Citation Nr: 1312554 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 11-00 550 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an effective date earlier than June 5, 2008, for the grant of service connection for posttraumatic stress disorder (PTSD), with a depressive disorder, not otherwise specified (NOS), and alcohol abuse. 3. Entitlement to an initial rating greater than 70 percent for service-connected PTSD with depressive disorder, NOS, and alcohol abuse, including entitlement to a total disability rating based on individual unemployability (TDIU). 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD S.K.C. Boyce, Associate Counsel INTRODUCTION The Veteran served on active duty from September 2001 to September 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which (1) granted service connection for PTSD, with a depressive disorder, NOS, and alcohol abuse, and assigned a 30 percent rating, effective June 5, 2008, in an April 2009 rating decision; (2) denied service connection for hearing loss and tinnitus in a November 2009 rating decision; and (3) increased the Veteran's initial rating for PTSD with depressive disorder, NOS, and alcohol abuse, to 70 percent disabling in December 2010. The claim for a higher disability rating for service-connected PTSD with a depressive disorder, NOS, and alcohol abuse, has been recharacterized on the title page in accordance with the medical and lay evidence of record raising the issue of entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). The issues of entitlement to service connection a back disorder, diabetes mellitus, type II, and high blood pressure, denied in the April 2009 rating decision, while frequently mentioned in the Veteran's statements, are not on appeal before the Board as the Notice of Disagreement (NOD) filed in July 2010 was not timely. In December 2012, VA sent a letter to the Veteran informing him that his NOD was not timely and the RO's April 2009 rating decision was final. In April 2009, documents showing the diagnostic test data ordered by the March 2009 examiner were associated with the claims folder a few days after the April 2009 rating decision was issued. However, the examiner fully reported the results of those same tests in a section of the examination report titled "Diagnostic Tests" and an addendum. As the diagnostic test data was already fully discussed by the medical examiner, the records displaying this duplicative data were not new and material. See 38 C.F.R. § 3.159(b) (2012). Consequently, the April 2009 rating decision is final with regard to all adjudicated issues other than the Veteran's appeal of the initial rating assigned for his service-connected PTSD with a depressive disorder, NOS, and alcohol abuse, as that claim was the sole issue listed on his September 2009 NOD. Therefore, the issues of entitlement to service connection for lumbago, hypertension, hallus valgus of the right foot, and diabetes mellitus, type II, and entitlement to an initial compensable disability rating for hallus valgus of the left foot are referred back to the AOJ for appropriate action, including consideration of whether new and material evidence sufficient to reopen the previously denied claims has been filed, as the Board does not have proper appellate jurisdiction where no timely NOD has been filed following initial AOJ adjudication of the issue. Similarly, review of the record shows that the Veteran has requested revision of multiple RO decisions on the grounds of clear and unmistakable error (CUE). As no CUE claims have yet been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have proper jurisdiction over those claims, and they are also referred back to the AOJ for appropriate action. The issues of entitlement to an initial rating greater than 70 percent for service-connected PTSD with depressive disorder, NOS, and alcohol abuse, including entitlement to TDIU and entitlement to service connection for tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have a current hearing loss disability for VA compensation purposes. 2. The Veteran separated from active military service in September 2004. His initial claim for entitlement to service connection for PTSD was received at the RO in Houston, Texas, on June 5, 2008, more than three years after he discharged from active service. 3. The Veteran did not file any formal or informal claim for service connection for any psychiatric disorder prior to June 5, 2008. 4. The Veteran's VA treatment records dating back to September 1, 2005, do not constitute an informal claim for service connection for PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. The criteria for an effective date prior to June 5, 2008, for the grant of entitlement to service connection for posttraumatic stress disorder (PTSD) with a depressive disorder, not otherwise specified (NOS), and alcohol abuse, have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.1, 3.155, 3.157; 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for Hearing Loss A. Duty to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), the Department of Veterans Affairs (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, 3.159, 3.326(a) (2012). Upon receipt of a substantially complete application for benefits, VA must notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); 38 C.F.R. § 3.159(b). Specifically, VA must notify the Veteran of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Quartuccio, 16 Vet. App. at 186. Furthermore, these 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) the degree of disability, and (5) the effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). Lastly, the required notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). An RO letter dated October 2009 informed the Veteran of all three elements required by 38 C.F.R. § 3.159(b), as stated above. As this decision denies the Veteran's claims for service connection, there can be no possibility of prejudice to the Veteran under the holding in Dingess as no disability rating or effective date can be assigned. See 19 Vet. App. at 487-88; see also Grantham v. Brown, 114 F.3d 1156, 1158 (Fed.Cir.1997) (noting that downstream elements not part of appeal of denial of service connection). Therefore, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and has not been prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VA also has a duty to assist a claimant in obtaining the evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A(a)(1); 38 C.F.R. § 3.159(c). This duty includes assisting the Veteran in obtaining his service and other treatment records and providing him with a medical examination and/or obtaining a medical opinion when necessary. Id. Here, the RO was unable to obtain the Veteran's complete service records. In July 2008, the RO contacted the Records Management Center (RMC) to request the Veteran's service records, as the RMC houses all service treatment records for Army Veterans with a separation date on or after October 16, 1992. See VA Adjudication Procedures Manual, M21-1MR, pt. III, sbpt. iii, ch. 2, § A.4.f (Jan. 7, 2007) (hereinafter M21-1MR). The RMC responded, and notified the RO that several searches were conducted but the records could not be located. The Veteran was provided with information about possible alternative sources of evidence in December 2008, and some service records were obtained from the Department of Defense in January 2009. In December 2010, the Veteran was notified that VA was unable to locate a complete copy of his service treatment records and informed of the specific efforts that the RO undertook to attempt to obtain those records. A formal finding on the unavailability of the Veteran's service treatment records was also associated with the claims folder in December 2010. Therefore, all appropriate steps have been to taken to obtain the Veteran's service treatment records and any further attempts to locate these records would be futile. The Veteran's VA treatment records have been obtained, and he has not identified any additional federal or private records that he would like VA to obtain. Therefore, VA has fulfilled its duty to make reasonable efforts to assist the Veteran in obtaining his relevant records. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159 (c)(1)-(3). The duty to assist includes obtaining an adequate medical examination report or medical opinion when necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that VA must ensure that any requested examination report or opinion is adequate). The medical examination or opinion provided is adequate where it is based upon consideration of the Veteran's prior medical history, including any prior medical examinations and the relevant lay evidence in the record, and describes the disability in sufficient detail to allow for a fully informed evaluation. D'Aries v. Peake, 22 Vet. App. 97, 104 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Green v. Derwinski, 1 Vet. App. 121, 124 (1991); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). As it is the factually accurate, fully articulated, and sound reasoning for the conclusion that contributes probative value to a medical opinion, a medical examiner must also provide a reasoned medical explanation connecting his observations and his conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-04 (2008). The Veteran was provided with a VA audiological examination in November 2009. The examiner reviewed the claims file, and noted the lack of any audiological data from service. The examiner reviewed the Veteran's relevant medical history and conducted an audiological examination. As this exam was accurate, sufficiently descriptive, and based on the complete medical record, including the Veteran's lay assertions, VA has fulfilled any duty to provide a thorough and contemporaneous medical examination. See Roberson v. Shinseki, 22 Vet. App. 358, 366 (2009); Barr, 21 Vet. App. at 310-11. The duty to assist has been satisfied as there is no reasonable possibility that any further assistance to the Veteran by VA would develop the evidence necessary to substantiate his claim. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); Canlas v. Nicholson, 21 Vet. App. 312, 317 (2007); Forcier v. Nicholson, 19 Vet. App. 414, 421-22 (2006); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that there is no basis for a remand when no benefit would flow to the Veteran). Therefore, because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. B. Evaluation of the Evidence The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Madden v. Grober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In doing so, equal weight is not accorded to each piece of evidence in the record as every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board's responsibility to evaluate the evidence applies to both medical evidence and competent lay evidence. Madden, 1125 F.3d at 1481; see also Nieves-Rodriguez, 22 Vet. App. at 300; Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). When evaluating lay evidence, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana, 24 Vet. App. at 433 n.4. Lay evidence may establish the existence of a medical condition where (1) a layperson is competent to identify the medical condition, (2) a 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) (citing Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)); Kahana, 24 Vet. App. at 434. Accordingly, lay evidence can, in some cases, establish the both the diagnosis of a medical condition and the causation, or nexus, element of a service connection claim. King v. Shinseki, 700 F.3d 1339, 1344 (2012) ("The governing statute, regulation, and our precedent make clear that competent lay evidence may be used to establish a medical condition, including causation."); Jandreau, 492 F.3d at 1377 (holding that lay evidence can, in some cases, establish the diagnosis of a medical condition). A lay witness may also be competent to testify to the occurence of an in-service injury or incident where the issue is factual in nature. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); see also McClain v. Nicholson, 21 Vet. App. 319, 320-21 (2007). The Board must also weigh any conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). Under the guidelines governing the evaluation of expert witness testimony in the Federal Rules of Evidence, expert testimony may only be received if (1) it is based on sufficient facts or data, (2) it is the product of reliable principles and methods, and (3) the expert has applied the principles and methods reliably to the facts of the case. Id. at 302 (citing FED. R. EVID. 702). In the context of a claim for VA benefits, a medical expert opinion must rest on correct facts and reasoned medical judgment. Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Therefore, in order for the Board to assess whether the opinion provided is the product of sound medical analysis applied to the significant facts of the particular case, the medical expert must identify the facts considered and fully articulate the reasoning for the opinion. Nieves-Rodriguez, 22 Vet. App. at 304. In other words, a medical opinion must contain clear conclusions, supporting data, and a reasoned medical explanation connecting the data to the conclusions. Id. at 301 (citing Stefl, 21 Vet. App. at 124). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53; 38 C.F.R. § 3.102. Where service records are lost or missing, through no fault of the Veteran, VA has a heightened obligation to consider the applicability of reasonable doubt doctrine, to assist the claimant in developing the claim, and to explain its decision. Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (citing Russo v. Brown, 9 Vet. App. 46, 51 (1996)). However, no adverse presumption is created that lowers threshold for the allowance of claims where service records are missing. See Cromer, 19 Vet. App. at 218. Rather, the Board's obligation to discuss and evaluate the evidence is heightened. See Russo, 9 Vet. App. at 51. Lastly, in the case of a Veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions, or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The determination as to whether evidence establishes that a Veteran engaged in combat with the enemy must be resolved on a case-by-case basis with evaluation of all pertinent evidence and assessment of the credibility, probative value, and relative weight of the evidence. VAOPGCPREC 12-99 (Oct. 18, 1999). 38 U.S.C.A. § 1154(b) does not create a presumption of service connection for a combat Veteran's alleged disability; the Veteran is still required to meet his evidentiary burden on the elements of the existence of a present disability and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Collette v. Brown, 82 F.3d 389, 392 (1996). C. Service Connection The Veteran contends that he currently suffers from hearing loss due to acoustic trauma in service from exposure to noise from firearms, machine guns, incoming mortars and missiles, helicopters, artillery, bombs, low-flying jets, and improvised explosive devices (IEDs). Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may still be granted when the disease is not diagnosed until after service by evidence demonstrating that the disease was in fact incurred during service. Brock v. Brown, 10 Vet. App. 155, 160 (1997) (quoting Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) and Cosman v. Principi, 3 Vet. App. 503, 505 (1992). 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, 1167 (Fed. Cir. 2004); see generally 38 C.F.R. § 3.303(a). The threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). However, under VA regulations, impaired hearing is only considered a ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Audiological data is of record from the Veteran's November 2009 VA audiological examination. He did not exhibit auditory thresholds above 25 at any relevant frequency, bilaterally, and his speech recognition scores were 100 percent for both the right and left ear. Therefore, the Veteran does not have a ratable hearing loss disability under 38 C.F.R. § 3.385. Under VA law and regulations, a valid claim of service connection does not exist absent evidence of a current disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). Consequently, the preponderance of the evidence is against the Veteran's claim, as the first element needed to substantiate a service connection claim is not met. Shedden, 381 F.3d at 1167; 38 C.F.R. § 3.303(a). Therefore, the claim for service connection for hearing loss must be denied. II. Earlier Effective Date Claim Because the application of the law to the undisputed facts is dispositive of the Veteran's appeal of the effective date assigned for PTSD with depressive disorder, NOS, and alcohol abuse, no discussion of VA's duty to notify and assist is necessary. See Mason v. Principi, 16 Vet. App. 129, 132 (2002). The Veteran maintains that an earlier effective date is warranted for the grant of service connection for PTSD with depressive disorder, NOS, and alcohol abuse, because VA medical evidence documented the existence of his disability prior to June 5, 2008, and, further, that medical evidence included an examination report that met the requirements for an informal claim under 38 C.F.R. § 3.157. He further alleges that these medical records were dated within a few months of his discharge from service such that he should be assigned an effective date of the day following his separation from service. See 38 C.F.R. § 3.400(b)(2)(i). In this case, the basic facts are not in dispute. The Veteran filed a formal claim for service connection that was received on June 5, 2008. Under the law, the effective date assigned in a direct service connection case is the day following separation from active service or date the entitlement arose if the claim is received within one year after separation from service. Id. Otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. Id. The Veteran contends that 38 C.F.R. § 3.157 operates to establish an earlier "informal claim" via his VA treatment records that would establish entitlement to an earlier effective date. However, this applicability of this regulation is clearly limited to claims for increased evaluations or claims to reopen previously denied claims. Id. Furthermore, under § 3.157(a), reports of examination or hospitalization can only serve as an informal claim in cases where a formal claim has already been either allowed or disallowed for the reason that the service-connected disability was not compensable in degree. Here, no formal claim or informal claim was filed prior to June 5, 2008. Therefore, the undisputed facts in this case, involving VA medical evidence showing treatment for PTSD years prior to the receipt of a service connection claim are clearly outside the scope of that regulation. See, e.g., Jones v. Shinseki, 23 Vet. App. 122, 127 (2009) (explaining that the Board's failure to address a 1976 examination is nonprejudicial where the claim was submitted in 1989 as the effective date is the later of either the date entitlement arose or the date of the claim). Accordingly, the RO assigned the earliest possible effective date for its grant of service connection for PTSD with a depressive disorder, NOS, and alcohol abuse, the date the claim was received on June 5, 2008. 38 U.S.C.A. § 5110; Williams v. Principi, 15 Vet. App. 189, 195 (2001) (en banc) ("In general, the effective date for an award of benefits will be based on the date of the claim that resulted in the award."); 38 C.F.R. § 3.400(b)(2). Service connection was established for PTSD with a depressive disorder, NOS, and alcohol abuse, because the Veteran's psychiatric condition was found to be due to his military service. However, it does not follow that the effective date of the award for service connection will therefore be the day following service or the date of the first VA or private medical examination of record, as that interpretation would render meaningless many of the provisions of 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. ORDER Entitlement to an effective date prior to June 5, 2008, for service connection for PTSD with a depressive disorder, NOS, and alcohol abuse, is denied. Service connection for hearing loss is denied. REMAND Unfortunately, a remand is required before the Board can properly adjudicate the Veteran's remaining claims on appeal. Although the additional delay is sincerely regretted, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so he is afforded every possible consideration. The Veteran contends that his psychiatric disability causes more impairment than reflected by the 70 percent rating currently assigned for his service-connected psychiatric disorder, diagnosed as PTSD, with a depressive disorder, NOS, and alcohol abuse. Specifically, he contends that he suffers from total occupational and social impairment such that a 100 percent disability rating is warranted. Treatment records, including the July 2010 statement submitted by the Veteran's treating VA psychologist, indicate that his condition is progressively worsening. However, he has not been provided with a VA examination in over four years. Accordingly, a remand is warranted for a VA examination to assess the current severity of the Veteran's service-connected PTSD with a depressive disorder, NOS, and alcohol abuse. See Hart v. Mansfield, 21 Vet. App. 505, 508 (2007); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993) (holding that VA's should provide a new examination when the evidence is too old for an adequate evaluation of the Veteran's current condition); see also VAOPGCPREC 11-95 (1995) (advising that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). Furthermore, entitlement to a TDIU has been raised by the evidence of record. See, e.g., September 2009 and July 2010 VA psychologist statements. Since entitlement to a TDIU is part of the Veteran's increased rating claim, the proper remedy is for the Board to remand, rather than refer, the TDIU component of the increased rating issue to the AOJ for proper development and adjudication. See Rice, 22 Vet. App. at 453-54; see generally 38 C.F.R. § 4.16. Therefore, on remand, the Veteran and his representative should be provided with notice of any information or lay or medical evidence necessary to substantiate the TDIU claim. The notice should also indicate what information or evidence should be provided by the Veteran and what information or evidence VA will attempt to obtain on the Veteran's behalf. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Veteran's claim for entitlement to service connection for tinnitus must also be remanded for additional development as the VA audiological examiner provided an inadequate etiological opinion. See Barr, 21 Vet. App. at 312. Specifically, the examiner found that military noise exposure did not cause tinnitus because there was no corresponding hearing loss, the Veteran could not recall any specific incident or date of onset of his symptoms, and his description of the noise was more consistent with "transient head noises" than with tinnitus. Further explanation is needed to allow the Board to assess the probative value of this opinion. See Nieves-Rodriguez, 22 Vet. App. at 302. On remand, the examiner should clearly identify the specific type of noise heard by the Veteran, whether tinnitus, transient head noises, or another underlying cause, and fully describe the meaning of the phrase "transient head noises" used in the November 2009 examination report. If the cause of the noises heard by the Veteran is determined to be from an underlying cause other than tinnitus, the examiner should determine whether it is at least as likely as not that the other identified diagnoses had its onset in service or is related to an in-service event, like the acoustic noise trauma and/or IED explosions described by the Veteran. Lastly, an effort should be made to obtain any outstanding VA treatment records for the Veteran showing psychiatric or audiological treatment, dated since July 2010. 38 U.S.C.A. § 5103A(b)(3), (c)(2); 38 C.F.R. § 3.159(c)(2), (3). Accordingly, the case is REMANDED for the following action: 1. Send a VCAA notice letter notifying the Veteran and his representative of any information or lay or medical evidence not previously provided that is necessary to substantiate the TDIU component of the increased rating claim on appeal. This notice must inform the Veteran of the information or evidence the Veteran should provide and what information or evidence VA will attempt to obtain on his behalf. See 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). 2. Obtain all of the Veteran's outstanding VA psychiatric or audiological treatment records from the VA Medical Center in Houston, Texas. All information which is not duplicative of evidence already received should be associated with the claims file or the Veteran's electronic claims folder. 3. Thereafter, schedule the Veteran for a VA psychiatric examination. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. Any indicated tests and studies are to be conducted. Following examination of the Veteran, the examiner should identify what symptoms, if any, the Veteran currently manifests or has manifested in the recent past that are specifically attributable to his service-connected PTSD with a depressive disorder and alcohol abuse. The examiner must conduct a detailed mental status examination. The examiner must also discuss the effect, if any, of the Veteran's PTSD on his social and occupational adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the Veteran's PTSD consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) and explain the significance of the score. The examiner should opine as to whether it is at least as likely as not that the Veteran's service-connected psychiatric disability renders him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. If any requested information cannot be provided without resort to speculation, indicate whether the inability to provide a definitive opinion is due to a need for further information, because the limits of medical knowledge have been exhausted, or for some other reason. The examiner must provide a comprehensive report including a complete rationale for all opinions and conclusions reached that clearly states the conclusions, identifies the supporting data for each conclusion, and provides a reasoned medical explanation connecting the supporting data to each conclusion. 4. Request an addendum to the November 2009 VA examination report from, if possible, the same examiner who conducted the November 2009 examination. If the same examiner is not available, a different examiner should be asked to review the claims folder and provide the requested information. (a) Clearly identify the specific type of noise described by the Veteran, e.g., tinnitus, transient head noises, or some other potential underlying cause, and provide a reasoned explanation for the conclusion. (b) Fully describe the meaning of the phrase "transient head noises" used in the November 2009 examination report in order to facilitate the Board's review of the medical evidence. Please explain any medical significance or meaning of this phrase. (c) If the noise described by the Veteran is attributed to a diagnosable disorder other than tinnitus, the examiner should determine whether it is at least as likely as not that the other identified diagnoses had its onset in service or is related to an in-service event, like the acoustic trauma from firearms, mounted guns, bombs, helicopters, and artillery and/or the IED explosions described by the Veteran. If any requested information cannot be provided without resort to speculation, indicate whether the inability to provide a definitive opinion is due to a need for further information, because the limits of medical knowledge have been exhausted, or for some other reason. The examiner must provide a comprehensive report including a complete rationale for all opinions and conclusions reached that clearly states the conclusions, identifies the supporting data for each conclusion, and provides a reasoned medical explanation connecting the supporting data to each conclusion. 5. Review the medical examination report and supplemental opinion obtained to ensure that the remand directives have been accomplished, and return the case to the examiner(s) if all questions posed are not answered. 6. Finally, readjudicate the claims on appeal, including the claim of entitlement to TDIU as a component of the claim for a rating greater than 70 percent for PTSD with a depressive disorder, NOS, and alcohol abuse. If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs