Citation Nr: 1301690 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 06-06 899 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss disability. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for residuals of a right leg injury. 4. Entitlement to service connection for residuals of a right knee injury. 5. Entitlement to service connection for diabetic retinopathy. 6. Entitlement to service connection for heart disease and/or carotid artery disease, to include due to herbicide exposure or as secondary to diabetes mellitus. 7. Entitlement to service connection for erectile dysfunction, to include secondary to diabetes mellitus. 8. What evaluation is warranted for posttraumatic stress disorder (PTSD) from December 20, 2004 to August 11, 2009? 9. What evaluation is warranted for PTSD from August 12, 2009? REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2005 and January 2007 rating decisions by Department of Veterans Affairs (VA) Regional Offices (ROs). In an April 2005 rating decision, the Montgomery, Alabama RO, in pertinent part, granted entitlement to service connection and assigned an initial 30 percent rating for PTSD, effective December 20, 2004, and denied entitlement to service connection for bilateral hearing loss, tinnitus, right leg, and right knee disorders. In a January 2007 rating decision prepared by the St. Petersburg, Florida RO, and promulgated by the RO in Montgomery, Alabama, VA denied entitlement to service connection for diabetic retinopathy, coronary artery disease, erectile dysfunction, and peripheral vascular disease of the lower extremities. In a September 2012 rating decision, VA granted entitlement to service connection for peripheral vascular disease of the lower extremities. Because that decision represents a full grant of the benefits sought with respect to this issue, this matter is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Also in the September 2012 rating decision, the RO increased the evaluation for PTSD to 70 percent, effective August 12, 2009. As a higher rating for this disability is theoretically assignable before and after this date and the Veteran is presumed to seek the maximum available benefit, the claim for initial higher ratings (as characterized on the title page) remain viable on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The Virtual VA file has been reviewed in conjunction with the disposition of the issues on appeal. The issues of entitlement to service connection for residuals of right leg and knee injuries 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. A bilateral hearing loss disability was not manifested in-service, a sensorineural hearing loss was not compensably disabling within one year of separation from active duty, and a current bilateral hearing loss disability is unrelated to service. 2. Chronic tinnitus was not manifested in service or for many years thereafter, and the currently diagnosed tinnitus is unrelated to service. 3. Diabetic retinopathy is not shown by the record. 4. The Veteran served in the Republic of Vietnam, and is presumed to have been exposed to herbicides, to include Agent Orange. 5. Competent medical evidence reflects a diagnosis of stable angina, a disability recognized by VA as presumptively associated with Agent Orange exposure. 6. The Veteran's carotid artery disease is aggravated by service-connected diabetes mellitus. 7. The Veteran's erectile dysfunction is aggravated by service-connected diabetes mellitus. 8. Resolving reasonable doubt in the Veteran's favor, between December 20, 2004, to August 11, 2009 his PTSD was manifested by symptoms that produced occupational and social impairment with reduced reliability and productivity. 9. From August 12, 2009, the Veteran's PTSD has been manifested by symptoms productive of not more than occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. A bilateral hearing disability was not incurred in or aggravated by service, nor may a sensorineural hearing loss be presumed to have been incurred in service. 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). 2. Tinnitus was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. Diabetic retinopathy was not incurred in or aggravated by service, nor is it secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. Stable angina is presumed to have been incurred in-service. 38 U.S.C.A. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(e). 5. Carotid artery disease is aggravated by service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b); 38 C.F.R. § 3.310 (prior to October 10, 2006); 38 C.F.R. §§ 3.102, 3.159. 6. Erectile dysfunction is aggravated by service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b); 38 C.F.R. § 3.310 (prior to October 10, 2006); 38 C.F.R. §§ 3.102, 3.159. 7. From December 20, 2004 to August 11, 2009, the criteria for a 50 percent rating, but not higher, for PTSD were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). 8. From August 12, 2009, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The requirements of 38 U.S.C.A. § 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or the completeness of the application. VA notified the Veteran in January 2005 and August 2006 of the information and evidence needed to substantiate and complete the claims, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. This case was most recently readjudicated in September 2012. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims herein decided, and as warranted by law, affording VA examinations. For the reasons discussed below, the Board finds that the examinations are adequate to make a determination on the claims. The Board notes that during a February 2005 VA examination, the Veteran reported that he was receiving disability benefits from the Social Security Administration for "problems with [his] neck." He later discussed treatment he received for carotid artery disease. The RO did not attempt to obtain records from Social Security; however, the Board finds no prejudice to the Veteran in this regard. As will be discussed below, the Board is granting service connection for carotid artery disease, therefore any potentially relevant Social Security records concerning this disability are moot. Regarding the remaining claims, there is no evidence or allegation that such records would be relevant. Thus, there is no duty to assist in obtaining these records. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (VA has no obligation to secure SSA records if there is no reasonable possibility that the records would help to substantiate a veteran's claim.). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Service Connection In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In order to establish service connection or service-connected aggravation for a present disability, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection will be presumed for certain chronic diseases, including arteriosclerosis and organic diseases of the nervous system (e.g., sensorineural hearing loss), if manifest to a compensable degree within one year after discharge from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). If a veteran served on active duty in the Republic of Vietnam during the Vietnam era (beginning on January 9, 1962 and ending on May 7, 1975), he is presumed to have been exposed to herbicides, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent during active military, naval, or air service and develops diabetes and or ischemic heart disease postservice, those disorders shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Finally, where the statutory presumptions are inapplicable, the Federal Circuit has held that the Veterans Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a claimant from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A disability may be found to be service connected on a secondary basis if the claimant demonstrates that the disability is either (1) proximately due to or the result of an already service-connected disease or injury, or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet.App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 . Hearing Loss and Tinnitus The Veteran asserts that his current hearing loss and tinnitus are a result of noise exposure during service. Specifically, he has reported being exposed to small arms fire, heavy artillery, grenades, helicopters, and tanks. For the reasons explained below, the Board finds that service connection is not warranted for hearing loss and tinnitus because the evidence preponderates against finding a link between the claimed disabilities and service. Initially, the Board notes that for the purpose of applying the laws administered by the VA, impaired hearing is considered to be a disability when the auditory threshold at any of the frequencies 500, 1000, 2000, 3000, or 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 utilizing the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385 . Prior to November 1967, service departments used ASA units to record puretone sensitivity thresholds in audiometric measurement. VA currently uses ISO (ANSI) units. For purposes of comparison between the service audiometric data and more recent VA audiometric data, the table below shows the ASA measurements recorded in service, with the comparable ISO (ANSI) measurements in parentheses. At the time of the Veteran's August 1966 enlistment examination, pure tone thresholds, in decibels, were noted as follows: HERTZ For ISO add 500 (15) 1000 (10) 2000 (10) 3000 (10) 4000 (5) RIGHT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 10 (25) 5 (15) 0 (10) 0 (10) 0 (5) The enlistment examination report indicates the Veteran's ears and hearing were clinically evaluated as normal. His service treatment records do not show any complaints, treatment, or diagnoses related to hearing loss or tinnitus. A separation examination was conducted in March 1969. (Parenthetically, the Board notes that the separation examination appears to be misdated with the year 1967 instead of 1969). The report reflects that his ears and hearing were clinically normal. Pure tone thresholds, in decibels, were noted as follows (in ISO units): HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 5 --- 5 LEFT 5 0 5 --- 5 On the corresponding report of medical history, the Veteran denied ear trouble and hearing loss. Hence, neither hearing loss nor tinnitus was shown in service. In December 2004, the Veteran filed claims of entitlement to service connection for hearing loss and tinnitus. A VA examination was conducted in February 2005. During the examination, the Veteran said that he began noticing hearing loss over the prior 10 years and that the onset of his tinnitus was approximately 10 or 11 years previously. He said that he was exposed to small arms fire, heavy artillery, grenades, helicopters, and tanks during service. As a civilian, he said he was exposed to occupational noise from traffic and recreational noise from lawnmowers, hunting, chainsaws, and table saws. On audiological evaluation, the Veteran's puretone thresholds, in decibels, were as follows (in ISO units): HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 30 50 45 LEFT 15 25 30 35 40 Speech audiometry revealed speech recognition ability of 100 percent in each ear. The diagnoses were normal to moderate sensorineural hearing loss for the right ear, and normal to mild sensorineural hearing loss for the left ear. The examiner opined that it was "less than likely as not" that the Veteran's current hearing loss was related to service. In rendering this opinion, the examiner explained that the Veteran's hearing evaluations during service and at discharge showed that he had normal hearing. Regarding tinnitus, the examiner opined that the "cause of tinnitus cannot be determined with certainty, but the late date of onset suggests that it is less likely as not due to military noise exposure." At the outset, the Veteran is competent to report a history of noise exposure during service and when his hearing loss and tinnitus began. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 470 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board also finds the Veteran's statements regarding his noise exposure and the history of hearing loss and tinnitus credible. Here, the Veteran stated that his hearing loss and tinnitus began in 1994 or 1995 - over 25 years after service. The first medical record documenting either a hearing loss disability or tinnitus is the February 2005 VA examination-almost 36 years after service. The passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Hence, the present case involves not simply a lack of clinical evidence, but normal findings and a denial of hearing loss at separation and a time gap of over three decades. In this case, neither medical evidence nor credible lay evidence establishes that hearing loss or tinnitus manifested in service or that there has been continuity of symptomatology since service. Therefore, the Board finds that hearing loss and tinnitus did not manifest in service or for many years thereafter. Hence, the only remaining issue is whether there is a nexus between the Veteran's service and current hearing loss and tinnitus. See 38 C.F.R. § 3.303(d). In this case there is no competent evidence linking either the Veteran's hearing or tinnitus to service. As noted above, the February 2005 VA examiner opined that the Veteran's current hearing loss and tinnitus were less likely than not related to service. As the VA examiner explained the reasons for her conclusion, which was based on examination findings and review of the claims file, this opinion is adequate for the adjudication of these claims and is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board has considered the Veteran's lay contentions that his current hearing loss and tinnitus are related to noise exposure during military service. To the extent that these assertions are being offered to establish a nexus with his military service, such evidence must fail. The Board finds that determining the etiology of his sensorineural hearing loss and tinnitus is a complex medical matter beyond the ken of a layperson. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The question of etiology goes beyond a simple and immediately observable cause-and-effect relationship. Whether his hearing loss and tinnitus are related to noise exposure that occurred many years ago requires specialized training. As a lay person untrained in the field of audiological disorders the appellant is not competent to render an opinion on etiology in this case. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claims for service connection for a bilateral hearing loss and tinnitus. Hence, the claims are denied. Diabetic Retinopathy The Veteran asserts he had diabetic retinopathy secondary to his service-connected diabetes mellitus. For the reasons explained below, the Board finds that service connection is not warranted because the evidence does not establish that he currently has diabetic retinopathy. The Veteran was diagnosed with diabetes mellitus in October 2005. In February 2006, a VA diabetic eye screen indicated that he did not have diabetic retinopathy. A VA eye examination was conducted in December 2006. The Veteran reported having slightly blurry vision and he was diagnosed as having a refractive error. There was no diabetic retinopathy in either eye. The report of a January 2008 VA diabetes mellitus examination reflects that he reported having intermittent blurred vision and eye pain; however, the eye examination was normal and the examiner indicated that there was no visual impairment associated with diabetes mellitus. In August 2008, a VA diabetic eye screen indicated that no diabetic retinopathy was present. Diabetic retinopathy was also not present during an eye ophthalmology consultation in August 2010. In November 2011, an eye optometry note reflects that the Veteran was diagnosed as having early cataracts, hypertensive retinopathy, and refractive error. The report of a December 2011 VA eye examination indicates that the Veteran was diagnosed as having cataracts in both eyes and mild hypertensive retinopathy in addition to a refractive error. The examiner noted that the Veteran did not have diabetic retinopathy. Whether service connection is claimed on direct, presumptive, or secondary basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that 38 U.S.C.A. § 1110 requires the existence of a present disability for VA compensation purposes). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran is competent to report symptoms that which he has personally experienced, such blurred vision or eye pain, and such statements are credible. As a layperson, however, the Veteran is not competent to diagnose diabetic retinopathy. See Jandreau, 492 F. 3d at 1376-77. Such a determination requires specialized training, which the Veteran does not have. In sum, the preponderance of the most probative evidence shows that the Veteran does not have diabetic retinopathy. While the appellant has been diagnosed as having early cataracts and hypertensive retinopathy there is no competent evidence that either condition is related to service. As for his refractive error, that is not a disease or injury within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). For these reasons, the Board finds that the claim for service connection must be denied. In denying entitlement to service connection for hearing loss, tinnitus and diabetic retinopathy the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Erectile Dysfunction and Coronary Artery Disease The Veteran asserts that he has erectile dysfunction and coronary artery disease secondary to his service-connected diabetes mellitus. As will be explained below, the Veteran has been diagnosed as having stable angina and carotid artery disease, rather than coronary artery disease. Stable angina is presumed to be related to herbicide exposure during his service in Vietnam; therefore, the Board finds that service connection is warranted for this condition on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Regarding erectile dysfunction and carotid artery disease, the preponderance of the evidence indicates that the Veteran's service-connected diabetes mellitus aggravates these conditions. Therefore, service connection is warranted for erectile dysfunction and carotid artery disease on a secondary basis. 38 C.F.R. § 3.310. Ischemic heart disease includes, but is not limited to, stable, unstable and Prinzmetal's angina. 38 C.F.R. § 3.309(e). In this case, VA treatment records indicate that the Veteran has been diagnosed as having carotid artery disease. There has been some confusion, however, as to whether he also has coronary artery disease because of the abbreviation "CAD" in the record. The abbreviation could refer to either carotid artery disease or coronary artery disease. In June 2011, the RO requested a VA medical opinion from Dr. W.P., a primary care physician. The examiner reviewed the claims file and concluded that the Veteran did not have a diagnosis of coronary artery disease, noting that there were multiple references to normal cardiac testing in the record. Although the Veteran has not been diagnosed as having coronary artery disease, there is evidence that he has stable angina. In April 2011, the Veteran was seen by a VA cardiologist for symptoms of chest pain and shortness of breath. The physician opined that the breathless feeling on exertion relieved by rest was angina and the Veteran was referred for a stress test. The results were normal. (See June 2011 myocardial perfusion imaging (MPI)). The physician stated that even though the results of the MPI were normal, he still felt that the symptoms were classic angina and therefore started the Veteran on beta blockers. In September 2011, the Veteran reported feeling a little better on beta blockers. The physician indicated that the Veteran's symptoms still sounded like moderate stable angina and recommended a conservative approach. It was decided that catheterization would be put on hold. Here, the VA cardiologist's opinion that the Veteran has stable angina is especially probative. As a cardiologist, this physician specializes in the specific area of medicine at issue and he has the esoteric knowledge and expertise required to make such a determination. Hence, the Board finds that the preponderance of the evidence establishes that the Veteran has stable angina, which is a disease presumed to be associated with exposure to herbicide agents pursuant to 38 C.F.R. § 3.309(e). Therefore, service connection is warranted for stable angina. Regarding carotid artery disease and erectile dysfunction, the Veteran does not assert, nor does the evidence show, that these conditions were manifested in service. Furthermore, there is no competent evidence relating either of these disorders directly to service. Rather, the Veteran asserts that they are secondary to his diabetes mellitus. Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310. Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). While the regulation pertaining to secondary service connection was amended effective October 10, 2006 because the Veteran's claim was received in March 2006 it is controlled by the more liberal regulation governing awards of secondary service connection in effect prior to October 10, 2006. In this case, a December 2006 VA examiner noted that the Veteran's history of erectile dysfunction pre-dated his diabetes mellitus and opined that it was "not as likely as not" that the erectile dysfunction was secondary to diabetes mellitus. A January 2008 VA examiner opined that erectile dysfunction was a complication of diabetes. A July 2007 private physician, Dr. D.W., opined that the Veteran's diabetes mellitus "definitely increases his risk to small vessel disease, which will contribute to erectile dysfunction as well as artery occlusion." In September 2008, a VA nurse practitioner opined that the Veteran's diabetes had worsened his erectile dysfunction and had a negative impact on his entire cardiovascular system. An August 2009 VA examiner noted that the Veteran's diabetes mellitus was not severe enough to cause significant "CAD" and that the diabetes was reasonably well-controlled and was not likely to have caused erectile dysfunction. The examiner stated that he was unable to predict the extent that the diabetes had contributed to the Veteran's peripheral vascular disease, erectile dysfunction, and "CAD", but did state that diabetes mellitus can aggravate all three of these conditions by the detrimental affect it has on large and small vessel integrity. As noted above, it is unclear whether the examiner was referring to carotid artery disease or coronary artery disease when referencing "CAD", but the Board notes that he included a discussion of the Veteran's history of carotid artery disease when discussing peripheral vascular disease. Hence, it can reasonably be assumed that the examiner meant to include carotid artery disease as one of the conditions that can be aggravated by diabetes mellitus. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that erectile dysfunction and carotid artery disease are caused by or are a result of the appellant's service-connected diabetes mellitus. The evidence, however, does establish that these disorders are aggravated by diabetes. Hence, service connection is warranted for erectile dysfunction and carotid artery disease as a result of aggravation due to diabetes mellitus. Increased Rating for PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations include: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's PTSD is evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, which is governed by the General Rating Formula for Mental Disorders, a 30 percent rating is assigned for 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for 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 effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near - continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. One factor for consideration in evaluating mental disorders is the global assessment of functioning score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242(1995) (citing American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV)). A global assessment of functioning score ranging between 51 and 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Board has reviewed all of the evidence in the Veteran's claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Court has also held that in determining the level of impairment under 38 C.F.R. § 4.130 VA is not restricted to the symptoms provided in the diagnostic code. Ratings are to consider all symptoms of the disability that affect the level of occupational and social impairment, including if applicable, those identified in the DSM-IV. See Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). The Veteran has also been diagnosed with major depressive disorder in addition to PTSD. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Here, the medical evidence does not clearly distinguish between psychiatric symptoms related to PTSD and depression, and the February 2005 VA examiner indicated that the Veteran's depression was partially related to his PTSD. Hence, in this case, the Board has considered all of the Veteran's psychiatric symptoms in evaluating his service-connected PTSD. Period from December 20, 2004 to August 11, 2009 After a careful review of the evidence of record, the Board finds that the evidence most nearly approximates a higher, 50 percent rating for PTSD during this time period. The report of a February 2005 VA examination reflects the Veteran's history of alcohol abuse, social withdrawal, anger outbursts, and an inability to get along with others. He said he only had one friend, but rarely saw him. He said he spent most of his time alone or with his wife. He said his wife complained that he did not talk to her, but that they seemed to get along well. He said that he had many jobs and at one time had his own business painting lines on interstates and roads. He said he had to go on disability four or five years previously because of problems with his neck. He said that he felt that his PTSD symptoms affected his ability to keep a job and that he had to work for himself because he could not work for anyone else. On mental status examination, the Veteran was cleanly and casually dressed. His speech was normal and no bizarre mannerisms were displayed. He appeared nervous but remained pleasant and cooperative. He was alert and lucid, thought processes were relevant. He had full affect. He reported that his level of depression was 8/10 with the most recent episode of depression lasting over a year. He endorsed anhedonia, weight gain, difficulties sleeping, psychomotor retardation, fatigue, feelings of guilt, worthlessness and hopelessness, difficulties concentrating, and reoccurring thoughts of death. He rated his level of anxiety as being 8-9/10. He reported worrying about everything. He rated his level of anger as 8/10 except in dealing with his wife, which was a 0/10. He said he had difficulties falling and staying asleep and estimated getting three hours of sleep a night. He said he had nightmares about three times a week and experienced flashbacks at night. He reported being both irritable and short-tempered. He did not endorse any symptoms of paranoia, visual hallucinations, suicidal ideations, or homicidal ideations. He said he sometimes thought that he heard people, but his ears rang and he did not pay attention to it. He reported sometimes think that he heard "messages from above," but does not pay attention to it. The examiner indicated that the Veteran was in contact with reality and oriented to person, place, month, year, and day of week but not to date. His immediate, recent, and remote memory skills were grossly intact. He had fair to moderate concentration skills and exhibited no gross impairment in communication skills or cognitive functioning other than his complaints of memory deficits. The examiner diagnosed moderate, chronic PTSD and moderate, recurrent major depressive disorder. A global assessment of functioning score of 50 was assigned for PTSD, and a global assessment of functioning score of 55 was assigned for major depressive disorder. The examiner opined that the Veteran's PTSD symptoms had a moderate to significant negative impact on his occupational functioning and a severe negative impact on his social relationships. VA outpatient psychiatric treatment records dated in September 2007 and March 2008 reflect that the Veteran showed sustained improvement in his reported anxiety and PTSD symptoms with the use of anti-depressants. He reported sleeping better and denied any intent or plan to harm himself or others. On mental status examination, his mood was euthymic with a congruent affect. He displayed no psychomotor agitation or retardation. Thought content revealed no delusions or other problems. He denied perceptual problems. He was alert and oriented in three spheres, his memory was intact, and his cognitive functions were within normal limits. During a November 2007 depression screen, when asked how often he had little interest or pleasure in doing things or had problems feeling down, depressed, or hopeless, the Veteran replied, "not at all." Collectively, the aforementioned medical evidence reflects that, during the relevant time period, the Veteran's PTSD was manifested by difficulties falling and staying asleep, nightmares, flashbacks, intrusive thoughts, social withdrawal, irritability, depression, anxiety, and anger outbursts. While the Veteran does not demonstrate all of the symptoms associated with the 50 percent rating criteria, the symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan. Here, the Board finds that his overall disability picture - particularly, disturbances of motivation and mood, very low interest in activities, irritability, social isolation, and sleep impairment - suggest occupational and social impairment with reduced reliability and productivity. This is supported by the February 2005 VA examiner's opinion that the Veteran's PTSD was "moderate" and resulted in moderate to significant negative impact on his occupational functioning and a severe negative impact on his social relationships. Furthermore, the Veteran was assigned a global assessment of functioning score of 50 for PTSD and 55 for depression. Such a score contemplates serious symptoms, as noted above a global assessment of functioning score of 51 and 60 contemplates moderate symptoms. Here, the Veteran's score of 50 for PTSD is at the high end of serious symptomatology while the score of 55 for depression represents moderate symptomatology. Hence, the Board finds that the global assessment of functioning scores assigned are consistent with a 50 percent disability rating. At no point during this time period, however, did the Veteran's overall PTSD symptomatology meet the criteria for a 70 percent rating. There was no evidence of such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; or near-continuous panic or depression affecting ability to function independently, appropriately and effectively. There was no evidence of any impaired impulse control, spatial disorientation, or a neglect of personal appearance and hygiene. The appellant was not shown to have difficulty in adapting to stressful circumstances, nor shown to be unable to establish effective relationships. Although the Veteran described having long bouts of depression and anxiety, his mood was euthymic in September 2007 and March 2008, and a depression screen was negative in November 2007. There is no indication that anxiety or depression affected his ability to function independently. The evidence consistently shows no suicidal ideation, and no obsessional rituals. His speech was normal, and there was no impairment in independent functioning. He was fully orientated and demonstrated adequate hygiene. The Veteran is married and he reports having a good relationship with his wife. Further, although he indicated that he had difficulty working for others and preferred working for himself, he reported that he stopped working due to physical reasons and was apparently able to maintain self-employment despite his symptoms. As the criteria for a 70 percent rating were not met prior to August 12, 2009, it logically follows that the symptoms for the maximum 100 percent rating under the general rating formula likewise are not met. While the Veteran reported memory deficits, no memory or cognitive impairment was shown on mental status examinations. The Veteran did not exhibit any impairment in thought processes or communication. Although he said he sometimes thought he heard things, he attributed this to tinnitus, and later denied any perceptual problems. There is no indication that he engaged in grossly inappropriate behavior. He was not in persistent danger of hurting self or others, and could perform activities of daily living (including maintenance of minimal personal hygiene). Finally, he was not disoriented to time or place. Accordingly, the Board finds that a 50 percent, but no higher, rating for PTSD is warranted for the period from December 20, 2004 to August 11, 2009. Period from August 12, 2009 After a careful review of the evidence of record, the Board finds that an evaluation in excess of 70 percent rating for PTSD is not warranted during this time period. The report of the August 12, 2009 VA examination reflects that the Veteran provided a history of PTSD symptoms similar to those mentioned above. He indicated that he enjoyed positive relationships with his wife, son, and daughter, but did not have any close friendships beyond his family. He denied hobbies or activities of interest. He reported having three to four nightmares per week. He endorsed having intrusive thoughts, avoidance tendencies, and increased arousal symptoms. He stated that he struggled with inappropriate behavior, including impatience, irritability, anger-management deficits, and social avoidance. He also endorsed having obsessive/ritualistic behavior in that he found himself always having to perform certain acts in groups of four. He denied panic attacks, homicidal thoughts, suicidal thoughts, and episodes of violence. He was able to maintain minimum personal hygiene and had no problems with activities of daily living. He reported that he retired nine years previously due to medical (physical) problems and was receiving Social Security disability compensation. On mental status examination, the Veteran was casually dressed and cooperative. His mood was anxious, agitated, and dysphoric. His affect was constricted. He was oriented to person, time, and place. Thought processes involved a flight of ideas and circumstantiality. Thought content involved preoccupation with one or two topics. He had no delusions or impairment in judgment. His remote, recent, and immediate memory was normal. The examiner diagnosed chronic PTSD and major depressive disorder with anxiety in partial remission, and assigned a current global assessment of functioning score of 42. The examiner later stated that the Veteran's status had worsened since the February 2005 VA examination and that he would now estimate the impact with a global assessment of functioning score of perhaps 47. The examiner noted that the Veteran's wife had reported memory deficits in recent years as the impact of blocked carotid arteries became more apparent. The examiner opined that the Veteran's PTSD did not result in total occupational and social impairment, but that his symptoms did result in deficiencies in most areas - specifically, thinking, family relations, work, and mood. Two days following the VA examination in August 2009, a VA outpatient treatment record reflects that the Veteran reported that his PTSD symptoms "used to be bad" and that he had "gotten mellow." He reported feeling "pretty good" and had "kind of leveled out." On objective examination, he was anxious and jittery. He reported still experiencing nightmares three to four times per week and depression, but he denied suicidal and homicidal ideation. He denied auditory hallucinations, but stated that he saw shadows. In December 2010, he reported doing okay, but described short term memory problems. His mood was irritable and low, his affect was congruent, his speech, thought content, and thought processes were normal. He denied suicidal or violent ideations. An April 2011 VA outpatient psychiatric treatment record indicates the Veteran reported worsening of symptoms after stopping medication due to side effects. Specifically, he complained of a depressed mood and nightmares three to four times per week, exaggerated startle response, interrupted sleep, inadequate appetite and energy. His mood was "well" and his affect was appropriate. Speech and thought were normal with no suicidal or homicidal ideations. There was no psychomotor agitation or retardation, hallucinations, or delusions. A nursing note, however, reflects that he reported hearing voices and seeing shadows. He was assigned a global assessment of functioning score of 50. The plan was to start him on medication. An August 2011 VA nursing note reflects that the Veteran reported that he was doing "fairly good." He said that he was sleeping well and the medications were very helpful. He denied auditory and visual hallucinations. He reported occasional nightmares and flashbacks, decreased feelings of stress, depression, and anxiety. He was assigned a current global assessment of functioning score of 60. In December 2011, he reported that he was doing "okay," but that it seemed that his nightmares were getting worse lately. His mood was pleasant with congruent affect. He denied auditory or visual hallucinations. He said that he probably only got four hours of sleep per night. He was assigned a current global assessment of functioning score of 55. His medication was increased. In March 2012, he reported that he was doing "alright" and that the increase in medication had been helpful, but he was still having bad dreams and nightmares, although not as bad. Depression screen was negative. In May 2012, a nursing note reflects that he reported feelings of mild to moderate depression and poor sleep patterns with recurrent nightmares and flashbacks. He said he averaged five to six hours of sleep per night. A psychiatric note reflects that he reported no significant depression and that his medication was working well. He was assigned a global assessment of functioning score of 60 each month. The report of a December 2012 VA examination reflects that the Veteran reported ongoing PTSD symptoms similar to those described above. He reported having good relationships with his wife and children but stated that he had problems with his temper and irritability, which put a strain on these relationships. He endorsed depressed mood, anxiety, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory. He was diagnosed as having PTSD and depressive disorder. A global assessment of functioning score of 50 was assigned. The examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas, but did not result in total occupation and social impairment. The Board finds that the balance of the medical evidence of record establishes that the Veteran's PTSD most nearly approximates the criteria associated with a disability rating of 70 percent and that an evaluation in excess of 70 percent is not warranted. The criteria for a 70 percent rating for a psychiatric disability are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). During this time period the evidence reflects that the Veteran had moderate to serious symptoms as reflecting in the assignment of global assessment of functioning scores ranging from 42 to 60. The description of his symptoms were consistent with the variance in the global assessment of functioning scores assigned; however, the Board observes that he generally reported worse symptomatology during VA Compensation and Pension examinations and that there is an obvious financial incentive in doing so. Hence, these examinations must be carefully weighed against his VA outpatient treatment records. At times, he reported doing well, had no depression, and only had occasional symptoms - mostly involving nightmares and sleep impairment. At other times his symptoms were more severe. On a few occasions, he endorsed having auditory hallucinations and seeing "shadows"; however, these symptoms were not persistent. The record reflects that he mostly denied having problems with perception and that his thought processes were generally described as being normal. For the foregoing reasons, the Veteran's PTSD most closely approximates the criteria for a 70 percent rating during this time period as his symptomatology was productive of social impairment with deficiencies in most areas. At no point, did PTSD meet the criteria for the maximum 100 percent rating as the evidence does not show that his symptoms have been productive of total occupational and social impairment. In this regard the Board finds the August 2009 and December 2012 VA examiners' opinions especially probative in demonstrating that entitlement to a 100 percent rating for posttraumatic stress disorder is not in order. Both Periods The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. 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. Therefore, 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, therefore, adequate, and no referral is required. Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). As discussed above, the applicable rating criteria reasonably describe the Veteran's disability level and symptomatology and higher evaluations are available for greater levels of disability. Thus, as the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate. Finally, the Board considered whether an inferred claim for a total disability rating based on individual unemployability has been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the Veteran is no longer employed; however, he indicated that he retired due to physical reasons rather than psychiatric. Although he indicated feeling that symptoms due to posttraumatic stress made it difficult for him to work for others, he was able to maintain self-employment. He has not alleged and the medical evidence does not show that he is unemployable due to PTSD. As such, Rice is inapplicable in the present case. For all the foregoing reasons, the Board concludes that there is no basis for any further staged rating of the disabilities on appeal, pursuant to Fenderson; that a 50 percent, but no higher, rating is warranted for PTSD from December 20, 2004, to August 11, 2009; and that a rating in excess of 70 percent is not warranted from August 12, 2009. ORDER Entitlement to service connection for a bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for diabetic retinopathy is denied. Entitlement to service connection for stable angina is granted. Entitlement to service connection for carotid artery disease as a result of aggravation due to diabetes mellitus is granted. Entitlement to service connection for erectile dysfunction as a result of aggravation due to diabetes mellitus is granted. From December 20, 2004 to August 11, 2009, entitlement to a 50 percent rating for PTSD is granted, subject to statutory and regulatory provisions governing the payment of monetary benefits. From August 12, 2009, entitlement to a rating in excess of 70 percent for PTSD is denied. REMAND The Veteran asserts that he has right leg and knee disabilities related to a jeep accident in service. He was not afforded a VA examination with respect to these claimed disabilities. For the reasons explained below, the Board finds that a VA examination is warranted. The service treatment records reflect that he was in a jeep accident in December 1968. Treatment records indicate that he injured his right knee, ankle, and foot. He suffered a right great toe fracture with an overlying laceration. He was placed in a short leg walking cast for three weeks, after which the cast was removed and he was returned to duty. The March 1969 separation examination indicates that his lower extremities and feet were normal. He denied trick or locked knee and any foot trouble on the corresponding report of medical history. Service connection is currently in effect for right great toe fracture residuals. In various pleadings, the Veteran alleges that he also has problems with his right knee and leg. VA outpatient treatment notes reflect that he complained of right ankle pain and stiffness in December 2011, and was assessed as having degenerative joint disease of the ankle. VA has a duty to assist a veteran in the development of a claim. This includes providing a VA examination when necessary. An examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4). In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court held that the third prong has a low threshold. The Veteran has met the standards of McLendon and on remand should be afforded VA nexus examinations regarding his claimed disabilities. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should obtain updated treatment records from the Central Alabama Health Care System, East and West Campuses, as well as any other pertinent outstanding records. Any records obtained must be associated with the appellant's claims folder. If the AMC/RO cannot locate any identified record, the AMC/RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AMC/RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must be given an opportunity to respond. 2. Thereafter, schedule the Veteran for a VA orthopedic examination to determine the nature and etiology of any diagnosed right knee or leg disability. All indicated tests should be accomplished. The claims file, access to Virtual VA, and a copy of this remand must be available for review by the examiner. The examiner is requested to diagnose any current right leg disorder, to include any disorder affecting the right knee and/or ankle. Thereafter, the examiner is to opine whether it is at least as likely as not, i.e., is there a 50/50 chance or greater, that any diagnosed right leg disorder is etiologically related to service. The examiner is to address the role, if any, that the December 1968 motor vehicle accident played in the etiology of any diagnosed right leg, knee, or ankle disorder. The examiner is to provide a complete rationale for any opinion offered. If the examiner is unable to provide an opinion that fact must be stated and the reasons why an opinion cannot be provided explained. 3. The AMC/RO must notify the Veteran that it is his responsibility to report for the scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. The AMC/RO must ensure that the examination report is in complete compliance with the directives of this remand. The AMC/RO must ensure that the examiner has documented his/her consideration of records that are part of Virtual VA. If any examination report is deficient in any manner, the AMC/RO must implement corrective procedures at once. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If any claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs