Citation Nr: 1304207 Decision Date: 02/06/13 Archive Date: 02/19/13 DOCKET NO. 11-10 383 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 50 percent for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) and anxiety disorder. 2. Whether new and material evidence has been submitted in order to reopen a previously denied claim of entitlement to service connection for a dental condition, to include entitlement to outpatient dental treatment. 3. Entitlement to service connection for an eye disorder, diagnosed as cataracts, to include residuals of a bilateral phacoemulsification. 4. Entitlement to service connection for diabetes mellitus, type 2. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. Thomas Knope, Counsel INTRODUCTION The Veteran served on active duty from October 1947 to February 1951. This matter is on appeal from an April 2010 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Veterans Law Judge in October 2012. A transcript of the hearing is of record. In a February 2011 rating decision, the RO increased the Veteran's rating for his service-connected PTSD and anxiety disorder from 30 percent to 50 percent. As this is, however, only a partial grant of the Veteran's increased rating claim, the pending appeal is not abrogated by that award. AB v. Brown, 6 Vet. App. 35, 38 (1993); Corchado v. Derwinski, 1 Vet. App. 160 (1991). Please note that 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). As will be discussed in further detail in the following decision, the Board is granting the Veteran's application to reopen his previously denied issue of entitlement to service connection for a dental condition (to include entitlement to outpatient dental treatment). However, the underlying claim for service connection for a dental condition (to include entitlement to outpatient dental treatment), as well as the issue of entitlement to TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's psychiatric disorder has been characterized by irritability, flashbacks and insomnia; characteristics such as suicidal ideation, obsessional rituals, impaired impulse control, near-continuous panic or depression affecting ability to function independently, spatial disorientation, illogical or obscure speech, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships have not been shown. 2. In a June 1960 rating decision, the claim of entitlement to service connection for a dental condition, to include entitlement to outpatient treatment, was denied on the basis that there was no evidence of a service-incurred dental disability or that a dental disability was based on service trauma. The Veteran did not appeal the decision or submit additional evidence within one year of the decision. 3. The evidence added to the record since the June 1960 decision became final, when viewed by itself or in the context of the entire record, raises a reasonable possibility of substantiating that claim. 4. Diabetes mellitus, bilateral hearing loss and a chronic eye disorder were not shown in service or for many years thereafter, and are unrelated to active duty. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for an acquired psychiatric disorder, diagnosed as PTSD and anxiety disorder, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9400 (2012). 2. The June 1960 rating decision that denied the Veteran's claim for entitlement to service for a dental condition, to include entitlement to outpatient dental treatment, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The evidence received subsequent to the June 1960 rating decision is new and material, and the requirements to reopen the claim of entitlement to service connection for a dental condition, to include entitlement to outpatient dental treatment, have been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159 (2012). 4. An eye disorder, diagnosed as cataracts and to include residuals of a bilateral phacoemulsification, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 5. Diabetes mellitus, type 2, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 6. Bilateral hearing loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As will be discussed in further detail in the following decision, the Board is granting the Veteran's application to reopen his previously denied issue of entitlement to service connection for a dental condition (to include entitlement to outpatient dental treatment). Accordingly, no further discussion of VA's duty to notify and to assist the Veteran with respect to this aspect his appeal is necessary. With respect to the increased rating and service connection claims adjudicated herein, the Board notes that proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. With respect to increased rating claims in particular, the Board notes that the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular veteran's circumstances; that is, VA need not notify a veteran of the specific diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, a pre-decisional letter dated in August 2009 complied with VA's duty to notify the Veteran with respect to his claim for an increased rating for his service-connected psychiatric disability. Specifically, this letter apprised the Veteran of what the evidence must show to establish entitlement to the benefit sought, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. It also notified the Veteran of the criteria for assigning a disability rating and an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition, the correspondence informed the Veteran that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Moreover, the August 2009 correspondence fully addressed all notice elements as to the service connection claims adjudicated herein. The letter informed him of what evidence was required to substantiate these issues and of his and VA's respective duties for obtaining evidence. It also provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of her case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In any event, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 556 U.S. 396 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO has obtained the Veteran's service treatment records, and the Veteran submitted treatment records from private facilities. While the RO was unable to acquire records from a VA Medical Center in Brockton, Massachusetts, the Board is nonetheless satisfied that a diligent attempt was made to acquire them. Next, VA examinations with respect to the issues on appeal were obtained in December 2004, December 2009 and August 2011. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are more than adequate, they are predicated on a full understanding of the Veteran's medical history, and provide a sufficient evidentiary basis for the claim to be adjudicated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Recognition is given to the fact that the most recent VA examination for the Veteran's psychiatric disability is now over three years old. However, in the contest of increased rating claims, the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since this VA examination, and he has not contended otherwise. With regard to the Veteran's eye disorder and diabetes mellitus claims, the Board acknowledges that VA medical opinions were not obtained to determine the nature and etiology of these disorders. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In deciding whether to remand the issue for a medical nexus opinion, the Board notes that a VA medical examination is not required as a matter of course in every disability case involving a nexus issue. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran, in which case an examination may not be required). In this case, neither disorder was shown during active duty, nor has the Board determined that the Veteran's statements were sufficient to indicate that they were present in service. Further, his diabetes and chronic eye disorders were not first shown until many years after his active duty. As such, there would be no basis for a VA examiner to provide an opinion, and a remand for VA opinions regarding these issues would not be beneficial in their adjudication, and are thus not required. Finally, the Veteran was afforded a hearing before the undersigned Veterans Law Judge in October 2012. This hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), which consist of (1) fully explaining the issue and (2) suggesting the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Notably, the Veteran was specifically asked about the nature and extent of his psychiatric symptoms, as well as the nature and origin of his claimed diabetes mellitus, eye, and hearing loss disabilities. Hence, no further notice or assistance 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). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2011). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Psychiatric disorders are rated through the use of a general rating formula set forth in 38 C.F.R. § 4.130. The Veteran is currently rated at 50 percent for his service-connected acquired psychiatric disorder under DC 9400, which is subject to this general rating formula. In order to be entitled to the next-higher 70 percent rating, the evidence must show an "inability" to establish and maintain effective relationships due to symptoms such as: * suicidal ideation; * obsessional rituals which interfere with routine activities; * speech intermittently illogical, obscure, or irrelevant; * near-continuous panic or depression affecting 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); and * inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, DC 9400. After a review of the pertinent evidence, the Board determines that a rating in excess of 50 percent is not warranted. As an initial matter, the evidence does not indicate the existence of any physical manifestations or similar symptoms, such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, or any other similar types of symptoms. Although the Veteran did not submit the claim on appeal until June 2009, the Board has also considered the results of his VA examination in December 2004, which provides a context for his symptoms. See Moore v. Shinseki, 555 F.3d 1369 (2009) (holding that records from other than a relevant period on appeal must nevertheless be considered, as 38 C.F.R. § 4.1 requires that "a veteran's disability must be evaluated in light of its whole recorded history"). On that occasion, the Veteran stated that he felt anxious, tense and restless almost daily. He gets tired easily, sleeps only 3 to 4 hours per night, and he has trouble concentrating. He also complained of nightmares and flashbacks. However, upon examination, he appeared largely normal. His thought process normal, his affect was stable, speech and communication skills were normal and there was no evidence of impaired impulse control. There was no evidence of suicidal or homicidal ideation, no any evidence of inappropriate behavior, and his appearance was normal. The Veteran's symptoms at his most recent VA examination in December 2009 were largely similar. On that occasion, the Veteran again complained of nightmares approximately 2 to 3 times per week, some flashbacks of seeing enemy soldiers, and appeared to ruminate on his experiences in Korea. However, upon examination, he exhibited normal personal hygiene, and did not display any inappropriate behavior. Moreover, his communication skills were largely normal, as he had normal speech, logical thought process and displayed a stable affect. His cognitive skills were also largely normal, as he exhibited fair judgment and insight, no delusions, no suicidal or homicidal ideation. In addition to the VA examinations, the record also includes some more recent outpatient psychiatric treatment records where his symptoms were observed. For example, in August 2010, he stated that he was doing "much better" and that he was doing woodworking as a hobby. He also was able to complete housework with the help of his son, who lived in the same house. In March 2011, he stated that he had repeated nightmares about his experiences in Korea, but was observed to be "very pleasant" to the observing psychiatrist. His affect was appropriate, and his thoughts were logical and coherent, with fair insight and good judgment. In April 2011, he stated that he continued to experience flashbacks, loss of interest in certain activities and poor concentration. However, in June 2011, he stated that his mood had been good, and that he was busy with medical appointments. He also routinely denied suicidal ideation. At his hearing before the Board in October 2012, he stated that he experiences nearly continuous panic attacks. However, this assertion is contradicted by the fact that a history panic attacks was not noted on most occasions when he was clinically evaluated. Therefore, when considering the Veteran's observed symptoms in their entirety, most notably his VA examinations, the evidence does not indicate that the presence of PTSD related symptoms such as suicidal ideation, obsessional rituals, illogical or obscure speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, or neglect of personal appearance or any other similar symptoms to the point where a rating in excess of 50 percent would be warranted. Although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment." Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational inadaptability. In this regard, the Veteran stated at his December 2004 VA examination that he "sometimes tries to isolate from others" and, at his December 2009 VA examination, he stated that he quit his job because he "couldn't put up with people." However, it is clear in the record that his social functioning is not very limited. For example, in his December 2009 VA examination, he stated that he had been married for 53 years (before his spouse passed away) and that he still maintains contact with his three living children. As mentioned above, one of his children lives with him. Moreover, while the Board acknowledges that the Veteran has interpersonal relationships may be somewhat hindered, a complete "inability" has not been shown, despite his assertions to the contrary. For example, while he has stated that he got irritated with people, he also stated that he still keeps in touch with friends who he knew from his employment. Additionally, it does not appear that he was necessarily unable to do this job, as he had been employed for the previous six years, but instead left on his own accord. Thus, even though there may be some symptoms that demonstrate a difficulty in maintaining social relationships, they are not so severe as to indicate that he has an "inability" to maintain them. Thus, an increased rating is also not warranted based on such impairment. In addition to these symptoms, the Board has also considered the Veteran's Global Assessment of Functioning (GAF) scores. 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) (DSM-IV)). Here, the Veteran's GAF scores have ranged from 60 (at the December 2009 VA examination) to 75 (at a psychiatric evaluation in August 2010). A GAF of 51-60 reflects "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). By comparison, scores ranging from 61-70 reflect more "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. By comparison, a GAF between 71-80 is assigned if symptoms are present, but are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument). Additionally, such a rating is assigned when there is no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Based on the symptoms observed by the VA examiners and the mental health professionals, it would appear that a GAF score in the range of 61-70 is most appropriate. Specifically, even though the Veteran experiences mild insomnia and some limitations in social and occupational functioning, the totality of the evidence indicates that he still functions well, and appears to have stable relationships with his children. However, as this discussion illustrates, a GAF score in the range of 61-70 is not sufficient to warrant the next-higher 70 percent rating, as the criteria for a 70 percent rating are clearly more severe than the symptoms associated with such GAF scores. The Board has also considered the Veteran's statements asserting that his psychiatric disorder is worse than the rating he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. In this regard, the Board specifically notes the statements he made at his hearing in October 2012, such as his claimed history of panic attacks. The Board is also respectful of the testimony he provided about his experiences in Korea. However, it should be reiterated that it is his current symptoms that are most relevant when assessing his disability rating. In any event, even though he may testify about his symptoms, he is not competent to identify the specific level of disability he should be receiving according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's psychiatric disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which his psychiatric symptoms are evaluated. The Board also finds that a referral for an extraschedular evaluation, which is a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). In this regard, the Court of Appeals for Veterans Claims (Court) has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the symptoms related to his psychiatric disorder were applied to the applicable rating criteria, general counsel opinions, and case law. Although the diagnostic code in this case allows for higher ratings, the Board fully explained why the higher ratings were not warranted. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable, and the appeal is denied. New and Material Evidence In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulation, "new" evidence is defined as evidence not previously submitted to agency decision-makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. However, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C.A. § 5103A (eliminates the concept of a well-grounded claim). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Because the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim, regardless of the RO's determination on the question of reopening, the Board will determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In this case, the Veteran seeks service connection for a dental condition, which includes a claim for VA outpatient dental treatment under 38 C.F.R. § 3.381 (2012). Mays v. Brown, 5 Vet. App. 302 (1993). This claim was previously denied by the RO in June 1960 on the basis that his condition was not based on a service-incurred dental disability, was not related to in-service trauma and was not submitted within one year of his release from active duty or December 31, 1954, whichever is later. He did not appeal that decision, nor did he submit any new and material evidence within a year of the June 1960 rating decision. See Buie v. Shinseki, 24 Vet. App. 242 (2011). As such, this represents the last final denial of the claim. At the time of the June 1960 decision, the evidence of record included the Veteran's service treatment records as well as a VA examination from May 1956 and a VA dental examination from June 1960. Of note, this May 1960 VA dental examination includes a recommendation that the Veteran's claim be rejected, as he failed to meet the time requirements for outpatient dental care. However, at his hearing before the Board in October 2012, the Veteran stated that some of his teeth were "kicked out" while playing football. It does not appear that he made this assertion prior to the June 1960 decision. Shade v. Shinseki, 24 Vet. App. 110 (2010) (a veteran's testimony should not be rejected as not being material solely because he is a lay person offering observations). While it unclear in the evidence whether such trauma actually occurred, his statements are presumed credible when considering applications to reopen. Justus 3 Vet. App. at 513. Therefore, as new and material evidence on the issue of entitlement to service connection for a dental condition has been submitted, the Board concludes that VA's duty to assist has been triggered to consider this claim, to include undertaking any further necessary development. Shade, 24 Vet. App. at 118. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Generally, the evidence 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); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Moreover, under 38 C.F.R. § 3.303(b), the second and third elements of Shedden and Caluza may be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (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. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). For sensorineural hearing loss claims, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater, when the auditory thresholds for at least three of the above frequencies 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. Service connection will also be presumed for certain chronic disorders, to include diabetes mellitus and sensorineural hearing loss, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309. Finally, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). As is relevant here, the Veteran is claiming entitlement to service connection for residuals of eye surgery; diabetes mellitus, type 2; and bilateral hearing loss. It is noted at the outset that he claims to have been a prisoner of war while serving in Korea. According to his previous statements, as well as at his hearing before the Board, he specifically described being taken into custody by a Russian military unit in 1948 and was detained for approximately 5 days. Where disability compensation is claimed by a former prisoner of war, omission of history or findings from clinical records made upon repatriation is not determinative of service connection, particularly if evidence of comrades in support of the incurrence of the disability during confinement is available. Special attention will be given to any disability first reported after discharge, especially if poorly defined and not obviously of intercurrent origin. The circumstances attendant upon an individual veteran's confinement and the duration thereof will be associated with pertinent medical principles in determining whether disability manifested subsequent to service is etiologically related to the prisoner of war experience. 38 C.F.R. § 3.304(e). In this case, the nature and circumstances of the Veteran's detainment are unclear, and it is uncertain whether the Veteran was a "prisoner of war" for VA purposes. See 38 C.F.R. § 3.1(y) (2012) (defining the term "prisoner of war"). However, the Board need not reach this question, as he has not asserted that any of the nonservice-connected disorders are related to his detention. Moreover, there is no basis for service connection for any of the service connection issues on appeal purely on the basis of being a former prisoner of war. While there are a number of disorders for which service connection will be presumed related to active duty service if a veteran was a prisoner of war, see 38 C.F.R. §§ 3.307, 3.309, none of the diseases listed in this section are among the disorders claimed on appeal. Moreover, while 38 C.F.R. § 3.304(f) relaxes the requirements for establishing service connection for psychiatric disorders such as PTSD, the Veteran is already service connected for this disorder. Therefore, the provisions related to prisoners of war are not applicable in this case. However, based on the evidence of record, the Board is willing to concede that the Veteran is a combat veteran. At his hearing before the Board in October 2012, he stated that he was in receipt of the Combat Infantryman Badge (CIB). Although there is no record that he ever received this decoration, there is other evidence of record to support his assertions of combat participation. For example, a service treatment note from October 1950 indicates that he participated in "about 20 days of active combat." An abbreviated clinical record from September 1950 also indicates that he operated as a "rocket launcher" who participated in 20 days of combat. In the case of combat veterans, VA shall accept lay evidence as sufficient proof for service-connection of any disease or injury alleged to have been incurred in or aggravated by during active service, so long as such lay evidence is consistent with the circumstances of such service. The Veteran's assertions may be rebutted only upon a showing of clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). Here, the Veteran stated at his hearing before the Board that he was hospitalized for an enlarged heart while on active duty and that, when there, he began to experience blurriness in the eyes, which prevented him from reading and other tasks. He also attributed his eye symptoms to a separate incident where he was struck in the head by a machine gun. See Hearing Transcript (T.) at 8-9. With regard to his bilateral hearing loss, the Veteran stated that he was routinely exposed to acoustic trauma while in service while participating in combat while in Korea, to include machine gun fire and artillery. He has also asserted that his diabetes is related to the food he ate while on active duty. The Board accepts the Veteran's testimony that he was struck in the head by a machine gun and also recognizes that he was exposed to significant acoustic trauma may also be conceded. However, his recollections pertaining to his eyesight were not in the context of participation in combat. Thus, there is no obligation to accept his assertions related to this treatment as fact under 38 U.S.C.A. § 1154(b). Moreover, the service treatment records reflect no symptoms, diagnoses or treatment indicative of diabetes mellitus or a chronic eye disorder. To the contrary, an ophthalmologic evaluation in September 1950 was substantially normal. While there were indications of a bilateral astigmatism, this is merely a refractive error of the eye that is developmental or congenital in nature, and is not within the meaning of the applicable VA regulations regarding disability compensation. 38 C.F.R. § 3.303(b). A physical evaluation in October of that same year observed clear conjunctivae and pupils and, significantly, his separation physical examination in January 1951 did not note any eye disorders other than a slight refractive error. Also, while the fact that the Veteran was exposed to acoustic trauma is presumed, there is no indication that this had any impact on his hearing while he was on active duty. Unfortunately, the Veteran did not undergo any audiological testing at the time of his separation physical examination in January 1951. However, it is notable that he never complained of hearing loss on this occasion or during any other period of active duty treatment treatment. Thus, there is no clinical evidence of a chronic eye disorder, diabetes mellitus or impaired hearing in service. Next, the post-service evidence does not indicate the presence any of these disorders for many years after he left active duty. Specifically, the first indication of diabetes mellitus was not until a May 1999 evaluation, which also noted that this disorder had become manifest only very recently. The first indication of a chronic eye disorder was not until a March 2006 eye evaluation, which indicated that he had been diagnosed with bilateral cataracts approximately two years before, or in approximately 2004. The post-service audiological treatment is noteworthy for an episode of acute otitis media in September 1970, which impacted the hearing in his left ear. However, there is no evidence to suggest that this led to any sensorineural hearing loss that was chronic in nature. In fact, the first indication of impaired hearing for VA purposes was not until his VA examination in December 2009, where an audiogram reflected tonal thresholds of 30 dB or higher at all frequencies from 1000 to 4000 Hz in each ear. The Board emphasizes that these post-service diagnoses for diabetes mellitus, a chronic eye disorder and bilateral hearing loss were not diagnosed until 48, 55 and 58 years after he left active duty, respectively. Thus, a continuity of symptoms has not been shown based on the clinical evidence of record. In so concluding, the Board has also considered the Veteran's statements asserting continuity of symptoms. McClain v. Nicholson, 21 Vet. App. 319, 325 (2007). In doing so, factors such as facial plausibility, bias, self-interest, and consistency with other evidence of record may be considered. Caluza v. Brown, 7 Vet. App. at 511; see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); cf. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Veteran is competent in some cases to self-diagnose some disorders despite his status as a lay person. Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, he is not competent diagnose disorders chronic eye disorders such as cataracts, nor is he able to diagnose diabetes mellitus or sensorineural hearing loss, as these require specific testing that can be administered only by trained professionals. Nevertheless, the Veteran's lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection, if credible, regardless of the lack of contemporaneous medical evidence. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, however, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. Of particular note, the post-evidence includes a VA employee health record summary from 1954 to 1970, which briefly lists all of the treatment he received during this time. However, none of these disorders were noted during this period. In fact, the only two incidents of any relevance to these disorders were the removal of a piece of cinder from his left eye in August 1957, and complaints of "burning" in the eyes in January 1969. However, chronic ocular disorder was not identified on either occasion. Moreover, there is no mention at all of any symptoms related to sensorineural hearing loss or diabetes. Thus, his assertions of continuous symptoms are rebutted by this evidence. The Board also notes that the Veteran has previously sought service connection for other disorders, during which time he never made a reference to hearing loss, an eye disorder or diabetes mellitus. This also weighs against his credibility. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, and cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board as factfinder to draw a reasonable inference). Finally, the Board also cannot ignore the significance of the fact that the Veteran did not file his claim for service connection for these issues for at least 48 years after he left active duty. Shaw v. Principi, 3 Vet. App. 365 (1992) (a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim). Therefore, continuity is not established based on the clinical evidence of record or the Veteran's statements. Next, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's claimed disorders to active duty, despite his contentions to the contrary. First, the Board finds that the weight of the competent evidence does not attribute the Veteran's cataracts (or any other chronic eye disorder) or his diabetes mellitus to active duty, despite his contentions to the contrary. Significantly, none of the competent evidence of record indicates a relationship between these disorders and active duty, nor has any treating professional indicated such a relationship. As for the Veteran's bilateral hearing loss, the Board places great probative value on a VA examination conducted in August 2011. At that time, the examiner observed that there was no diagnosis of hearing loss while in service, nor were there any complaints of such symptoms. This examiner also reviewed the results of a previous VA examination in December 2009, and specifically noted that the Veteran had reported experiencing hearing loss symptoms since 1950. Moreover, an audiometric evaluation indicated puretone thresholds of 35 dB or greater in each ear at all frequencies from 1000 to 4000 Hz, which established impaired hearing under 38 C.F.R. § 3.385. Despite the Veteran's assertions to the contrary (which, as previously discussed herein, the Board does not find credible), the examiner opined that this hearing loss was not at least as likely as not related to his military service. In providing this opinion, the VA examiner reiterated that there was no evidence of hearing loss in service, and, in fact, there were no complaints of hearing loss until many years later. The examiner noted also clearly placed great weight on the Veteran's stated work history at the December 2009 VA examination, which included long-term occupational acoustic trauma, such as the use of jackhammers and power tools. The Board finds that the examination was adequate for evaluation purposes. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, there is no contradicting medical evidence of record. Thus, the Board finds the VA examiner's opinion to be of great probative value. The Board has also considered the statements made by the Veteran relating his claimed disorders to his active service. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of his diabetes mellitus, hearing loss or chronic eye disorder. See Jandreau, 492 F.3d at 1377, n.4. Because these disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is competent to make. Therefore, the unsubstantiated statements regarding the claimed etiology of the Veteran's diabetes mellitus, hearing loss or chronic eye disorder are found to lack competency. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. ORDER A rating in excess of 50 percent for an acquired psychiatric disorder, diagnosed as PTSD and anxiety disorder is denied. New and material evidence having been submitted, the application to reopen a previously denied claim of entitlement to service connection for a dental condition, to include entitlement to dental treatment, is granted, and, to this extent, the appeal is granted. Service connection for an eye disorder, diagnosed as cataracts, to include residuals of a bilateral phacoemulsification, is denied. Service connection for diabetes mellitus, type 2, is denied. Service connection for bilateral hearing loss is denied. REMAND The Board concludes that additional development is necessary related to the claims of entitlement to TDIU and for a dental disorder. With regard to the Veteran's claim for TDIU, the RO has denied this claim on the basis that the evidence has not established that the Veteran is unable to maintain gainful employment due to his psychiatric disability, which is the only disability for which he is service-connected. However, there does not appear to be a sufficient medical basis to make such a conclusion. Notably, the VA examiner in December 2009 stated that the Veteran's irritability was likely related to his service-connected psychiatric disorder and that such symptoms would make it difficult to interact with the public or other co-workers. However, this examiner did not state whether his acquired psychiatric disorder made him unemployable. That conclusion appears to have been made solely by the RO. Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (VA adjudicators may not make their own medical conclusions). The Board has also noted the statements from a private physician, who contends that the Veteran is "100 [percent] disabled," although this doctor failed to mention the Veteran's psychiatric disorder as a factor. Thus, a VA medical opinion is necessary. With regard to the Veteran's claim for outpatient dental treatment, eligibility for VA outpatient dental treatment is comprised of different classes. As is relevant here, dental treatment is warranted for those having a noncompensable service-connected dental condition that is the result of a combat wound or other service trauma (Class II(a)), and for any veteran whose service-connected disabilities are rated at 100 percent by schedular evaluation or who is receiving TDIU (Class IV). As the issue of entitlement to TDIU requires further development, his dental claim cannot be adjudicated until this development is complete. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Although the Veteran mentioned that he had teeth "kicked out," it is unclear when or where this occurred. He should be afforded the opportunity to describe these events. Additionally, while the evidence does include some in-service dental treatment records, the Board lacks the specific training to properly interpret them. Therefore, these records should be forwarded to a VA dental examiner for review. Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested. This case is REMANDED for the following action: 1. Issue to the Veteran a VCAA notice letter pertaining to the claim for service connection for a dental condition, to include entitlement to dental treatment. 2. Contact the Veteran and request further explanation of his assertion that he experienced dental trauma while on active duty. He should be afforded the appropriate opportunity to submit any additional information that may be relevant to this claim or to his employability claim (such as occupational health information, pay statements or other similar information). 3. If the Veteran references any additional treatment related to his dental condition, or any employment-related records, and such documents are not of record, acquire any such available records after obtaining the Veteran's authorization. 4. Schedule the Veteran for a VA psychiatric examination to determine the effects of his service-connected PTSD and anxiety disorder on his ability to maintain employment that is consistent with his education and occupational experience. The claims file and a complete copy of this Remand must be made available to the VA examiner for review in conjunction with the examination. All necessary special studies or tests are to be accomplished. The VA examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on a review of the claims file, as well as an interview with the Veteran, the examiner must provide an opinion as to whether the Veteran's service-connected PTSD and anxiety disorder precludes him from securing and following substantially gainful employment that is consistent with his education and occupational experience. [The term "substantially gainful employment" is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. Faust v. West, 13 Vet. App. 342 (2000).] The examiner must consider the Veteran's lay statements regarding his disorder. All findings and comments should be set forth in a legible report, and any opinions should be accompanied by a thorough discussion explaining the basis for the given opinion. 5. Also, forward the claims file to a VA dental examiner for review. The examiner is specifically asked: (a) to explain the dental treatment the Veteran received while on active duty as noted in the service dental records (to include any observations made by examiners) and (b) to opine as to whether there is any evidence that the Veteran incurred dental trauma in service. An examination of the Veteran is not necessary unless deemed necessary by the VA examiner. 6. Thereafter, readjudicate the issues of entitlement to TDIU and entitlement to service connection for a dental disorder, to include entitlement to outpatient dental treatment. If any of the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and provided opportunity to respond. Then, the case should be returned to the Board for further appellate consideration, as appropriate. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2012). He has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs