Citation Nr: 1306977 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 09-40 878 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to a rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, including as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Calvin Hansen, Attorney ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to August 1971. This case comes to the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Des Moines, Iowa, Regional Office (RO) of the Department of Veterans Affairs (VA), that in pertinent part, denied an increase in a 50 percent rating for service-connected PTSD with major depressive disorder, and denied service connection for hypertension. In an April 2012 decision, the Board remanded these issues to the RO for additional development. The case was subsequently returned to the Board. While this case was on remand, in a June 2012 rating decision, the RO restored a 50 percent rating for the Veteran's service-connected bilateral hearing loss. In a December 2012 rating decision, the RO granted an increased 70 percent rating for service-connected bilateral hearing loss, effective October 29, 2012. The Veteran filed a notice of disagreement as to the effective date, and in a December 2012 rating decision, the RO granted an earlier effective date of February 11, 2011 for the 70 percent rating, and informed the Veteran that his appeal was withdrawn. The Board disagrees. Hence, the issue of entitlement to an effective date prior to February 11, 2011 for the grant of a 70 percent rating for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's PTSD is manifested by no more than occupational and social impairment with reduced reliability and productivity. 2. The most probative (competent and credible) medical and other evidence of record indicates the Veteran's current hypertension was not manifested during a period of active duty. Nor does the evidence show that hypertension was presumptively incurred during a period of active duty or that it is otherwise related to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 50 percent for PTSD with major depressive disorder are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Codes 9411, 9434 (2012). 2. Hypertension was not incurred in or aggravated by military service, nor may it be presumed to have been so incurred, and it was not caused or aggravated by service-connected diabetes mellitus. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, an April 2009 notice letter was sent to the Veteran prior to the July 2009 rating decision on appeal, i.e., in the preferred sequence. These letters informed him of the type of information and evidence required to substantiate these claims for service connection and for an increased rating, and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. He was also advised to provide evidence showing that his service-connected disability of PTSD with major depressive disorder had worsened, so as to in turn entitle him to an increased rating for this disability. He was advised, as well, of the downstream disability rating and effective date elements of these claims in this letter. See Dingess/Hartman, supra. So he has received all required VCAA notice concerning these claims. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and, moreover, above and beyond this, that it is unduly prejudicial - meaning outcome determinative of his claims. Thus, absent this pleading or showing, the duty to notify has been satisfied. VA also fulfilled its duty to assist the Veteran with these claims by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO obtained his service treatment records (STRs), private medical records, VA outpatient treatment records, and a statement from his employer, and arranged for VA compensation examinations in May 2009 and August 2010. The May 2009 VA examiner provided a medical opinion regarding the claimed relationship between diabetes mellitus and hypertension. With respect to the claim for an increased rating for PTSD with major depressive disorder, only if the record is inadequate or there is suggestion the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2012). Here, the most recent VA compensation examinations for this condition were conducted in August 2010. The mere passage of time since does not, in and of itself, necessitate another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that the most recent VA examinations are adequate as they provide the information needed to properly rate his PTSD with major depressive disorder. 38 C.F.R. §§ 3.327(a), 4.2. The Board finds that the examination reports were each sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. The examinations were conducted by competent medical professionals. In addition, it is not shown that the examinations were in any way incorrectly conducted or that the VA examiners failed to address the clinical significance of the Veteran's symptoms. Further, the VA examination reports addressed the applicable rating criteria. In this regard, the reports of record contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the service-connected psychiatric disorder to provide probative medical evidence for rating purposes. The Board finds that another examination is not needed since there is sufficient evidence, already on file, to fairly decide this claim. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). The Board concludes that the appellant was afforded adequate examinations. The Board further finds that the RO has substantially complied with its April 2012 remand orders. In this regard, the Board directed that additional treatment records be obtained and the Veteran be contacted in an attempt to obtain relevant private medical records. He did not respond to the RO's August 2012 development letter. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is not always a one-way street and if a Veteran desires help with his claim he must cooperate with VA's efforts to assist him). Additional VA treatment records have been associated with the claims file. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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). Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. Increased Rating for PTSD with Major Depressive Disorder Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). The current level of disability, however, is of primary concern in a claim for an increased rating; the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994). That being said, given unintended delays during the appellate process, VA's determination of the "current level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending. In those instances, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "it is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection was established for PTSD with major depressive disorder in an April 2006 rating decision. The RO has rated the Veteran's PTSD with major depressive disorder as 50 percent disabling throughout the rating period on appeal. The Veteran contends that this disorder is more disabling than currently evaluated. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: 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 and maintaining effective work and social relationships. A 70 percent rating is assigned 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 worklike setting); inability to establish and maintain effective relationships. 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 of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9434. The above set of symptoms is not an exclusive or exhaustive list, as evidenced by use of the phrase "such symptoms as," followed by a list of examples. So, rather, it serves as merely an example of the symptoms that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In determining whether the Veteran meets the criteria for a higher rating, the Board must consider whether he has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." 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). The higher the score, the higher the overall functioning of the individual is. GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 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). GAF 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 (i.e., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). While the Rating Schedule indicates the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence bearing on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. At a March 2006 VA PTSD examination, the examiner diagnosed PTSD with major depressive disorder secondary to PTSD. The GAF was 55. The examiner indicated that based on the Veteran's 30-year work history with Burlington Northern, his marriage of many years, and many other positive indicators, he had moderate impairment related to PTSD with depressive features. He had never received mental health intervention or psychiatric medication management in spite of his reported symptoms. The Veteran filed a claim for an increased rating for service-connected PTSD with major depressive disorder in April 2009. VA medical records dated from 2007 to 2012 reflect treatment for a variety of medical conditions but are negative for treatment of PTSD or major depressive disorder. Multiple depression screens performed during outpatient visits from 2008 to 2011 were negative. At a May 2009 VA PTSD examination, the Veteran denied symptoms during the past year, and denied current psychiatric treatment. He reported that he and his wife had been married since 1980, and had four children. One son lived at home. He saw his grandchildren every two months. He had no one he associated with. His hobby was gardening. He said he had been sober for 20 years. On examination, he was clean, neatly groomed, and casually dressed. He was tense, speech was clear and monotone, attitude was irritable, affect was restricted, and mood was anxious. Attention was intact; he was able to do serial sevens and spell a word forward and backward. He was oriented to person, place, and time. Thought process and content was unremarkable. There were no delusions or hallucinations. He understood the outcome of his behavior. He understood that he had a problem. The examiner indicated that he did not have sleep impairment or inappropriate behavior. He interpreted proverbs appropriately, and did not have obsessive/ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. Impulse control was good, there were no episodes of violence, and he was able to maintain minimum personal hygiene. There were moderate problems with the activities of daily living. Remote, recent and immediate memory were normal. Regarding PTSD symptoms, intrusive thoughts, images, or memories occurred on a daily basis. He reported nightmares at least two times or more per week. He had some nights when he was not able to back to asleep, and then got up to sit in a chair. Other nights, he was able to go back to sleep. He tried not to talk about military combat or veterans' trauma issues. His physiological reactions included sweating, rapid heartbeat, feeling overwhelmed, and shallow breathing. His ability to talk and think about the trauma was moderately severe. Avoidance of activities, places and people was moderately severe. His affective restriction was moderately severe. Diminished interests or participation in activities showed moderately severe impairment. He averaged three to four hours of sleep on a good night. He had irritability, and in his younger years was angrier. He also reported startle reaction and auditory hypervigilance. He had held his current job for 33 years. He worked as a driver. Since his last appointment in 2006, his work assignment had changed, and he now worked in a crew, instead of driving a truck by himself. He really preferred to be by himself and was not fond of working with a group. The Axis I diagnosis was PTSD and major depressive disorder in partial remission. The GAF was 53. The examiner commented that there had been some level of increase in the C criteria, but overall, his symptoms really seemed to be the same. He had not sought active forms of intervention such as individual or group therapy and had not sought psychiatric medication intervention. His prognosis was good, and the examiner indicated that he required intervention to address his PTSD. The examiner stated that there was not total occupational and social impairment due to PTSD signs and symptoms, and PTSD signs and symptoms did not result in deficiencies in the following areas: judgment, thinking, family relations, work, mood, or school. He opined that there was reduced reliability and productivity due to PTSD symptoms. He said productivity would be impaired at a moderate level, and reliability had been adequate. On VA general medical examination in August 2010, the Veteran reported that he worked as a section truck driver for the railroad. He reported problems due to blood pressure variability, and due to diabetes mellitus. He said his job was becoming more stressful and he planned to retire at the end of the month, primarily due to social interaction difficulties with his boss. He reported a history of interpersonal relationship difficulties, depression, panic attacks, memory problems, loss of control/violence potential, homicidal thoughts in the past but none now, anxiety and confusion. He denied a history of suicidal ideation. He denied any suicidal or active homicidal thoughts today. On psychiatric examination, there was a somewhat flat affect, sad mood, normal judgment, and normal comprehension of commands. He had no obsessive behavior, hallucinations or delusions. He lost no time from work in the past year. On VA PTSD examination in August 2010, the examiner stated that the claims file was reviewed. The Veteran denied outpatient or inpatient treatment for a psychiatric disorder. He reported decreased appetite and fatigue. He said he did not sleep well, and his mood was pervasively blue or depressed, nearly every day. Symptom severity was mild and the symptoms had not remitted since his last VA examination in 2009. The Veteran reported limited contact with his children and grandchildren. He had been married since 1980, and he and his wife's main activity was spending time together at home. On examination, he was clean and neatly groomed, and casually dressed. He was tense, speech was unremarkable, and his attitude toward the examiner was cooperative and attentive. His affect was restricted, and his mood was anxious. Attention was intact; he was able to do serial sevens and spell a word forward and backward. He was oriented to person, place, and time. Thought process and content was unremarkable. There were no delusions or hallucinations. He understood the outcome of his behavior. He understood that he had a problem. The examiner indicated that he did not have sleep impairment or inappropriate behavior. He interpreted proverbs appropriately, and did not have obsessive/ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. Impulse control was good, there were no episodes of violence, and he was able to maintain minimum personal hygiene. There were moderate problems with the activities of daily living. Remote, recent and immediate memory were normal. PTSD symptoms included recurrent and intrusive distressing recollections, recurrent dreams, flashbacks, and efforts to avoid thoughts, feelings or conversations associated with the in-service trauma. He also reported markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect. He also reported difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. He said his nightmares occurred once per week and were mild. Intrusive thoughts were moderate. Internal or external reminders could be a few times daily or less per day. Psychological tests were conducted and showed moderate severity of PTSD symptoms. The Veteran was currently employed on a full-time basis, and had held his job for 34 years. He lost no time from work in the past 12 months. He said that due to diabetes, hypertension, and his hearing that he might be unfit to work in the future. The diagnosis was PTSD and major depressive disorder, mild severity. The GAF was 55. The examiner commented that the Veteran's PTSD and MDD were mild, intertwined and inseparable, with a combined GAF of 55. The examiner indicated that his psychiatric disorders remained essentially the same as when he was seen in 2009. He observed that the Veteran's PTSD had not risen to a level such that he sought psychotherapy or psychiatric medication for symptom relief. His PTSD alone would not render him unemployable. His prognosis for improvement was good. The examiner stated that there was not total occupational and social impairment due to PTSD signs and symptoms, and that PTSD signs and symptoms did not result in deficiencies in the following areas: judgment, thinking, family relations, work, mood, or school. He opined that there was reduced reliability and productivity due to PTSD symptoms. In a September 2010 statement, the Veteran's employer indicated that the Veteran was formerly employed there as a motor vehicle operator from April 1976 to early September 2010, and he retired at the end of August 2010. In a January 2011 rating decision, the RO granted entitlement to a total disability compensation rating based on individual unemployability (TDIU rating) effective September 1, 2010. After reviewing the evidence of record, the Board finds no support for an evaluation in excess of 50 percent for the Veteran's service-connected PTSD with major depressive disorder throughout the rating period on appeal. The reasons and bases for this determination will be set forth below. In this case, the Veteran has been assigned GAF scores between 53 and 55 during the pendency of this appeal. On VA examination in May 2009, the GAF was 53, and the examiner opined that his productivity would be impaired at a moderate level, and reliability had been adequate. On VA PTSD examination in August 2010, the GAF was 55, and the examiner opined that there was reduced reliability and productivity due to PTSD symptoms, and his PTSD alone would not render him unemployable. Throughout the rating period on appeal, the Veteran has never sought or received treatment or medication for his service-connected PTSD with major depressive disorder, and multiple depression screens have been negative. He has consistently reported that he did not lose time from work due to PTSD with major depressive disorder. Records reveal that he retired in late August 2010, after holding the same job for over 30 years. It is not shown that his PTSD with major depressive disorder alone renders him unemployable. He has been married to the same woman for many years, and they spend much of their time together at home. He has reported limited social interaction other than with his wife, and has a relationship with his children and grandchildren. The evidence does not demonstrate that a rating in excess of 50 percent is warranted at any time throughout the rating period on appeal. During this period, there is no evidence of suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; spatial disorientation; or neglect of personal appearance. There is no objective evidence at his VA examinations indicating or approximating near-continuous panic. Likewise, while the Veteran has at times complained of depression, recent evidence shows that this has improved. There is no objective evidence in either his treatment records or at his VA examinations that he has depression that is so severe as to prevent him from functioning independently, appropriately, and effectively. There is no objective evidence in either his treatment records or at his VA examinations of impaired impulse control to the extent required for a rating in excess of 50 percent. Moreover, notwithstanding the problems that the Veteran reported experiencing at the work-place, given the fact that he has managed to both maintain full-time employment for three decades, as well as a successful marital relationship and relationships with his family, leads the Board to conclude that the Veteran's PTSD is productive of impairment that does not approximate that required for a 70 percent evaluation. Accordingly, the Board finds that throughout the rating period on appeal, PTSD was not productive of disability warranting a rating in excess of 50 percent. Hart, supra. Furthermore, the Board also finds that the criteria for higher rating of 100 percent have not been met, as the evidence does not show total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board, in reaching these conclusions, has considered the Veteran's reported history. In this regard, his lay statements are probative, in conjunction with the other evidence of record, particularly the objective medical evidence, in determining the PTSD with major depressive disorder symptoms and resulting occupational and social impairment they cause. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In consideration of all the evidence and for the reasons and bases explained above, it is concluded that a rating higher than 50 percent for PTSD with major depressive disorder is not warranted, throughout the rating period on appeal. 38 C.F.R. §§ 4.3, 4.7. The Board has considered the benefit-of-the-doubt rule in making the current decision. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors that would render application of this schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to VA regulation, an extra-schedular rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). See also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). According to the holding in Thun v. Peake, 22 Vet. App. 111 (2008); aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009), there is a three-step inquiry for determining whether a Veteran is entitled to an extra-schedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Here, though, with respect to the first prong of the Thun analysis, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD with major depressive disorder is inadequate. A comparison between the level of severity and symptomatology of this disability with the established criteria found in the Rating Schedule for this disability shows the rating criteria reasonably describe and contemplate his disability level and symptomatology. See also 38 C.F.R. § 4.1, indicating that, generally, the degrees of disability specified in the Rating Schedule 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, too, Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). Further, the Board notes that the Veteran is currently in receipt of a TDIU rating, which has been retroactively awarded effective September 2010. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is unwarranted. Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). Service Connection for Hypertension The Veteran contends that he has hypertension that was caused or aggravated by his service-connected Type II diabetes mellitus. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Hypertension will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)). So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). When determining service connection, all theories of entitlement - direct, presumptive and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). If chronicity (i.e., permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). See also Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Establishing continuity of symptomatology under 38 C.F.R. § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to establish chronicity (permanency) of disease or injury in service and, in turn, link the currently claimed disability to service. See also Clyburn v. West, 12 Vet. App. 296, 302 (1999). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, 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," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b) (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence also is generally, though not always, required to associate the claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The medical evidence shows that in the Veteran has hypertension. VA medical records dated since 1999 reflect a diagnosis of hypertension. Therefore, there is competent medical evidence establishing that the Veteran has a current diagnosis of hypertension during the pendency of this appeal. See Degmetich, supra. Thus, the resolution of his appeal turns on whether any current hypertension is attributable to his service or to a service-connected disability. See 38 C.F.R. §§ 3.303, 3.310. A review of the claims file reflects that the Veteran has filed multiple claims over the years. In May 1973, he filed a claim for service connection for hearing loss. In November 1973, he filed a claim for service connection for vision impairment. In February 1994, he filed a claim for service connection for a skin disorder. In March 2005, he filed claims for service connection for headaches, diabetes mellitus, and Meniere's disease. In August 2005, he filed claims for service connection for peripheral neuropathy of the extremities. His initial claim for service connection for hypertension was not filed until April 2009. He contended that his hypertension was secondary to service-connected diabetes mellitus. The Veteran's service treatment records show that his blood pressure was 122/76 during his military entrance medical examination in August 1968, and 120/76 during his July 1971 military separation examination. On separation medical examination, his vascular system was listed as normal. In a June 1971 report of medical history, the Veteran denied a history of high or low blood pressure. His service treatment records are negative for a diagnosis of hypertension. On VA general medical examination in June 1973, the Veteran's only complaint was hearing loss. His blood pressure was 124/74 sitting, 130/86 standing, 144/76 sitting after exercise, and 124/76 two minutes after exercise. Hypertension was not diagnosed. VA medical records dated from 1977 to 1978 are negative for hypertension. An April 1977 electrocardiogram report reflects that his blood pressure was 118/72. The first medical evidence of hypertension is dated in 1999. A September 1999 VA history and physical examination reflects that the Veteran reported that he had been treated by a private physician, Dr. N.B., for essential hypertension with medication for the past two months. On examination, his blood pressure was 133/80. The pertinent diagnosis was hypertension. He was treated for hypertension in August 2000, which was well-controlled with medication. Subsequent VA medical records reflect ongoing treatment for hypertension. A March 2002 VA primary care note reflects that the Veteran's fasting glucose level was borderline elevated. In August 2002, his treating physician diagnosed hypertension and non-insulin-dependent diabetes mellitus, and indicated that his diabetes was borderline and he was not on any medication. An August 2002 diabetes education note reflects that the Veteran was first told he had diabetes in July 2002. At a May 2009 VA examination performed to evaluate the Veteran's diabetes mellitus, the Veteran reported that his hypertension dated back to 1995, and his diabetes mellitus was diagnosed in 2002. After a clinical examination, the examiner diagnosed type 2 diabetes mellitus. The examiner stated that the Veteran's hypertension was not a complication of his diabetes. The rationale for this opinion was the duration of the Veteran's diabetes and the date of onset of hypertension in relation to the date of onset of diabetes. The examiner also opined that the Veteran's hypertension was not worsened or increased by the Veteran's diabetes. The Board remanded this case in April 2012, primarily to attempt to obtain private medical records from Dr. N.B., observing that the only private medical records on file from this doctor are dated in July 2005. The RO wrote to the Veteran in August 2012, and asked him to identify health care providers who treated him for hypertension. He did not respond or submit any medical records. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons and bases 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. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility 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"). There are no relevant post-service medical records regarding hypertension until 1999, so for nearly 30 years after the Veteran's separation from service in 1971. The evidence does not reflect, and the Veteran does not contend, that he had continuous hypertension symptoms from service until 1999. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). And there is no competent medical evidence of record linking the hypertension to service. Moreover, he has never reported continuous symptoms of this condition ever since service. There is no evidence of treatment or diagnosis of this condition for many years after service, and in fact the evidence clearly demonstrates that hypertension was diagnosed in 1995 (per the Veteran's reported history) or in 1999 (per the medical records), well before diabetes mellitus was first manifested in 2002. The Veteran has never asserted that hypertension began in service or soon afterward. Here, after reviewing all the relevant lay and medical evidence, the Board finds that the weight of this evidence (the most probative of it) indicates the Veteran has not experienced continuous symptoms of hypertension since service, so has not shown the required continuity of symptomatology under 38 C.F.R. § 3.303(b) to establish the required nexus between this claimed condition and his military service. Moreover, the May 2009 VA examiner opined that the Veteran's service-connected diabetes mellitus did not cause or aggravate his current hypertension. This medical report is of high probative value and is fully adequate for compensation purposes. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The examiner had the benefit of reviewing the Veteran's medical records and his current reported history and complaints in conjunction with medical findings on examination, and provided a supporting rationale. There is no contrary medical opinion of record. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms of the claimed condition since service. The Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's current hypertension began years after his active duty and was not caused by any incident of service, or caused or aggravated by a service-connected disability. Additionally, the Board considers it significant that no VA examiner or other treating provider has indicated that the Veteran's hypertension arose during a period of active duty or is otherwise related to service or a service-connected disability. The Board recognizes that the Veteran himself has asserted that this disease was caused by service-connected diabetes mellitus. In some cases, such lay evidence is competent and credible on the issues of diagnosis and etiology. See Jandreau, supra. However, hypertension is a medically complex condition, not readily amenable to lay diagnosis, because it cannot be substantiated by mere lay observation or opinion. See Barr, 21 Vet. App. at 307. It follows, as an unfortunate consequence, that the Veteran is only competent to report experiencing certain symptoms which are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994) (holding that competent testimony is limited to that which the witness has actually observed, and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses, that which is heard, felt, seen, smelled or tasted). He is not similarly competent to render an opinion as to the etiology of his hypertension, or to state whether or not it is attributable to a service or a service-connected disability. Moreover, as the Veteran has not been shown to have the requisite clinical training to etiologically relate his claimed condition to diabetes, there is no need to assess the credibility of his lay assertions in this regard. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability, including during service and since, even where not corroborated by contemporaneous medical evidence such as treatment records, but also indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). As the preponderance of the evidence is against the claim for service connection for hypertension, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An increased rating in excess of 50 percent for PTSD with major depressive disorder is denied. Service connection for hypertension is denied. REMAND The Board finds that additional procedural development is necessary with respect to the claim for an earlier effective date for the grant of a 70 percent rating for service-connected bilateral hearing loss. While this case was on remand, in a June 2012 rating decision, the RO effectuated the Board's April 2012 decision and restored the prior 50 percent rating for the Veteran's service-connected bilateral hearing loss. In a December 2012 rating decision, the RO granted an increased 70 percent rating for service-connected bilateral hearing loss, effective October 29, 2012. In December 2012, the Veteran filed a timely notice of disagreement as to the effective date. In a December 2012 rating decision, the RO granted an earlier effective date of February 11, 2011 for the 70 percent rating, and informed the Veteran that his appeal for an earlier effective date was withdrawn. The Board disagrees. Although the RO has assigned the date of receipt of the Veteran's February 2011 claim for an increased rating as the effective date for the 70 percent rating, this is not the earliest possible effective date, and the Veteran has not indicated that he wishes to withdraw this appeal. Governing law and regulation provide that the effective date for an increased rating [for a disability once service connected] will be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, provided a claim is received within one year from such date; otherwise, the effective date for an increased rating will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o). In Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. May 20, 2010), the Federal Circuit Court explained that the legislative history of 38 U.S.C.A. § 5110(b)(2) shows that the intent was to provide Veterans with a one-year grace period for filing a claim following an increase in the severity of a service-connected disability. As the RO has not provided the Veteran with a statement of the case concerning this "downstream" claim for an earlier effective date, the Board must remand this claim to the RO, to provide this necessary statement of the case and to give him an opportunity to complete the steps necessary to perfect his appeal to the Board of this claim by filing a timely substantive appeal (e.g., a VA Form 9 or equivalent). See Manlincon v. West, 12 Vet. App. 238 (1999) and 38 C.F.R. § 20.200 (2012). Accordingly, the case is REMANDED for the following action: Send the Veteran a statement of the case addressing the appeal for an effective date prior to February 11, 2011 for the grant of an increased 70 percent rating for service-connected bilateral hearing loss. Notify him that he still needs to file a timely substantive appeal (VA Form 9 or equivalent statement) in response to this statement of the case to complete the steps necessary to perfect an appeal to the Board as to this issue. Only if he perfects an appeal of this additional claim should it be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs