Citation Nr: 1237441 Decision Date: 11/01/12 Archive Date: 11/09/12 DOCKET NO. 09-27 406 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for lung cancer. 2. Entitlement to service connection for scars as residuals of cancer. 3. Entitlement to service connection for a neck disorder. 4. Entitlement to service connection for a hearing loss disability. 5. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a back disorder. 6. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran served on active duty from February 1983 to February 1987, from August 1990 to April 1991, and from April 1995 to June 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. The issues of entitlement to service connection for lung cancer, residual scars from the cancer surgery, and neck and back disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have a hearing loss disability within the meaning of the laws and regulations providing compensation benefits. 2. A sensorineural hearing loss was not manifested within the year after the Veteran completed any period of active service. 3. In May 2004, a VA RO denied service connection for a back disorder. The Veteran did not submit a timely notice of disagreement with that decision. 4. Evidence of record at the time of the May 2004 RO decision included the service treatment records showing a back injury in service and post service VA treatment records that were interpreted as not showing a chronic back disability. 5. Evidence received since the May 2004 RO decision, includes VA hospital records with a diagnosis of a chronic back disability. This evidence was not previously submitted to agency decisionmakers. By itself or when considered with previous evidence of record, it relates to an unestablished fact necessary to substantiate the claim. It is neither cumulative nor redundant of evidence of record at the time of the May 2004 denial and raises a reasonable possibility of substantiating the claim. 6. The service-connected PTSD approximates 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. CONCLUSIONS OF LAW 1. The criteria for service connection for a hearing loss disability have not been met. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 2. The May 2004 rating decision that denied service connection for a back disorder is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2012). 3. Evidence received since the RO's 2004 decision is new and material and the veteran's 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 (2012). 4. The criteria for a 100 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims file and Virtual VA file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Consequently, the following discussion will be limited to the evidence the Board finds to be relevant. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board specifically finds that any evidence not discussed does not support the claims. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA) and subsequent legislation, VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In a letter dated in October 2008 the RO provided the Veteran with an explanation of the type of evidence necessary to substantiate his claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. He was advised that service connection for a back disorder was previously denied and was notified of the information and evidence that was necessary both to reopen the claim and to establish entitlement to the underlying benefit sought. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The October 2008 notice letter also provided notice regarding potential ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The initial notice letter was provided before the adjudication of his claims in February 2009. VA has complied with the notice requirements of VCAA and has no outstanding duty to inform the appellant that any additional information or evidence is needed. Therefore, the Board may decide the appeal without a remand for further notification. For the issues decided herein, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service medical records have been obtained. His available post-service treatment records have also been obtained. Social Security Administration (SSA) records have been associated with the claims folder. The Veteran has had VA examinations and medical opinions have been obtained. He has declined the offer of a hearing. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Hearing Loss Disability In order to establish service connection, three elements must be established. There must be medical evidence of a current disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 U.S.C.A. §§ 101(16), 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). It is not enough to show injury during service, there must currently be a residual disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There must be a current disability. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A sensorineural hearing loss may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent or more within the first year following active service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). What constitutes a hearing loss disability is defined by regulation. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). The service treatment records do not show a hearing loss within the regulatory definition of Section 3.385. On examination for separation from active service, in February 2000, the Veteran's ears and drums were reported to be normal. Audiologic evaluation showed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 05 05 05 05 00 10 LEFT 05 00 10 10 05 20 There was a diagnosis of mild high frequency hearing loss in the left ear. On the authorized VA audiologic evaluation in September 2011, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 15 25 LEFT 5 10 15 20 35 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 100 percent in the left ear. The examiner reviewed the service treatment records and noted that the Veteran had multiple audiograms is service. From the earliest to the most recent, the Veteran did not exhibit a shift in audiologic thresholds. The examiner explained that there was no current evidence in the medical literature to support the delayed onset of hearing loss following noise exposure. Therefore, the examiner was of the opinion that it was less likely than not that military noise exposure caused the Veteran's hearing loss. The February 2000 examination for separation from active service included an audiometric examination resulting in a diagnosis of mild high frequency hearing loss in the left ear. The September 2011 VA audiology examination concluded by diagnosing sensorineural hearing losses in the frequency range of 6000 Hertz or higher for the right ear and in the range of 500 to 4000 Hertz for the left ear. Thus, there is no dispute that the Veteran may experience decreased hearing in some situations. However, compensation is based on average industrial impairment and not all diagnoses or conditions result in a compensable level of industrial impairment. The audiometric examination findings provide the preponderance of evidence in this case and show that the Veteran does not have a hearing loss disability within the meaning of the laws and regulations providing compensation benefits. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 510 7(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Whether New and Material Evidence Has Been Received to Reopen a Claim of Entitlement to Service Connection for a Back Disorder In May 2004, a VA RO denied service connection for a back disorder. The RO explained that although there was a record of treatment in service for low back pain, no permanent residual or chronic disability subject to service connection was shown by the service treatment records or demonstrated by the evidence following service. The Veteran did not submit a timely notice of disagreement with the May 2004 decision. Decisions of the RO which are not appealed are final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2012). However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the claim will be reopened and the former disposition reviewed. 38 U.S.C.A. § 5108 (West 2002). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of 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. 38 C.F.R. § 3.156(a) (2012). In this case, the claim was denied in May 2004 because there was no evidence that met the first criteria for service connection. That is, there was no evidence of a chronic back disability. However, when the Veteran was hospitalized by VA in December 2004, the physical diagnoses on Axis III included a diagnosis of chronic episodic back pain with left sciatica, quiescent, in setting of reported outside MRI evidence of lumbarization of S1 with spurring and disc bulging causing neuroforaminal encroachment. Similar diagnoses were reported on VA hospitalizations in June 2005, October and November 2005, and January and February 2007. In as much as the claim was previously denied because there was no evidence of chronic back disability and now we have such evidence, the claim must be reopened. The Board notes that the service treatment records do document a back injury in service, in May 1986, with subsequent complaints in September and October 1986. Rating PTSD, Currently 70 Percent Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2012). The Board has considered all the evidence of record. Specifically, we have gone back at least a year before the date the claim was received. See 38 C.F.R. §§ 3.157, 3.400(o) (2012). However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. See Francisco v. Brown, 7 Vet. App. 55 (1994). Criteria Effective on and after November 7, 1996, the General Rating Formula for Mental Disorders, including PTSD, is: 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...................................................................................100 percent; Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.................................70 percent; Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships........................50 percent; Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)..............................................................................................30 percent; Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication...............................................10 percent; A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication...................................................0 percent. 38 C.F.R. § 4.130 (2012). The global assessment of functioning (GAF) is a scale reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). See Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF from 51 to 60 is defined as 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). A GAF of 41 to 50 is defined as "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)." DSM-IV, at 32; Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF from 31 to 40 indicates some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family and was unable to work). See Cathell v. Brown, 5 Vet. App. 539 (1996). GAF scores attempt to cover the complete range of functioning from persons who must not only be hospitalized but require constant supervision to persons who function exceptionally well. VA Ratings for compensation purposes cover the much narrower range of industrial impairment. Consequently, GAF scores and VA ratings do not correlate well. We cannot say that a certain GAF score equals a certain rating. However, GAF scores do reflect a medical opinion as to the extent of the impairment and will be considered. Background The Veteran received inpatient treatment for chronic PTSD and depression NOS (not otherwise specified) in January and February 2007. The GAF was 38. He described the previous year as not so good. He reported frequent sad moods, anxiety, irritability, pan-insomnia, fatigability, memory problems, loss of concentration, restlessness, decreased libido, social withdrawal, and anhedonia. Mental status examination revealed an anxious and depressed mood, and an affect that was constricted but appropriate to thought content. Other findings were essentially normal. The Veteran was neat, clean, cooperative and in good contact. No gross motor abnormalities were noted. He was alert and oriented. There was no significant cognitive or memory impairment. There was no formal thought disorder. The records relating to the August 2007 lung cancer surgery do not reflect any active psychiatric symptomatology. The current claim was received in September 2008. The report of the December 2008 VA examination shows that the claims folder and medical records were reviewed. It was noted that on a previous examination, in January 2005, the GAF was 45. The examiner also noted a 2 week hospitalization in April 2008 for stabilization of PTSD symptoms. The Veteran complained of an occasional sad mood, anxiety, insomnia, irritability, being under stress, problems with memory and concentration, restlessness, decreased libido, and social withdrawal. PTSD symptoms included recurrent thoughts and dreams of traumatic combat experiences, flashbacks, emotional and physiological reactivity to cues, amnesia for parts of relative events, avoidant behavior, emotional numbing and distancing, a sense of a foreshortened future, hypervigilance, and an exaggerated startle response. The GAF at time of discharge was 40. It was the opinion of the treatment team that the Veteran was unemployable. The December 2008 VA examination provided details of many aspects of the Veteran's history. The Veteran discussed the factors that led to leaving his last job. The Veteran endorsed witnessing traumatic and life threatening events in service. He said he was currently bothered by recurrent memories, thoughts, and dreams about his traumatic military events, and distress when he heard or saw things that reminded him of the events. He also endorsed anger, persistent avoidance, numbing, and hyperarousal. Mental status examination revealed that the Veteran was mostly well oriented except that he identified the season as winter rather than fall (the examination was on December 15). He correctly responded to spelling tests. He was alert but his attention was impaired during the interview. He became tangential during the serial subtraction of 7's. His abstract reasoning was somewhat concrete. Memory for recent and remote events was spotty. Thought form was occasionally tangential. Overall, the Veteran was lucid and coherent. Thought content was appropriate and not obsessional or delusional. There was no evidence of obsessions, compulsions, ideas of reference, hallucinations, delusions, specific fears, social fears, hypomania, or mania. There was evidence of PTSD symptoms, depressed mood, excessive worry, panic attacks, agoraphobia, and anhedonia. The examiner went on to discuss the Veteran's activities of daily living. He had to push himself to maintain his hygiene. He avoided driving because of fear of panic attacks. As to interests, he liked music. He did not belong to any groups, organizations or clubs. He reported spending a typical day by himself, "just moping and sucking air." The examiner believed the Veteran would have difficulty carrying on a normal conversation due to the severity of his psychiatric symptoms, his social isolation and withdrawal, and his tendency to become tangential and perseverate, and become easily irritated. The examiner summarized that the Veteran's symptoms were chronic and severe despite a recent hospitalization. He essentially reported continuous symptoms of re-experiencing severe avoidance, severe emotional numbing, and considerable and serious symptoms of hyperarousal. His panic disorder had progressed to a panic disorder with agoraphobia. That was secondary to and related to the chronicity and severity of his service-connected anxiety disorder/PTSD. The GAF score was 45 and the examiner explained that it reflected a severe degree of impairment in all facets of the Veteran's daily life, including occupationally, socially, and interpersonally. The examiner was of the opinion that the Veteran's psychiatric conditions caused him to be unemployable. He was unable to obtain or maintain gainful employment of any kind, including physical or sedentary due to the severity of his PTSD. The Veteran was hospitalized for stabilization of his PTSD symptoms, at a VA facility for almost two weeks in February 2009. Current symptoms included hypervigilance, poor sleep, nightmares, occasional flashbacks, depression, severe anxiety at times, intrusive thoughts of war experiences, anger, rage, emotional numbing, social isolation, survivor guilt, a sense of a foreshortened future, avoidance of things that reminded him of war experiences, and an exaggerated startle reflex. Mental status at time of discharge was alert, calm, cooperative, clear, and goal directed. The GAF went from 38 on admission to 48 at time of discharge. A March 2009 VA mental health clinic note shows the Veteran was very pleasant but very anxious and close to expression of painful emotion. He was alert, oriented, casually dressed, and well groomed. He made good eye contact. No abnormal movements were noted. Speech was spontaneous and normal in rate and rhythm. Mood was euthymic and affect was congruent. Thought processes were linear and goal oriented with content reality based. There were no delusions, suicidal or homicidal ideation, or audio or visual hallucinations. Insight and judgment were good. He had an angry tone but was calm and not personal. Attention and concentration as well as recall were intact. He felt he had no goals. The GAF was 55-50-50. The GAF screening score was 45. There were similar mental status findings and GAF scores on VA clinical notes dated in December 2009, March 2010, and April 2010. The Veteran was reached by telephone in May 2010. He was not suicidal but depressed and suffering from PTSD symptoms greatly. He was not sleeping more than a few hours, restless, having trouble with his chest, isolative, withdrawn, and not relating to family much. The contact he had with his mother was mostly negative because she conveyed a lack of understanding and intolerance. He asked to have an admission arranged. The writer entered a GAF of 46. The Veteran was admitted to a VA Medical Center in May 2010 for three weeks of inpatient treatment. The June 2010 discharge summary noted that his clinical course during the admission was uneventful. The Veteran was complaint with program guidelines, active in treatment, and utilized the program to learn and implement coping skills. At discharge, he displayed improved coping skills, mood and behavior. He developed concrete goals to pursue post discharge. Mental status examination on discharge showed a brighter affect and was otherwise unchanged from admission. Diagnoses were chronic PTSD and Depression NOS (not otherwise specified). The GAF was 38. A staff psychiatrist reported that the Veteran was competent but unemployable during his hospitalization. The Veteran was admitted to a VA medical center in May 2011 for a 3 week voluntary, scheduled admission. On admission, he reported frequent sad moods, anxiety, pan-insomnia, irritability, fatigability, problems with memory and concentration, restlessness, decreased libido, social withdrawal, and essential anhedonia. He also reported recurrent thoughts and dreams of traumatic combat experiences, flashbacks, emotional and physiologic reactivity to cues that reminded him of the events, amnesia for parts of relevant events, avoidant behavior, emotional numbing and distancing, a sense of a foreshortened future, hypervigilance, and an exaggerated startle response. Mental status examination on admission disclosed a moderately depressed mood with mild anxiety. Other findings were within normal limits. The Veteran was awake, alert, cooperative, and had good eye contact. No tremors or abnormal movements were noted. Speech had a normal rate, rhythm, tone, and prosidy. His affect was full range and mood congruent. Cognition and memory were intact. There was no suicidal or homicidal ideation or intent. There were no auditory or visual hallucinations. Thought processes were linear. There were no delusions. Insight and judgment were good. The admission diagnoses were chronic PTSD and depression, NOS (not otherwise specified). The GAF was 38. Upon completion of the 3 week program, the Veteran described ongoing problems with high anxiety, intrusive combat memories, hypervigilance, anger, mistrust, difficulty being in public places, a sense of estrangement, fear of intimacy, avoidance of reminders of combat trauma, frequent social isolation, and depression. He said he had not been able to work since 2005, due to his symptoms. He described limited socializing at home. His GAF was continued at 38. Outpatient treatment was planned. The Veteran was seen for a VA mental examination in July 2011. PTSD was specifically included in the assessment. The Veteran's claims folder and medical files were reviewed. The Veteran's history was discussed. Physical problems were noted. The Veteran reported that he tended to be in hiding and not go out. He said that loud noises put him in a trance. He did not sleep well and was hypervigilant. He had lung cancer and joint pain. On mental status examination, findings were essentially normal. The Veteran described his mood as "okay." His affect was euthymic. He was cooperative, pleasant and appeared to be reliable. He was reasonably dressed and groomed. He was not withdrawn or agitated. There was no evidence of motor retardation or motor abnormalities. Eye contact was good and speech was within normal limits. He denied auditory, tactile, or visual hallucinations. He was oriented. There was no evidence of lost or altered consciousness. Short and long term memory was good. He had difficulty completing serial 7's, but other tests of mental function had normal results. He was able to interpret 2 out of 3 proverbs. He denied any obsessive thinking or compulsive behaviors. The Veteran reported that he had feelings of inadequacy and worthlessness along with hopelessness, sometimes. He slept 3 to 5 hours and had difficulty staying asleep. He stated that his energy level was okay once he started moving. His only interests and hobbies were listening to music and walking. He stated that he had no libido. He was irritable. He denied tearfulness, symptoms of mania, or panic attacks. The Veteran said that on a typical day he would get up at 5 O'clock in the morning, go out on the porch, and then go for a 20 minute walk. He would then come home and have breakfast. His girlfriend would visit in the afternoon. He also watched television. He had trouble sitting due to low back pain. The only relative he was close to was his sister. He estimated that he had two friends. He did not belong to any clubs or groups. He was casually acquainted with the other residents in the facility that he lived in. The examiner noted that concentration was unimpaired. The Veteran had no problems completing tasks, although he reported procrastination. With regard to PTSD symptoms, the Veteran stated he had recurrent nightmares 3 to 4 times a week and also had flashbacks. He tried to avoid thoughts and feelings associated with the trauma. He avoided certain activities and situations, particularly crowds that were recollections of the trauma. There was a markedly diminished interest in significant activities and he tended to feel detached from others. Persistent symptoms of increased arousal included difficulty staying asleep, irritability, hypervigilance, and an exaggerated startle response. The examiner noted that the symptoms of increased arousal seemed to be in remission. Ongoing treatment included medication and regular visits to the VA PTSD clinic. The July 2011 VA examination concluded with a GAF of 50. The examiner explained that the Veteran's PTSD symptoms had a moderate negative impact on his ability to obtain and to maintain physical or sedentary employment and his thought processes and communication skills were expected to cause significant interference with his social functioning. Conclusion A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the criteria ("such symptoms as") provides guidance as to the severity of symptoms contemplated for each rating in addition to permitting consideration of other symptoms particular to the Veteran. Id. For the next higher evaluation under the rating schedule, the evidence must show 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. In this case, the record shows that the Veteran has a number of recent GAF scores below 40. This reflects some impairment in reality testing or communication or major impairment in several areas. Such a disability picture is consistent with the symptomatology for which the rating schedule provides a 100 percent evaluation. Further, there have been several hospitalizations for PTSD. There are also a number of medical opinions to the effect that he is unemployable. Giving the Veteran the benefit of the doubt, the Board finds that his PTSD symptoms do indeed approximate the total occupational and social impairment required for a 100 percent evaluation under the rating schedule. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.120, 4.130, Diagnostic Code 9411 (2012). ORDER Service connection for a hearing loss disability is denied. In as much as new and material evidence has been received, the claim of entitlement to service connection for a back disorder is reopened. To that extent, the appeal is granted. A schedular disability rating of 100 percent for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary awards. REMAND A VA medical opinion will be deemed necessary when there is competent evidence of a current disability or persistent or recurrent symptoms of disability; and, the evidence, including statements by the claimant, indicates that the disability or symptoms may be related to active service; but, there is not sufficient medical evidence to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4) (2012). See McLendon v. Nicholson, 20 Vet. App. 79, 82-83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed Cir. 2010); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010). A service treatment record, dated in May 1986, shows the Veteran fell down a ladder and had back pain. He had some pain on range of motion and a small red spot on his back. He also complained of pain in the left shoulder. The assessment was a muscle strain secondary to a fall. In September 1986, the Veteran complained of upper and middle back pain from the neck radiating down the right side. The only known trauma was in May 1986. There were complaints of posterior neck and mid-back pain. Examination revealed some spasms in the mid-back. The assessment was spastic torticulosis. Further complaints of neck and mid-back spasm and pain were recorded in October 1986. There was a limited range of motion due to spasm in the neck. The assessment was muscle spasm in the neck and mid-back pain. On VA hospitalizations in December 2004, June 2005, October and November 2005, and January and February 2007, there were diagnoses of chronic episodic back pain with left sciatica, quiescent, in setting of reported outside MRI evidence of lumbarization of S1 with spurring and disc bulging causing neuroforaminal encroachment. VA imaging studies of the cervical spine, in November 2005, disclosed mild C5-6 and C6-7 degenerative disc disease. On a VA mental examination in January 2005, the Veteran claimed that he had aches and pains associated with arthritis and bulging discs in his back, as well as a broken neck, from service. Under these circumstances it is desirable to obtain a medical opinion as to the likelihood that the current neck and back findings are related to the injury and neck and back findings in service. In August 2007, the Veteran had surgery to remove lung cancer found in his right upper lobe. He claims that the cancer and its residuals are the result of chest pain noted when he was examined for separation from service in February 2000. As a lay witness, the Veteran is considered to be competent to report continuing chest symptoms, although he does not have the medical training and experience to diagnose the cause of those symptoms. 38 C.F.R. § 3.159(a) (2012). Here, again, a medical opinion is desirable. Accordingly, the issues of entitlement to service connection for lung cancer, residual scars from the cancer surgery, and neck and back disorders are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should associate the Veteran's clinical records from August 2002 to August 2007 with his electronic Virtual VA records. 2. The term "at least as likely as not," as used below, does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against causation. 3. The Veteran should be scheduled for a VA examination of his neck and back. The claims file should be made available to the examiner. Current imaging studies of the neck and back, as well as any additional tests or studies that the examiner thinks might be helpful to respond to the following question should be done. a. What can be determined from the degenerative changes seen on the November 2005 VA imaging study? Specifically, can it be determined from the state of advancement seen in November 2005, whether it was at least as likely as not that the degenerative changes began prior to the Veteran's release from active service in June 2000? Please explain. b. By definition, lumbarization is a congenital anomaly of the lumbosacral junction characterized by development of the first sacral vertebra as a lumbar vertebra, resulting in six lumbar vertebrae instead of five. STEDMAN'S MEDICAL DICTIONARY, 1034 (27th ed., 2000). While service connection cannot be granted for a congenital anomaly, benefits can be granted for superimposed injury. 38 C.F.R. §§ 3.303(c), 4.9 (2012). Is it at least as likely as not that the Veteran has superimposed residuals of the back injury in service? Specifically, is it at least as likely as not that the lumbosacral disc bulging causing neuroforaminal encroachment is the result of injury in service? Please explain. 4. The Veteran should be scheduled for a VA examination to determine the origin of his lung cancer and its residuals. The claims folder should be made available to the examiner for review in conjunction with the examination. Any tests or studies the examiner may feel would be useful to respond to the following questions should be done. The examiner should respond to the following: a. Given the stage of the Veteran's lung cancer when it was removed in August 2007, what would, at least as likely as not be the time frame for its onset? Please explain. b. Given the Veteran's documented complaints of chest pain on separation examination, in February 2000, was it at least as likely as not, that this was an early symptom of his lung cancer? Please explain. 5. Thereafter, the AOJ should review the examiner's opinions. If any opinion is incomplete or fails to respond to the Board's questions, it should be returned for completion. If any additional tests or specialist examinations are recommended, they should be done. See Hyder v. Derwinski, 1 Vet. App. 221 (1991). 6. Subsequently, the AOJ should readjudicate these claims in light of any evidence added to the record. If any benefit sought on appeal remains denied, the appellant and his representative should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Subsequently, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. 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. 2012). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs