Citation Nr: 1129577 Decision Date: 08/10/11 Archive Date: 08/23/11 DOCKET NO. 06-32 712 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to a PTSD rating in excess of 50 percent, earlier than November 8, 2007. 2. Entitlement to a compensable rating for right varicocele. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from July 1967 to July 1969. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2005 rating decision. By way of history, VA received the Veteran's claim for service connection for PTSD on June 30, 2000. In September 2001, the RO denied the Veteran's claim. He appealed this denial to the Board. In September 2003, the Board remanded the Veteran's claim for a VA examination which was provided in October 2005. Following this examination, the Veteran was first diagnosed with PTSD related to his military service. In November 2005, the RO granted the Veteran's claim for service connection for PTSD, effective from the date of the VA examination in October 2005, and assigned a 50 percent disability rating. The Veteran appealed both the effective date that was awarded and the level of the initial disability rating. In a March 2008 rating decision, the RO increased the Veteran's evaluation for PTSD to 100 percent, effective November 8, 2007. In August 2009, the Board granted an earlier effective date from June 30, 2000, for the award of service connection for PTSD. Thereafter, the RO extended back the initial 50 percent rating for PTSD to June 2000. As such, the issue of a rating in excess of 50 percent for PTSD from June 30, 2000 until November 8, 2007 remains for consideration. Regarding the right varicocele, it was remanded by the Board in August 2009, for an examination. The issues of entitlement to service connection for coronary artery disease, and for hearing loss have been raised by the Veteran's representative in the June 2011 Written Brief Presentation, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to April 9, 2007, the evidence does not show that the Veteran's PTSD caused occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. From April 9, 2007, the Veteran's PTSD was productive of total social and industrial impairment. 3. The Veteran's right varicocele is shown on medical examination to be generally asymptomatic. 4. The Veteran's urinary problems have not been related to his service connected varicocele. CONCLUSIONS OF LAW 1. Criteria for a rating in excess of 50 percent for PTSD prior to April 9, 2007 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2010). 2. Criteria for a 100 percent schedular rating for PTSD from April 9, 2007 have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2010). 3. Criteria for a compensable rating for a right varicocele have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, DC 7599-7120 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, it is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD As noted in the Introduction, the Veteran's PTSD was initially rated as 50 percent disabling from the date his claim was received (June 30, 2000) until it was increased to 100 percent (November 8, 2007). As such, the Board will consider whether a rating in excess of 50 percent is warranted for any distinct period prior to November 2007. A 50 percent rating is assigned when PTSD causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is assigned when PTSD causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when PTSD causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. By way of background, it is observed that there is evidence the Veteran spent much of his adult life in the prison system, apparently owing to drug related crimes. In addition, it was specifically noted on VA examination in 2006, that PTSD had not been a factor prior to 2005, but rather, the Veteran's drug use had dominated the clinical picture during those years. (See also Vet Center records dated in 2006.) In any event, the Veteran first submitted a claim for service connection for PTSD in June 2000, while he was in prison following a bank robbery, which apparently he committed while under the influence of cocaine. This evidently followed a relapse of drug abuse that occurred after the death of the Veteran's son in 1998. The Veteran then remained in prison until October 2005, and was first examined for VA purposes in connection with this claim the day after, or soon after, his release. There are few records from the Veteran's time in prison between 2000 and 2005. An evaluation conducted at the request of the Veteran's defense counsel in 2000 by Gerald Busch, MD., makes no mention of post traumatic stress disorder. Likewise, a letter from the Federal Bureau of Prisons dated in December 2001, revealed the Veteran had not requested, and had not been given, any psychological treatment at the prison up to that point. No evidence thereafter indicates the Veteran received any psychiatric treatment while imprisoned during this period. As indicated above, in October 2005, the Veteran underwent a VA examination at which it was noted that he was recently released from prison and was unemployed. At that time, the Veteran reported one suicidal attempt after his son's death (in 1998), and that he avoided crowds when possible. He also reported sleep problems, hypervigilance, and exaggerated startle response. The Veteran, however, was noted to be appropriately groomed and cooperative, alert and oriented. His speech was normal in rate and volume, and although his mood was dysphoric with a congruent affect, his thought processes were coherent and logical, (although tangential at times). There was no evidence of psychosis or suicidal ideation during the interview, and the Veteran's judgment was assessed as good. The examiner diagnosed the Veteran to have PTSD, depressive disorder, and substance abuse in remission. He assigned the Veteran a global assessment of functioning (GAF) score of 50. [In this regard, a GAF score between 41 and 50 is assigned when an individual presents either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score between 51 and 60 is assigned when an individual presents either 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 co-workers). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC, American Psychiatric Association, 1994, as referenced in 38 C.F.R. § 4.125. Records from a Vet Center show the Veteran referred himself to that facility in January 2006. An intake evaluation at that time showed the Veteran complained of anxiety, and adjustment problems. The Veteran was not taking any medications, and it was noted that he had been working for the previous week as a welder/fitter. At the same time, the evaluator commented that the Veteran did not know how to live in society, having spent most of his adult life behind bars, and that the Veteran had considerable unresolved grief associated with the death of his son in 1998. Nevertheless, the Veteran was described as neat, friendly, and cooperative. His speech was appropriate and he was fully oriented. His memory function was normal, his affect was appropriate, and he was relaxed with fair judgment. Later that month, (January 2006), however, the Veteran was hospitalized at VA after his wife found him wandering the street with a knife and threatening to kill himself. The Veteran was not responding to direct questioning, but his wife reported a declining mood with increased irritability, and pacing at night. It was noted that it was the eighth anniversary of their son's death. The Veteran was described as having a normal speech, and his thought processes were logical and goal directed. He also denied suicidal ideation and homicidal ideation, however, he reported hearing a radio which evidently was a response to internal stimuli. It is noted that the Veteran was wandering the streets because he could not find his car after drinking beer and using cocaine after 7 years of abstinence. When discharged, February 1, 2006, the Veteran was better oriented and more talkative. His mood was no longer depressed, but he still had a somewhat blunted affect. He also reported that his hallucinations had subsided, and denied any suicidal ideation or homicidal ideation. The Veteran only vaguely remembered the night he was hospitalized, and it appears the psychotic component of his presentation at that time was attributed to cocaine intoxication. Also listed as an Axis I diagnosis was history of PTSD, with depression, with exacerbation of bereavement after the anniversary of his son's death. The Veteran was enrolled in a substance dependence treatment program with VA between March 2006 and September 2006, completing the education phase, relapse phase and after care phase. Records during these months showed that the Veteran reported attending church regularly, and jogging regularly, although he was not working, and he continued to avoid old places and people as well as to deal with the loss of his son. In September 2006, the Veteran reported that he had been doing fairly well for the most part, with the exception of getting down approximately twice a month when he was irritable, easily angered and a-motivated. The Veteran denied any suicidal ideation or intent. He was fairly compliant with his medication, and he was alert, friendly, cooperative and interactive. His speech was normal and his thought processes were logical and goal-directed. He denied any hallucinations or delusions and his affect was appropriate and stable. He was oriented to person, place and time. His GAF was noted to be 50. The Veteran was examined for VA purposes in November 2006. The report from this examination revealed the Veteran appeared quite sedated throughout the examination, which was thought to be the result of medication (Nyquil) he used the night before, and earlier that morning. The Veteran was unsure whether his symptoms had changed since his previous examination. He stated that he felt all right, but frustrated. The Veteran acknowledged episodic cocaine use throughout the previous year most recently the month before, for which he was hospitalized to treat the psychotic symptoms the intoxication produced. It was noted that the Veteran was employed for 3-4 months as a welder, until March 2006. He felt that his medication prevented him from being as efficient as he would like, and he had concerns (apparently for safety reasons) performing his task 4 to 5 floors up, on a harness system . The Veteran reported having been married for 29 years. The Veteran talked to his parents weekly and he spoke regularly to one brother. The Veteran had friends at church and knew his neighbors, although he added that he tried to avoid long conversations with people. The Veteran spent his time cleaning, attending church, watching TV, and attending his parole officer appointments. It is noted that the examiner indicated that the Veteran's PTSD did not preexist the first diagnosis in 2005 in that the Veteran's drug use had dominated the clinical picture since his separation from the military. The examiner stated that occupational and social impairment were of a mild to moderate degree, and a GAF of 55 was assigned. VA outpatient records dated in November 2006 and January 2007, show the Veteran reported episodes of anxiousness and restlessness, but he was not suicidal. As the anniversary of his child's death approached, however, he reported he was somewhat low. In April 2007, the Veteran was hospitalized on a voluntary basis, due to increasing depression, poor appetite, repetitive motions, and hearing voices. This was for a period of 5 days, during which the Veteran was described as actively involved, but not very sociable with his peers; cooperative with the staff and compliant with ward routines. He improved every day, and it was thought that the metabolic derangements from the Veteran's chronic renal insufficiency sometimes caused the Veteran to be lethargic and confused. By the time of his discharge, the Veteran was alert, cooperative and interactive, with normal speech, and a pleasant affect. However, his GAF score was 49. Records dated two weeks after his discharge show the Veteran reported that he had done well and he denied any recurrence of auditory or visual hallucinations. He also stated that his mood had been stable and mellow, and he had been sleeping well. Of note, the Veteran reported good compliance with his medication and he denied abusing any illicit drugs. The Veteran spent his day doing chores and feeding his chickens, including painting and yard work in the neighborhood to supplement his income. The Veteran was cooperative and in good spirits. Speech was normal, affect was pleasant, and mood was good. Thought processes were logical and goal-directed, and there was no overt psychosis. The Veteran denied any hallucinations or delusions and denied any suicidal ideation or homicidal ideation. He was oriented to person, place and time. In July 2007, the Veteran reported being irritable and down nearly every day, together with feelings of disappointment and lack of motivation. He stated that he had nightmares approximately 3 times per week related to Vietnam or to drugs, but denied any hallucinations or delusion. He also stated that he prefers to be left alone and reported he broke a lamp during a recent disagreement with his wife. The Veteran was described as cooperative, but his speech was slow, and while his thoughts were logical, they were mildly tangential. In October 2007, the Veteran was examined by Community Counseling Associates to determine if he qualified for Social Security Administration (SSA) benefits. The Veteran was polite and cooperative, but he denied having any friends or hobbies. He did report enjoying television and he stated that he attended church twice a month. The Veteran was noted to be able to dress himself and make phone calls, but he was unable to drive, prepare his own meals or shop for himself. The Veteran reported difficulty maintaining attention or concentration long enough to finish tasks. His hygiene. grooming and concentration were fair, and his speech was clear and spontaneous. The Veteran's thought processes did not appear clear or goal-directed as there was evidence of disorganized thought. The Veteran denied any delusions, or suicidal ideation or homicidal ideation, but he did state that he sometimes heard voices. The Veteran's mood was tired and his affect was congruent with his mood. The Veteran's insight and judgment were poor. The examiner opined that the Veteran was not able to manage benefits payments in his own best interest, though he understood the meaning of filing for benefits. It was ultimately concluded the Veteran was unable to perform sustained competitive work without interruption from psychological symptoms. November 2007 VA records reflect the Veteran reported having good and bad days, but was cooperative and well-groomed. His mood was "okay" but the treatment provider noted that the Veteran looked depressed. The Veteran's affect was described as constricted, but stable and appropriate. His speech was normal in rate/tone and was not pressured. The Veteran denied any delusions or hallucinations, and his thoughts were coherent and logical. As to the appeal period coinciding with the Veteran's incarceration (2000 -October 2005), the Board considers the most probative evidence of the impairment arising from PTSD to be the absence of any treatment for it, in the context where any such treatment for it would have been readily available. Indeed, the pertinent letter from the associate warden indicated the Veteran would have needed to only sought it out to obtain an assessment and appropriate treatment. This absence of treatment is a strong indication that the Veteran was not exhibiting symptoms as would warrant the next higher rating, many of which are of such a nature that it would seem likely to have garnered the attention of prison staff, and triggered some evaluation or treatment. (The 70 percent rating may be assigned with manifestations of symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships.) The absence of any treatment in the context of the Veteran's confinement, would outweigh any self serving statements from the Veteran, or statements from relatives concerning the Veteran's impairment during that time, since those relatives would not have been in a position to observe him on a regular basis. Under the foregoing circumstances, the Board concludes that the criteria for a rating in excess of 50 percent prior to October 2005, have not been met. As to the appeal period from October 2005 to November 2007, when the Veteran was awarded a 100 percent schedular evaluation, the Board observes that when examined for VA purposes in October 2005, while the Veteran reported he was depressed and had sleep problems, he was appropriately groomed and cooperative, with a normal rate and volume of speech. He was alert and oriented, with his judgment assessed as good, and his thought processes considered coherent and logical, (although tangential at times). There was no evidence of psychosis or suicidal ideation during the interview. Thus, he does not appear at that time to satisfy the criteria for a 70 percent schedular evaluation, (deficiencies in most areas). Thereafter, the record shows the Veteran apparently obtained employment as a welder, and sought out the services of a Vet Center. Certainly these actions are not indicative of an individual with deficiencies in most areas, but rather those of an individual appropriately re-entering society following years of incarceration. Indeed, the Vet Center records describe the Veteran as fully oriented, relaxed, with an appropriate affect and speech. Although the Veteran was hospitalized for a brief period at the end of January 2006, the psychotic symptoms which brought this about were triggered by cocaine intoxication, and he evidently maintained employment through March 2006. At that time, he apparently enrolled in a substance dependence treatment program which he successfully completed in September 2006. Although he stopped working during this period, this is not shown to be exclusively due to PTSD symptoms, but also contemplated what appear to be reasonable concerns for safety. (It is also noted that the criteria for a 30 percent rating , the next lower evaluation, contemplates intermittent periods of inability to perform occupational tasks.) Likewise, during this time, the Veteran was described in various treatment records as alert, friendly, cooperative, interactive and oriented. He also was apparently attending church and exercising regularly. When examined for VA purposes in November 2006, the Veteran's level of impairment was described as only mild to moderate. The following April, however, the Veteran was again hospitalized for his psychiatric symptoms. These records do not show any acute intoxication to account for them, and although one record shows a treatment provider implicated metabolic derangements as a cause for the lethargy and confusion, these were not the only symptoms which appear to have brought about this in-patient stay. In addition, at this point, the Veteran had not been working in excess of a year, and records dated in July 2007 show the Veteran reporting he was irritable and down on nearly a daily basis; that he had little motivation; and broke a lamp in a disagreement with his wife. By October 2007, an evaluation for Social Security purposes concluded the Veteran was unable to sustain competitive work due to his psychiatric symptoms. In view of this, the Board concludes that by the time of the Veteran's April 2007 hospitalization, his condition had deteriorated to the point that he was rendered totally disabled. Thus, while a rating in excess of 50 percent is not found warranted prior to April 2007, the Board finds that entitlement to a 100 percent schedular evaluation from April 9, 2007 is warranted, and to this extent, the appeal is granted. In reaching this decision, the Board has considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's PTSD that would render the schedular criteria inadequate. Indeed, the language of the rating criteria is so broad, it could be construed to contemplate most any particular symptom. Accordingly, an extraschedular rating is not warranted. Varicocele The Veteran currently receives a noncompensable rating for his varicocele. Varicoceles are rated by analogy to varicose veins under 38 C.F.R. § 4.104, 7599-7120. Under 38 C.F.R. § 4.20, when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. As such, there are other Diagnostic Codes under which the Veteran's right varicocele could be evaluated; however, in reviewing the evidence of record, the Board finds that the preponderance of the evidence is against a finding that the Veteran has any residuals of the right varicocele. Under Diagnostic Code 7120, a 10 percent rating is assigned when the varicocele causes intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent rating is assigned when the varicocele causes persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. In May 2006, the Veteran submitted a claim indicating that his right varicocele had increased in severity. In a November 2005 VA treatment record, the Veteran was noted to control his diet and work out. He denied any increased urgency or frequency, nocturia, hematuria, or erectile dysfunction. In May 2005, the Veteran was seen at VA where he complained of increased urinary frequency at night. It was noted that the Veteran had an enlarged prostate. In July 2006, the Veteran was seen for his varicocele. He complained of urinary frequency, but no dysuria or hematuria. The Veteran did not describe lethargy, weakness, anorexia or weight loss or gain. It was noted that the Veteran had right and left varicoceles, with the right being more pronounced than the left. However, the examiner found that the left varicocele was unrelated to the Veteran's military service. Moreover, the Veteran asserted that the varicoceles were not particularly more bothersome than they had been at previous times. In August 2007, the Veteran underwent a VA examination. The examiner reviewed the Veteran's claims file. At the examination, the Veteran was noted to do a poor job of describing his symptoms. He stated that he had varicose veins in the scrotum and in the upper and lower legs. He thought these were disabling, but when the examiner actually pressed him about the limitations caused, the Veteran was only able to respond in a very generalized way. The Veteran was able to ambulate without difficulty. When asked about his voiding ability, the Veteran stated that he voided satisfactorily. The Veteran acknowledged nocturia and had occasional urgency. The Veteran denied taking any medication for his scrotal or genital conditions. The Veteran reported being sexually active. On examination, the Veteran's testes were of normal size, shape and consistency. The examiner concluded that the Veteran's varicoceles were unlikely to contribute to the weakness and fatigue in the Veteran's lower extremities. In May 2009, the Veteran testified at a hearing before the Board. The Veteran's representative indicated that they were seeking a 10 percent rating for slow, weak stream and decreased force and hesitancy. The Veteran's wife testified that the Veteran took a pill that was supposed to stop the frequency of the urination. The Veteran was provided with a VA examination in February 2010. It was noted that the Veteran had never had any urinary procedure to correct his varicocele. The Veteran did have urinary symptoms, urgency, a weak stream, dysuria, straining to urinate, and a daytime voiding interval of 1-2 hours. The Veteran also reported urinary incontinence and stated that he wore absorbent material. However, after examining the Veteran, the examiner noted that there were no effects of the varicocele on the Veteran's activities of daily living. The examiner found that there was no active treatment for the varicocele and that the Veteran was not experiencing any current residual symptoms as a result of the varicocele. The examiner stated that symptoms of a varicocele may include aching pain within the scrotom, a feeling of heaviness in the testicle, atrophy of the testicle, or visible or palpable enlarged vein. In some cases it could cause infertility. In May 2010, the Veteran's claims file was again sent to a VA examiner to clarify whether the Veteran's voiding symptoms were due to his varicocele. The examiner found that BPH and kidney disease were responsible for the urinary problems. It is noted that the Veteran's spouse wrote a letter in January 2011 arguing that the Veteran displayed all the symptoms required for a 10 or 20 percent rating based on voiding problems, and based on weakness of stream. The Board understands her confusion, but her argument ultimately does not show that a compensable rating is warranted for the Veteran's varicocele. The Board does not dispute that the Veteran has a number of urinary symptoms including incontinence. This is clearly shown by the medical evidence of record. However, the issue is not whether the Veteran has these symptoms, but rather whether they are the result of his service connected varicocele. The Veteran was given a VA examination to ascertain if his varicocele caused any disabling symptoms, but the examiner in February 2010 did not find that any symptoms were the result of the Veteran's varicocele. This conclusion is supported by the fact that the Veteran has not undergone any medical procedure to treat the condition and that he is not receiving any treatment for it right now. The Veteran's claims file was reviewed again in May 2010 to determine whether the Veteran's varicocele caused any of his urinary problems, but the examiner concluded that the urinary problems were the result of impairment from other disabilities that are not service connected, namely BPH and kidney disease. As such, because the Veteran's service connected right varicocele is essentially asymptomatic, a compensable rating is not warranted, and the Veteran's claim is denied. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and 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. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In this case, the Veteran's claim for service connection for PTSD was granted. He then appealed the downstream issue of the rating that had been assigned. Under these circumstances, since the original claim was granted, there are no further notice requirements under the aforementioned law with regard to that issue. With regard to the Veteran's claim of entitlement to service connection for an increased rating for a varicocele, required notice was provided by a letter dated in June 2006, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above, as well as informing him how disability ratings and effective dates were assigned. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Private and VA treatment records have been obtained, as have SSA records. Additionally, the Veteran testified at a hearing before the Board. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). The Board finds the VA examinations in their entirety to be thorough and adequate in that they provide a sound basis upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. The Veteran's representative argued in a June 2011 statement that the examinations that were provided for the Veteran's varicocele were not adequate arguing that the examiner addendum addressed BPH, but that the Veteran's prostate was not specifically examined at the VA examination. The representative also felt that the Veteran's kidney should have been examined at the VA examination. However, while much of the Veteran's testimony at his hearing focused on his urinary problems, no medical evidence has been advanced suggesting that the Veteran's urinary problems were caused by his service connected varicocele. The first examiner examined the Veteran's varicocele and provided an opinion that it was not symptomatic. The RO then sought an opinion on the urinary problems in an effort to be thorough. This second opinion contemplated the Veteran's current medical problems and the examiner identified the likely causes of the Veteran's urinary problems. As such, nothing about either examination appears inadequate. To the extent that the Veteran believes his kidney disease is related to his military service, he may file a claim for service connection for it. However, to date this has not been done. VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Entitlement to a disability evaluation in excess of 50 percent for PTSD, prior to April 9, 2007, is denied. Entitlement to a 100 percent schedular rating for PTSD, from April 9, 2007, is granted. A compensable rating for right varicocele is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs