Citation Nr: 1301216 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 11-21 566 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for breast cancer, to include residuals thereof. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and his son-in-law ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran served on active duty from January 1951 to October 1952. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2010 and March 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a hearing before the undersigned Veterans Law Judge in September 2012 at the RO. A transcript of those proceedings has been associated with the Veteran's claims file. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Breast cancer and residuals thereof during the pendency of the claim are not shown by competent and credible evidence. 2. The Veteran's report of experiencing hearing loss during service, which continued to the present, is not credible. 3. The Veteran's report of experiencing tinnitus during service, which continued to the present, is not credible. 4. The Veteran's PTSD symptoms result in transient symptoms that cause no more than slight functional impairment, such as avoidance of thinking or talking about his military experiences, not going out much, and having less interest in hunting than he did before service. CONCLUSIONS OF LAW 1. The criteria for service connection for breast cancer, to include residuals thereof, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for service connection for hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2012). 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 4. The criteria for a rating in excess of 10 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). This notice should be provided prior to an initial unfavorable decision on a claim 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). With respect to the Veteran's claims for service connection for breast cancer, hearing loss, and tinnitus, VA's notice requirements were satisfied by letters issued in May 2010 and June 2010, which advised the Veteran of the criteria for establishing service connection, and which were sent prior to the initial adjudication of the Veteran's claims. With respect to the Veteran's claim for a higher initial rating for PTSD, VA has met its duty to notify for this claim. Service connection for this issue was granted in a March 2011 rating decision. The Veteran is now appealing the downstream issue of the initial rating that was assigned. Therefore, additional notice under the Veterans Claims Assistance Act of 2000 (VCAA) is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1131 (Fed. Cir. 2007), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of both service treatment records and other pertinent medical records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the RO has obtained and associated with the claims file the Veteran's service treatment records and records of his post-service VA and private treatment. The RO also requested the Veteran's records from the Social Security Administration (SSA), and SSA replied in September 2011 that there are no medical records pertaining to the Veteran, and because they do not exist further efforts to obtain them would be futile. The Veteran was afforded VA compensation and pension examinations germane to his claims for service connection for hearing loss and tinnitus, and for his claim for a higher initial rating for PTSD, on appeal; these examinations were adequate because the examiners based their opinions upon consideration of the Veteran's prior medical history, described the disabilities in sufficient detail so that the Board's evaluations of the claimed disabilities will be fully informed, and supported all conclusions with analyses that the Board could consider and weigh against contrary opinions. Additionally, the VA examinations of record fully describe the functional effects caused by the Veteran's claimed disorders. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). No VA examination was provided for the Veteran's claimed breast cancer because the information and evidence of record does not contain competent lay or medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of disability. Likewise, no VA examination was provided for the Veteran's claimed scar as a residual of breast cancer surgery because the evidence does not indicate that the claimed disability or symptoms may be associated with any event, injury, or disease in service, or with another service-connected disability. Specifically, the Veteran's treating physician reported that his surgery was for gynecomastia, and that there was no malignancy. Because the Veteran did not have breast cancer, it follows that his surgical scar cannot be a residual of breast cancer, and therefore no examination is warranted. (The Board notes that the Veteran has separately been denied service connection for post operative residuals of gynecomastia on multiple occasions. Since he has demonstrated an ability to distinguish between gynecomastia and breast cancer and they are obviously distinct, it is unnecessary to expand this appeal to include consideration of entitlement to service connection for gynecomastia.) The Veteran also testified before the undersigned Veterans Law Judge in a September 2012 videoconference hearing. The Veteran has not identified any additional relevant, available evidence that is not of record. The Board finds that the evidence already of record is adequate to allow resolution of the appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, specific questions were asked directed at identifying whether the Veteran had symptoms meeting the criteria for service connection and a higher initial rating, as applicable. The VLJ did not specifically seek to identify any pertinent evidence not currently associated with the claims. This was not necessary, however, because the Veteran volunteered his treatment history and symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). For the foregoing reasons, the Board concludes that VA made all reasonable efforts to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Service Connection In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. Establishing direct service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Analysis: Breast Cancer The Veteran asserted in January 2010 that he was exposed to radiation while stationed in Nevada, and that he subsequently had breast cancer surgically removed. In April 2010, the Veteran again asserted that he had cancer that was incurred during service. In his August 2010 notice of disagreement, the Veteran stated that he was denied a job with an oil company after his discharge from service in October 1952 because the company's physical examination of him revealed breast cancer. He stated that he then had surgery on his left breast, and later found out that he had mesothelioma. In January 2011, the Veteran reported that during service at the end of 1951 he was assigned to remove power lines in Nevada that had been exposed to nuclear radiation. At his September 2012 hearing, the Veteran testified that the presence of red blotches on his skin shows that he was exposed to radiation. See transcript, pp. 7-8. He further asserted that he was exposed to "radiation burn" on a "communication line" in service. Id., p. 8. Finally, the Veteran asserted that he has a tender and painful scar on his left breast as a result of breast cancer surgery in 1952; his representative characterized the scar as a residual of breast cancer. Id., pp. 9-11. Also of record are January 1994 Fact Sheets regarding Veteran's services for the Nuclear Test Personnel Review Program, and a February 2012 Ionizing Radiation Worksheet, VA Form 10-0020A, partially filled out by the Veteran. The Board finds that the January 1994 documents are of general applicability and do not show that the Veteran has a current diagnosis of breast cancer during the pendency of the claim. Similarly, the February 2012 document reflects the Veteran's self-diagnosis of multiple myeloma (to which he checked both "yes" and "no"); cancer of the renal pelves, ureters, and urethra; and cancer of the prostate. The Veteran's service treatment records include no complaints, diagnosis, or treatment of breast cancer. In his October 1952 Report of Medical History, the Veteran reported that he did not have, and had never had, a tumor, growth, cyst, or cancer. He also indicated that he had never worked with a radioactive substance. Likewise, in his October 1952 Report of Medical Examination, a clinician found that the Veteran's chest (including breasts) and skin were normal on evaluation. The Board finds that the Veteran's contemporaneous statements in October 1952 denying any tumor, growth, cyst, or cancer are entitled to greater probative weight than his statements to the contrary during the course of his claim. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than subsequently reported history). After service, according to a March 1960 document from the Veteran's treating physician, the Veteran was diagnosed with enlargement of the left breast in December 1952. The Veteran then underwent surgical excision of the left breast tumor, which was shown to be gynecomastia with no malignancy. (The Board notes that it most recently denied the Veteran's request to reopen a claim for service connection for post operative residuals of gynecomastia of the left breast in June 1997.) The Board finds that the Veteran does not have a current diagnosis of breast cancer during the pendency of the claim-in this case, in or after January 2010. The Veteran's lay statements that he has breast cancer, and that it resulted from radiation exposure in service, are not competent in this case because diagnosing breast cancer involves complex medical questions and the interpretation of objective medical tests such as biopsies, and the Veteran has not shown that he has such medical knowledge. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (certain conditions are not capable of lay diagnosis); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011) (when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent). Moreover, the probative value of the Veteran's lay statements to the effect that he had surgery for breast cancer in the 1950's, and other diagnoses of breast cancer, is outweighed by his treating physician's March 1960 report showing that the Veteran's surgically removed left breast tumor was shown to be gynecomastia with no malignancy-i.e., not breast cancer. Consequently, service connection for breast cancer is unwarranted in this case. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Giplin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). Likewise, service connection for a surgical scar as a residual of breast cancer is unwarranted because, as the Veteran's treating physician reported in March 1960, the Veteran's surgery was for gynecomastia, and the Veteran did not have any malignancy. Service connection is not warranted for the residuals of a disability that the Veteran did not, and does not, have. The most probative evidence of record shows that the Veteran does not have a current diagnosis of breast cancer or any residuals thereof. Accordingly, reasonable doubt does not apply, and the Veteran's appeal of this issue is denied. Analysis: Bilateral Hearing Loss and Tinnitus Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. However, this presumption is inapplicable in this case because the most probative evidence of record does not show that the Veteran manifested high frequency sensorineural hearing loss to a degree of 10 percent within one year from the date of termination of service. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). 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. The Court has held that service connection can be granted for hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for hearing loss which first met VA's definition of disability after service. Hensley, supra, at 159. The Veteran reported in a June 2011 statement that he had combat service in Korea, and that he was exposed to loud noises from M-1 grenades, M-1 carbines, .45 caliber pistols, enemy rifles, machine guns, and howitzers. He further asserted that he was not issued hearing protection in combat. The Veteran concluded that he has had hearing loss and ringing in both ears since his combat experience in Korea. In June 2012, the Veteran again asserted that his tinnitus commenced while he was in service due to small arms fire, bomb noise, and other constant loud noises; he further stated that his tinnitus is constant and persistent. At his September 2012 hearing, the Veteran testified that he served in combat in Korea, and was around mortars shells, rocket launchers, and artillery going off. See transcript, p. 5. He affirmed that he never wore earplugs during these firefights. Id., p. 6. He also stated that he currently has ringing in his ears. Id., p. 8. The Veteran's service treatment records include no complaints, diagnosis, or treatment of hearing loss or tinnitus. In his October 1952 Report of Medical History, the Veteran reported that he did not have, and had never had, ear trouble, and had never worn hearing aids. Likewise, in his October 1952 Report of Medical Examination upon release from active duty (RAD), a clinician found that the Veteran scored 15/15 on whispered voice hearing tests bilaterally. Nearly sixty years after service, VA provided the Veteran with an audiological examination in March 2012. The examiner found that the Veteran's audiometric test results were: Mar. 2012 HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 30 40 50 LEFT 35 30 40 75 80 The Veteran's speech discrimination scores were 78% in the right ear and 68% in the left ear. The VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss. The examiner opined that: [The Veteran] passed a Whisper Voice Test an enlistment and discharge. In my opinion this indicates no change in hearing sensitivity from enlistment to discharge. If administered properly, the whisper test has strong sensitivity and specificity for hearing loss through 2kHz (Swan and Browning, 1986). Moreover [the Veteran] reports he started having difficulty hearing in 1990[.] The March 2012 VA examiner also found that the Veteran did not report experiencing recurrent tinnitus. Finally, the VA examiner found that the Veteran's claimed hearing loss and tinnitus do not impact ordinary conditions of daily life, including the ability to work. The Board finds that the March 2012 VA examiner's opinion is competent based on the audiologist's medical expertise, and it is credible based on her duty to provide truthful opinions. It is likewise highly probative based on her medical reasoning, internal consistency, and consistency with the evidence of record. The Veteran is competent to report that he was exposed to loud noises from M-1 grenades, M-1 carbines, .45 caliber pistols, enemy rifles, machine guns, and howitzers during combat service in Korea, and that he has had difficulty hearing and ringing in his ears since that time. Layno v. Brown, 6 Vet.App. 465, 469-71 (1994). Additionally, in cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) (West 2002) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability that resulted during service from the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, there must be the evidence of a current disability and a causal relationship between the current disability and the in-service combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Consequently, the Board finds that the Veteran did experience noise exposure with hearing loss and ringing in his ears during combat in Korea. However, the Board finds that the most probative evidence of record shows that the Veteran's hearing loss and tinnitus had resolved by the time of his October 1952 Reports of Medical History and Medical Examination at separation from service, for two reasons. First, in his October 1952 Report of Medical History, the Veteran reported that he did not have, and had never had, ear trouble, and had never worn hearing aids. Likewise, in his October 1952 Report of Medical Examination, a clinician found that the Veteran scored 15/15 on whispered voice hearing tests bilaterally. The Board finds that the Veteran's contemporaneous statements in October 1952 denying any ear trouble are entitled to greater probative weight than his statements to the contrary during the course of his claim. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than subsequently reported history). Second, with respect to hearing loss, the March 2012 VA audiologist examiner opined, based on that contemporaneous evidence and her review of a pertinent medical study, that the Veteran's hearing sensitivity at the time of his discharge from service was unchanged from when he entered service. Moreover, the Board finds that the most probative evidence of record shows that there is no nexus between the Veteran's current bilateral hearing loss and tinnitus, and his service. The Board finds that the March 2012 VA examiner's negative nexus opinion as to bilateral hearing loss is entitled to greater probative weight than the Veteran's lay assertions of a nexus because the VA examiner has greater audiological expertise and relied on contemporaneous testing and a new examination. Furthermore, the Board finds that the Veteran's assertions that he has experienced hearing loss and tinnitus continuously during the decades since service are not credible. The Board notes that a lack of contemporaneous medical evidence does not necessarily render lay assertions non-credible. See Buchanan v. Nicholson, 7 Vet. App. 498, 511 (1998), aff'd per curium, 78 F. 3d 604 (Fed. Cir. 1996). Here, however, the Veteran affirmatively contradicted his allegations of continuous hearing loss and tinnitus since service in his October 1952 Report of Medical History when he reported that he did not have, and had never had, ear trouble, and had never worn hearing aids. He again contradicted his allegations of continuous hearing loss and tinnitus since service at his March 2012 VA examination when he reported that he did not have tinnitus, and that his hearing loss began in 1990. Finally, service connection is not warranted on the basis of chronicity because there is no diagnosis of chronic hearing loss or tinnitus during service. 38 C.F.R. § 3.303(b). Given the absence of any credible reports reflecting that the Veteran has experienced hearing loss and tinnitus continuously since service, the Board finds that there is no factual basis upon which to conclude any current chronic hearing loss or tinnitus is linked to service. While service connection is possible for hearing loss and tinnitus which first met VA's definition of disability after service, it is not warranted in this case because the most probative evidence of record shows that the Veteran's current hearing loss and tinnitus are less likely than not related to service. Hensley, supra, at 159. Accordingly, reasonable doubt does not apply, and the Veteran's appeal of these issues is denied. Initial Rating Analysis: PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree 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. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). The record shows that the Veteran first sought service connection for his PTSD in June 2010. He underwent a VA examination in December 2010. The RO issued a rating decision in March 2011 that granted the Veteran's claim for service connection and assigned a 10 percent rating. The Veteran filed a timely Notice of Disagreement, and the RO issued a Statement of the Case in February 2012. The Veteran filed a timely Substantive Appeal. He underwent a second VA examination in June 2011. He then testified at a travel board hearing in September 2012. The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorder. 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula, a 10 percent disability rating is warranted when there is 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. A 30 percent disability rating 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). Id. A 50 percent rating is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is 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. Id. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is 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 Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF of 61 to 70 is indicative of 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, has some meaningful interpersonal relationships. A GAF score of 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 peers or co- workers). A GAF score of 41 to 50 indicates 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). Since the issue in this case is entitlement to an increased rating, the present level of his disability is the Board's primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Following a review of the evidence of record, the Board finds that the Veteran is not entitled to an initial rating in excess of 10 percent for his PTSD. In reaching this decision, the Board has reviewed the evidence of record, to include VA examination reports and the Veteran's own statements. The Veteran contends in his testimony at the September 2012 travel board hearing that he does not go out much. See transcript, p. 14. He also testified that he has no suicidal or homicidal thoughts, no panic attacks, no nightmares about war, and no troubles with his memory. Id., pp. 14-16. In December 2010, a VA psychologist examiner interviewed the Veteran. The Veteran reported that he did not have less interest in activities, and stated that his appetite, sleep, energy, and concentration were good. He denied suicidal and homicidal ideation. The examiner determined that the Veteran does not have symptoms of clinical depression. The Veteran reported being less interested in hunting since his combat experience. He denied feeling emotionally distant or numb. The examiner determined that no symptoms of generalized anxiety, panic, mania, psychosis, or obsessive compulsive behaviors were noted. The examiner further found that the Veteran's thought processes were logical and goal-directed, although the Veteran tended to go off on a tangent. There was no evidence of hallucinations or delusions. The Veteran was oriented to person, place, date, and situation. The examiner found that his judgment was good, and his insight was fair. The examiner diagnosed PTSD and assigned a GAF score of 75. The examiner opined that the Veteran continues to avoid thinking or talking about his military experiences, but he no longer has symptoms that impair functioning or cause significant distress. The examiner found that the Veteran's symptoms are transient and cause no more than slight functional impairment. In June 2011, the same VA psychologist examiner interviewed the Veteran. The Veteran reported that he had not received any treatment for psychological problems since his last VA examination. The Veteran also reported that there were no changes in his psychiatric symptoms since his December 2010 VA evaluation. The examiner again diagnosed PTSD and assigned a GAF score of 75. The examiner opined that there have been no changes in symptoms since the Veteran's December 2010 examination. The Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by transient symptoms that cause no more than slight functional impairment, such as avoidance of thinking or talking about his military experiences, not going out much, and having less interest in hunting than he did before service. Based on the evidence of record described above, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). The Board notes that the evidence of record reflects that the Veteran has additional symptomatology which includes avoidance of thinking or talking about his military experiences, not going out much, and having less interest in hunting. See Mauerhan, 16 Vet. App. 436 (2002). However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 10 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Additionally, the Board notes that the Veteran was assigned a GAF score of 75 in December 2010 and June 2011. As noted above, GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); and reflect no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Therefore, the Board finds that the Veteran's PTSD does not more nearly approximate a rating in excess of 10 percent. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied, and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Veteran is retired, and the evidence does not show evidence of unemployability due to his PTSD. Thus, TDIU is not raised by the record. In summary, the Board finds that the Veteran's PTSD symptoms result in no more than 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. Accordingly, the Board concludes that reasonable doubt does not apply, and the criteria for a rating in excess of 10 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411. ORDER Service connection for breast cancer, to include residuals thereof, is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. A disability rating in excess of 10 percent for PTSD is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs