stated that the Veteran's PTSD symptomatology is serious. Dr. C. stated that when the Veteran was given the PTSD scale, the Veteran's symptom severity score indicated a very severe level of PTSD. In addition, Dr. C. assigned a GAF score of 50, indicating serious symptoms. However, in reviewing the overall reported symptoms and clinical findings of the Veteran's PTSD, the Board finds that the Veteran's PTSD more closely approximates the criteria for a 50 percent disability rating. The Board further observes that the next higher disability rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology approximates a 100 percent disability rating. In this regard, the Board notes that the medical evidence does not contain evidence which supports a finding that the Veteran has gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation as to time or place, or memory loss for names of close relatives, own occupation, or own name. Accordingly, his overall symptomatology more closely approximates the schedular criteria for the 50 percent disability rating. In this case, the Veteran has been assigned GAF scores ranging from 50 to 65. GAF scores ranging between 61 and 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). Nevertheless, the Board finds probative that the Veteran has not demonstrated the majority of the symptoms listed in the rating criteria for a 70 percent rating under Diagnostic Code 9411 or the majority of the symptoms listed in the GAF scale for serious symptoms (suicidal ideation, severe obsessional rituals, frequent shoplifting). The Board is aware that the symptoms listed under the 70 percent disability rating and in the GAF scale are essentially examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a 70 percent disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the preponderance of the evidence, including the clinical findings associated with the reported GAF scores, shows that the Veteran's PTSD symptoms more nearly approximate a moderate occupational and social impairment, and do not equal or more nearly approximate the criteria for a 70 percent disability rating. In reaching this conclusion, the Board acknowledges the Veteran's belief that his PTSD symptoms are more severe than the current disability evaluation reflects. The Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology and has addressed the Veteran's reported symptoms in this decision, the Board finds that the medical evidence of record is more persuasive regarding whether he is entitled to a higher disability rating in accordance with the schedular criteria. The VA examiners considered the Veteran's reported symptoms and provided the clinical findings to rate the Veteran's disability with respect to the rating criteria. Therefore, the Board finds that the medical evidence is more persuasive than the Veteran's general statements requesting a higher disability rating. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet App 492 (1992); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 50 percent for PTSD from November 25, 2008. Thus, the benefit of the doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered referral for extra-schedular 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). An extraschedular disability rating is warranted based 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) (2010). 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 first 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 claimant's level of disability and symptomatology and is found inadequate, the Board must 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 first prong in Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's symptoms with the established criteria found in the rating schedule for mental disorders shows that the rating criteria reasonably describe ratings for mental disorders, but the Veteran simply does not exhibit those symptoms. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), there is no evidence in the medical records of an exceptional or unusual clinical picture. Further, the record does not show that the Veteran has required frequent hospitalizations for his service-connected disability. In addition, there is nothing in the record which suggests that the above condition markedly impacted the Veteran's ability to work. In a statement, the Veteran explained that he quit his job in part because of his bosses but also because of his inability to hear due to his hearing loss. The evidence does not suggest that the Veteran's PTSD has a marked impact on his ability to work. In fact, the most recent VA examiner opined that the Veteran's PTSD would only cause reduced reliability and productivity in a work setting. While it is undisputed that the disability affects the Veteran's employment, but it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Therefore, the Board finds that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Initial disability rating in excess of 10 percent for unstable temporomandibular joint prior to January 26, 2009 The Veteran's unstable temporomandibular joint was rated as 10 percent disabling, prior to January 26, 2009, under the criteria of 38 C.F.R. § 4.150, Diagnostic Code 9905. Diagnostic Code 9905 provides for a 10 percent disability rating for range of lateral excursion from 0 to 4 mm or for inter-incisal range of 31 to 40 mm. A rating of 20 percent is warranted for inter-incisal range of 21 to 30 mm. A rating of 30 percent is assigned with inter-incisal range of 11 to 20 mm. A rating of 40 percent is assigned with inter-incisal range of 0 to 10 mm. A note to Diagnostic Code 9905 states ranges for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial disability rating in excess of 10 percent for unstable temporomandibular joint prior to January 26, 2009. The Veteran was afforded a dental and oral examination in September 2007. The Veteran stated that he had a recurrent history of subluxation of his right temporomandibular joint (TMJ) following an in-service accident when chewing hard foods or at maximum opening. Range of motion shows that the maximum vertical incisal opening was 38 mm., right lateral excursion was 12 mm., and left lateral excursion was 6 mm. without discomfort. The external masseter muscles and right and left internal pterygoids were non-tender to palpation. A slight late click was noted in the right TMJ on opening to auscultation and palpation with a right mandibular deviation of approximately 3 mm. The diagnosis was listed as slight limitation in mandibular range of motion on opening. The examiner stated that the Veteran demonstrated a slight limitation in range of motion on opening, but had normal excursive movements of the temporomandibular joints and mandible. The Veteran's temporomandibular dysfunction (TMD) symptoms consisted of intermittent subluxation of the right TMJ. In a May 2008 statement, the Veteran's private dentist stated that the type of discomfort that the Veteran presented with was typical with dysfunction of the temporal mandibular joint. It was as likely as not that the subsequent dislocations and pain could be the result of the trauma sustained during service in August 1952. To warrant a disability rating in excess of 10 percent for the Veteran's unstable temporomandibular joint, the evidence must show inter-incisal range of 21 to 30 mm. The only medical evidence addressing the Veteran's inter-incisal range of motion is the September 2007 VA examination. The evidence shows that the Veteran's maximum vertical incisal range opened to 38 mm. Therefore, the Veteran does not warrant an initial disability rating in excess of 10 percent prior to January 26, 2009. The Board notes that the Veteran has reported that he experiences recurrent subluxation of his jaw and the evidence shows slight limitation of range of motion. However, the medical evidence of record is absent for any indications of additional functional loss due to his service-connected disability. See DeLuca, supra. In reaching this conclusion, the Board acknowledges the Veteran's belief that he warrants a higher initial disability rating for his disability. The Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. The Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, such as dislocation and pain. However, the Board finds that the VA examination report is the most persuasive evidence addressing the Veteran's disability and whether he is entitled to a higher disability rating in accordance with the schedular criteria. The Board finds this is so because the VA examiner completed a complete oral examination and measured the Veteran's incisal range of motion. Thus, the Board affords more value to the clinical findings in the VA examination report than the Veteran's general statements requesting a higher disability rating. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet App 492 (1992); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board has considered whether there are any applicable alternative diagnostic codes that would be more advantageous to the Veteran. However, Diagnostic Code 9905 is the only appropriate diagnostic code for this disability. Diagnostic Code 9900 contemplates chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; Diagnostic Codes 9901 and 9902 address loss of the mandible; Diagnostic Codes 9903 and 9904 concern nonunion and malunion of the mandible, respectively; Diagnostic Codes 9906 and 9907 contemplate loss of the ramus; Diagnostic Codes 9908 and 9909 address loss of the condyloid process; Diagnostic Codes 9910 and 9910 concern loss of the hard palate; loss of the maxilla is addressed under Diagnostic Codes 9914 and 9915; and, Diagnostic Code 9916 concerns malunion or nonunion of the maxilla. The Veteran is not shown to have any of these symptoms. The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 10 percent for unstable temporomandibular joint prior to January 26, 2009. Thus, the benefit of the doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Initial disability rating in excess of 20 percent for unstable temporomandibular joint from January 26, 2009 In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial disability rating in excess of 20 percent for unstable temporomandibular joint from January 26, 2009. The Veteran was afforded a dental and oral examination in January 2009. The Veteran related a service-related temporomandibular joint injury in 1953. He stated that he experienced a recurrent history of subluxation of his right temporomandibular joint when chewing hard foods or at maximum opening. The Veteran's pain on the Wong-Baker Faces Pain Rating Scale when most symptomatic was 6/10. The range of motion findings show that the maximum vertical incisal opening was 30 mm., right lateral excursion was 11 mm., and left lateral excursion was 6 mm. without discomfort. External masseter muscles and right and left internal pterygoids were non-tender to palpation. A late and early click was noted in the right TMJ on opening on auscultation and palpation, with a right mandibular deviation of approximately 3 to 4 mm. The diagnosis was listed as limitation in manidbular range of motion on opening and history of subluxation of the mandible. The examiner explained that the Veteran demonstrated a slight limitation in range of motion on opening and slight to moderate limitation in left excursive movements of the temporomandibular joints and mandible; his overall range of motion decreased slightly from the previous examination. There was no increased loss of function or fatigue with repetitive motion in the temporomandibular joints. He has never worn an orthotic appliance. The Veteran's temporomandibular dysfunction (TMD) symptoms currently consisted of intermittent subluxation of the right TMJ and discomfort following talking for extended periods. There is a slight increase in limitation of function and decrease in range of motion in the TMJ from the previous examination. The Veteran was afforded another dental and oral VA examination in May 2010. The examiner noted that a previous VA examination confirmed a service-related temporomandibular joint injury in 1953. The Veteran related a recurrent history of subluxation of his right temporomandibular joint when chewing hard foods or at maximum opening. The Veteran's pain on the Wong-Baker Faces Pain Rating Scale when most symptomatic was 7/10, more particularly after chewing. The range of motion findings show that the maximum vertical incisal opening was 22 mm., right lateral excursion was 6 mm., and left lateral excursion was 4 mm. with some discomfort. External masseter muscles were non-tender to palpation; right and left internal pterygoids were slightly tender to palpation. A late click was noted in the right TMJ on opening on auscultation and palpation, with a right mandibular deviation of approximately 3-4 mm. The examiner provided diagnoses of limitation in mandibular range of motion and history of subluxation of the mandible. The Veteran demonstrated limitation in range of motion on opening and moderate limitation in left excursive movements of the temporomandibular joints and mandible; his overall range of motion has decreased slightly from the previous VA examination. There is no increased loss of function, pain, fatigue, lack of endurance or incoordination with repetitive motion in the temporomandibular joints within his current range of motion. He has never worn an orthotic appliance. The Veteran's temporomandibular dysfunction symptoms currently consist of intermittent subluxation of right TMJ and discomfort following talking for extended periods of eating. There was a decrease in function and decrease in range of motion in the TMJ from the previous examination. To warrant a higher disability rating of 30 percent, the evidence must show inter-incisal range of 11 to 20 mm. In this case, the evidence of record does not reveal that the Veteran's disability warrants a 30 percent disability rating or higher. The VA examination reports do not show that the Veteran has an inter-incisal range of motion of less than 20 mm. The most recent VA examination report does show range to 22 mm., but this is not sufficient to warrant a higher disability rating. Therefore, the Veteran does not warrant an initial disability rating in excess of 20 percent from January 26, 2009. Although the Veteran has presented with complaints of pain, the Board finds that the Veteran is not entitled to a higher disability rating under the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board notes that the Veteran did report pain during his range of motion testing. However, the effect of the pain in the Veteran's disability is contemplated in the currently assigned disability rating of 20 percent. The Board observes that 38 C.F.R. § 4.40 does not require a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased disability rating. In this respect, the January 2009 VA examiner noted that there was no increased loss of function or fatigue with repetitive motion in the temporomandibular joints. Moreover, the May 2010 VA examiner noted that there was no increased loss of function, pain, fatigue, lack of endurance or incoordination with repetitive motion. Therefore, the Veteran's disability does not warrant an initial disability rating in excess of 20 percent under Deluca, supra. In reaching this conclusion, the Board acknowledges the Veteran's belief that he warrants a higher initial disability rating for his disability. The Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, such as dislocation and pain. However, the Board finds that the VA examination reports are the most persuasive evidence addressing the Veteran's disability and whether he is entitled to a higher disability rating in accordance with the schedular criteria. The Board finds this is so because the VA examiners completed complete oral examinations of the Veteran and measured the Veteran's inter-incisal opening. Thus, the Board affords more value to the clinical findings in the VA examination reports than the Veteran's general statements requesting a higher disability rating. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet App 492 (1992); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board has considered whether there are any applicable alternative diagnostic codes that would be more advantageous to the Veteran. However, Diagnostic Code 9905 is the only appropriate diagnostic code for this disability. Diagnostic Code 9900 contemplates chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; Diagnostic Codes 9901 and 9902 address loss of the mandible; Diagnostic Codes 9903 and 9904 concern nonunion and malunion of the mandible, respectively; Diagnostic Codes 9906 and 9907 contemplate loss of the ramus; Diagnostic Codes 9908 and 9909 address loss of the condyloid process; Diagnostic Codes 9910 and 9910 concern loss of the hard palate; loss of the maxilla is addressed under Diagnostic Codes 9914 and 9915; and, Diagnostic Code 9916 concerns malunion or nonunion of the maxilla. The Veteran is not shown to have any of these symptoms. The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 20 percent for unstable temporomandibular joint from January 26, 2009. Thus, the benefit of the doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered referral for extra-schedular consideration. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong in Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected unstable temporomandibular joint is inadequate. It does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. A comparison between the level of severity and symptomatology of the Veteran's symptoms with the established criteria found in the rating schedule for dental and oral disorders shows that the rating criteria reasonably describe ratings for dental and oral disorders, but the Veteran simply does not meet the criteria for the higher disability ratings. Therefore, the Board finds that the record does not reflect that the Veteran's disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. In the absence of these factors, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected disability under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). Initial compensable disability rating for headaches Service connection was established for migraine headaches in a July 2008 rating decision. The Veteran was assigned an initial noncompensable disability rating under the criteria in 38 C.F.R. § 4.124a, Diagnostic Code 8100. Diagnostic Code 8100 provides for a 10 percent disability rating for migraine with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent disability rating is provided for migraine with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent disability rating is provided for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). According to Stedman's Medical Dictionary, 27th Edition (2000), page 1461, "prostration" is defined as "a marked loss of strength, as in exhaustion." According to Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007), "prostration" is defined as "extreme exhaustion or powerlessness." Moreover, the Board observes that headaches are the type of disorder for which lay evidence is competent. Barr, 21 Vet. App. at 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial compensable disability rating for headaches. The Veteran was afforded a VA examination in July 2008. The Veteran reported experiencing headaches on a near daily basis that can be mild to moderate in severity. He denied any periods of complete incapacity secondary to his headaches. The Veteran explained that he believed he had headaches ever since his time on active duty. The Veteran described his headaches in general as mild and that they did not typically limit activities. He reported no associated nausea, vomiting, photophobia, or phonophobia. The Veteran denied any severely prostrating episodes or periods of incapacity secondary to the headaches. The Veteran did report that he experienced flare-ups of his jaw condition approximately every two to three months. These flare-ups can last up to a week during which he experiences increased headache pain with regards to severity and duration. The examiner specifically noted that the Veteran's attacks were not prostrating and that ordinary activity was possible. The diagnosis listed was chronic headaches and that the headaches had no significant effects on usual occupation and no effects on usual daily activities. The Veteran was afforded a VA examination in January 2009. The examiner described experiencing headaches on a near daily basis that can be mild to moderate in severity. He denied any periods of complete incapacity secondary to his headache condition. The Veteran reports no associated nausea, vomiting, photophobia or phonophobia. There was little to no documentation regarding headache condition or treatment thereof over the last number of years. The Veteran described his headaches in generally as distracting but that they do not typically limit activities. The Veteran did not describe any severely prostrating episodes or periods of incapacity secondary to the headaches. He reported that he does experience flare-ups of the jaw condition during which time he experiences increased headache pain with regards to severity and duration. The examiner noted that the Veteran has headaches weekly, but that the attacks were not prostrating and ordinary activity was possible. The examiner listed a diagnosis of chronic headaches with no significant effects on usual occupation and no effects on usual daily activities. In a February 2010 VA treatment record, the Veteran stated that he had terrible headaches with the 5 mg. of Terazosin and the Veteran was going to try the 1 mg. capsule instead. During a December 2009 VA examination, the examiner noted that the Veteran has had long-standing headaches for many years. He woke up with them every morning, occasional Tylenol helped, but nothing makes them worse or aggravates them. He denied any specific incapacitating headaches; however, they did occur daily and were bothersome. The examiner noted that the Veteran had a diagnosis of migraine/tension headaches and that his neurological examination was normal. In a May 2010 VA examination report, the examiner noted that the Veteran appeared to have headaches daily and that they were a nuisance and bothersome. The examiner noted that they were likely to interfere with some types of employment and activities where he needed a good attention span, but overall, he appeared to tolerate them and that they were unlikely to render him unemployable and unlikely to prevent him from going about most daytime activities. In reviewing the medical evidence of records and the Veteran's reported symptoms, the Board finds that the Veteran is not entitled to an initial compensable disability rating for headaches. To warrant assignment of a 10 percent disability rating, there must be migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. Here, although the Veteran has chronic headaches that vary from mild to moderate, the VA examiners specifically noted that the headaches are not prostrating and that they have no effect on his usual daily activities. Although the May 2010 VA examiner noted that the headaches were a nuisance and bothersome, the Veteran appeared to tolerate them and it was unlikely that the headaches would prevent him from going about most daytime activities. As there is no evidence of any prostrating attacks, the Board finds that the Veteran's disability does not warrant an initial compensable disability rating. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. In reaching this conclusion, the Board acknowledges the Veteran's belief that he deserves a compensable disability rating for his service-connected headaches. The Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. The Board recognizes that the Veteran is competent to address his symptoms; however, the examiners considered the Veteran's statements regarding his headaches and determined that the Veteran did not experience prostrating attacks. The Board finds that the VA examination reports are the most persuasive evidence of record as the examiners specifically noted the Veteran's reported symptoms and addressed the schedular criteria. Thus, the Veteran is not entitled to an initial compensable disability rating for his headaches. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet App 492 (1992); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Based on the above, the Board finds that an increased disability rating is not warranted at any time during the pertinent appeal period. Therefore, staged ratings for the Veteran's service-connected headaches are also not warranted. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial compensable disability rating for headaches. Thus, the benefit of the doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The schedular evaluation for the Veteran's service-connected headaches is not inadequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology as due to his service-connected headaches. The Veteran has not submitted evidence indicating that his service-connected headaches or the difficulties flowing from it constitute "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Further, 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence does not demonstrate in this case is that the manifestations of the Veteran's service-connected headaches have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected headaches under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). New and Material Evidence Initially, the Board notes that the Veteran first submitted an application for VA compensation benefits in June 2007 and requested service connection for a back disorder. In the October 2007 rating decision, the RO denied service connection for a back condition. The Veteran disagreed with the decision and the RO issued a July 2008 statement of the case and denied service connection for a back condition. The Veteran filed a VA Form 9 dated in April 2009; however, it was not timely filed. Therefore, the October 2007 rating decision is final. See 38 C.F.R. § 20.1103. In November 2009, the Veteran submitted a petition requesting that his claim for entitlement to service connection for a back disability be reopened. In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C.A. § 5108. For applications filed after August 29, 2001, as was the application to reopen the claim in this case, new and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The evidence associated with the claims file at the time of the prior final rating decision includes the Veteran's service treatment records, VA treatment records, the Veteran's statements, and the July 2008 VA examination report. The RO denied the Veteran's claim for service connection for a back condition because the service treatment records were silent for any complaints, treatment, or diagnosis of a spinal condition. Furthermore, there was no evidence relating the Veteran's current disability to active service. Thus, the RO denied service connection since the current evidence of record did not show that the condition either occurred in or was caused by service. The evidence associated with the claims file subsequent to the October 2007 rating decision consists of private treatment records, a lay statement, the Veteran's statements and testimony, VA treatment records, and VA examination reports. The Board has thoroughly reviewed the evidence associated with the claims file subsequent to the October 2007 rating decision and finds that some of the evidence constitutes new and material evidence which is sufficient to reopen the previously denied claim for service connection. In a January 2009 private treatment record, Dr. M.S. noted that the Veteran had lumbar degenerative disk disease of L4-5 and L5-S1 and that there was a possibility that his symptoms and degenerative joint disease changes were related to his old injury during service. The Board must presume the credibility of this evidence for the purpose of determining whether it constitutes new and material evidence needed to reopen the claim and may not assess its probative weight in relation or comparison to other evidence for reopening purposes. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The Board finds that the January 2009 private treatment record is "new" in that it was not before the RO at the time of the prior decision. In addition, the evidence is "material." As noted above, evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The Board notes that in a recent case, the United States Court of Appeals for Veterans Claims (Court) clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110 (2010). Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. Therefore, as Dr. M.S. suggests that the Veteran's disability is related to service, the evidence relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. Id. Accordingly, the Board finds that new and material evidence has been presented to reopen the Veteran's claim for service connection for a back disorder. However, the Board notes that, the adjudication of the Veteran's appeal does not end with the finding that new and material evidence has been received. In further adjudication of the claim, the presumption that the additional evidence is true without regard to the other evidence of record no longer applies. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). However, medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (footnote omitted). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). In this case, the Veteran contends that his current back disorder is related to his period of active service. In various statements, the Veteran has explained that he initially injured his back during basic training when he climbed up a wall and then fell on his back. He stated that he did not want to complain because of the possible repercussions from his superiors. The Veteran also explained that when he was in Korea, he was in a rollover accident. He stated that they went off the road and he hit his head on the right side of the framework, hurt his jaw, and reinjured his back. Initially, the Board notes that the Veteran has a current disability of the back. The December 2009 VA examination report shows that the Veteran is diagnosed with moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1. The service treatment records are absent for any notation, documentation, or complaint regarding a back pain or back disorder. The September 1953 separation examination report shows that the Veteran's spine was clinically evaluated as normal. However, it does appear that the Veteran's service treatment records are fire-related and may be incomplete. When a Veteran's service treatment records are unavailable, VA's duty to assist and the Board's duty to provide reasons and bases for its findings and conclusions and to consider carefully the benefit-of-the-doubt rule (see 38 U.S.C.A. §§ 71204(d)(1), 5107(b)) are heightened. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board notes that the first objective evidence of a back disorder is dated in the 2000s, more than 50 years after separation from active service. The Board finds this gap in time significant and it weighs against the existence of a link between his current back disorder, and his time in service. Cf. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). Nonetheless, the Veteran has stated that he has experienced back pain since separation from active service. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board notes that the Veteran is competent to give evidence about what he experienced; i.e., that he has had back pain since his separation from service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding Veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). Furthermore, the Veteran's wife, A.S., submitted a lay statement and explained that she met the Veteran the first weekend after his discharge from the United States Army. She said that he has always suffered from back pain and explained to her that he injured his back in basic training when he jumped off a wooden wall. She also stated that a roll over accident in Korea contributed to his back pain. The Board finds nothing that would refute the competency and credibility of the Veteran and his wife with respect to his chronic pain since separation from service. In addition, the medical evidence of record weighs in favor of the Veteran's claim for service connection. The Veteran was afforded a VA examination in December 2009. The Veteran stated that he ran off the road in 1952 while in Korea and sustained a dislocation to his jaw and back. He believed his back condition started before the accident when he was forced to jump off of a wall during basic training. He recalled having pain in the lower back with left lower extremity pain since the jump in basic training. He did not see a doctor after the injury and claimed he had no access to a physician at the time. He did see a doctor after the motor vehicle accident. The examiner listed a diagnosis of moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1. The examiner opined that it was as least as likely as not that the Veteran's disability was caused by or a result of the injury during service. The examiner explained that the Veteran was a very good historian with good recall and presents a consistent history of the events leading up to the back injury. It was likely the current condition is reflective of a natural progression of the injury as it presented while in service. The Board concludes that in this case, as it now stands, the evidence of record is at least in relative equipoise as to whether the Veteran's back disorder, moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1, is related to active service. In light of the Veteran's statements, the Veteran's wife's statement, the VA examination report, the Board finds that the evidence is in equipoise as to whether the Veteran's back disorder is related to active service. Accordingly, resolving the benefit of the doubt in favor of the Veteran, the Board will grant service connection for moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1. ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD prior to November 25, 2008 is denied. Entitlement to an initial disability rating in excess of 50 percent for PTSD from November 25, 2008 is denied. Entitlement to an initial disability rating in excess of 10 percent for unstable temporomandibular joint prior to January 26, 2009 is denied. Entitlement to an initial disability rating in excess of 20 percent for unstable temporomandibular joint from January 26, 2009 is denied. Entitlement to an initial compensable disability rating for headaches is denied. Entitlement to service connection for moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S1 is granted. REMAND Reason for Remand: To provide a VA examination. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). The Veteran contends that he is unemployable due to his service-connected disabilities. The record reveals that the Veteran is currently service connected for PTSD, rated as 50 percent disabling, bilateral hearing loss, rated as 40 percent disabling, unstable temporomandibular joint, rated as 20 percent disabling, tinnitus, rated as 10 percent disabling, and chronic headaches, rated as noncompensably disabling. Furthermore, the Veteran has been granted service connection for moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S, which will also impact the Veteran's claim for a TDIU. In any event, the Veteran clearly meets the minimum schedular criteria for a TDIU under 38 C.F.R. § 4.16(a). However, the medical evidence of record is inadequate to adjudicate the Veteran's claim at this time. The Veteran has not been scheduled for a VA examination to determine whether he is unemployable due to his service-connected disabilities. The record reveals that the VA examination reports have noted that the Veteran's service-connected PTSD does not result in total occupational impairment and the June 2010 VA examiner explained that the Veteran's service-connected bilateral hearing loss, alone, would not significantly affect work. In addition, the May 2010 VA examiner noted that the Veteran's headaches were likely to interfere with some types of employment and activities where he needed a good attention span, but overall, they were unlikely to completely render him unemployable. However, there is no examination addressing whether the combined effect of his service-connected disabilities results in unemployability. Therefore, the Board finds that a VA examination and medical opinion are necessary for the purpose of determining whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. The Veteran should be afforded a VA examination to determine the effect of his service-connected disabilities on his employability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the effect of the Veteran's service-connected disabilities on his ability to engage in any type of full-time employment and whether, in the examiner's opinion, it is at least as likely as not (50 percent likelihood or greater) that the service-connected disabilities are of such severity to result in unemployability. It should be noted that the Veteran is currently service-connected for PTSD, bilateral hearing loss, unstable temporomandibular joint, tinnitus, chronic headaches, and moderate degenerative disc disease and moderate degenerative facet disease of L4-L5 and L5-S. Consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice- connected disabilities. In rendering the opinion, the examiner should not resort to mere speculation, but rather should consider that the phrase "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. Thus, unless the examiner concludes that the Veteran's unemployability is either likely or unlikely the result of his service-connected disabilities, the examiner should state whether it is at least as likely that the Veteran's unemployability is the result of his service-connected disabilities, as opposed to its being the result of some other factor or factors, such as nonservice-connected disabilities. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. When the development requested has been completed, the case should be reviewed by the RO on the basis of additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs