Citation Nr: 1315409 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 07-31 108 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, The Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for diabetes mellitus, Type II (diabetes). 2. Whether new and material evidence has been received to reopen service connection for a left knee disorder. 3. Entitlement to service connection for a lower back disorder (claimed as due to a left knee disorder). 4. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent from October 23, 1998, 50 percent from August 21, 2006, and 70 percent from November 15, 2010. 5. Entitlement to an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD. 6. Entitlement to an effective date earlier than November 15, 2010 for the grant of a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Christopher McEntee, Counsel INTRODUCTION The Veteran (Appellant) served on active duty from July 1965 to July 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, The Commonwealth of Puerto Rico. In March 2001, the Veteran testified at a personal hearing before the RO. In September 2003, the Board remanded the claim regarding PTSD (i.e., a service connection claim for PTSD) for additional development. In a final rating decision dated in October 1993, the RO denied the Veteran's original claim of service connection for a left knee disorder. See 38 C.F.R. §§ 3.156, 20.1103 (2012). In January 1999, the Veteran filed the claim on appeal regarding whether new and material evidence has been received to reopen the service connection claim for a left knee disorder. The question of whether new and material evidence has been received to reopen service connection for a left knee disorder must be addressed in the first instance by the Board because the question goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996), aff'd 8 Vet. App. 1 (1995). If the Board finds that new and material evidence has been received to reopen service connection, that is where the analysis must end. Barnett, 83 F.3d at 1383. For this reason, the Board has characterized the claim regarding a left knee disorder as one to reopen service connection for a left knee disorder. In this decision, the Board will reopen service connection for a left knee disorder. The Board will remand the underlying issue for service connection for a left knee disorder, along with the claim for service connection for a back disorder (which is claimed as due to a left knee disorder). The issues 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. The Board notes that the Veteran appealed to the Board two additional issues, which will not be addressed in this decision. In February 2012, the Veteran appealed to the Board the issue of entitlement to an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD, and the issue of entitlement to an effective date earlier than November 15, 2010 for the grant of a total disability rating based on individual unemployability (TDIU). As a result of the decision below, which will grant a 100 percent initial schedular rating for PTSD effective October 23, 1998, these additional issues are now moot. As such, the claims for entitlement to effective dates earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD, and for the grant of a TDIU, will not be discussed further in this decision. FINDINGS OF FACT 1. The Veteran had active service in Vietnam and has diabetes mellitus. 2. An unappealed October 1993 RO decision denied service connection for a left knee disorder based on evidence indicating that the Veteran did not incur a chronic disorder during service, or manifest symptoms of a left knee disorder within one year of discharge from service. 3. In January 1999, the Veteran filed a request to reopen service connection for a left knee disorder, which the RO denied in the July 1999 rating decision on appeal. 4. Certain items of additional evidence received since the October 1993 rating decision are so significant that they must be reviewed to fairly decide the merits of the Veteran's claim of service connection for a left knee disorder. 5. For the entire appeal period, from October 23, 1998, the Veteran's psychiatric disability has caused total occupational and social impairment. 6. There remains no question of law or fact to decide regarding an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD. 7. There remains no question of law or fact to decide regarding an effective date earlier than November 15, 2010 for the grant of a TDIU. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, service connection for diabetes is warranted. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The October 1993 RO decision that denied a reopening of service connection for a left knee disorder became final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 3. New and material evidence has been received to reopen service connection for a left knee disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2001). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for a 100 percent initial disability rating for PTSD have been met from October 23, 1998. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 5. The issue of entitlement to an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD has been rendered moot by the grant of 100 percent disability rating for PTSD from October 23, 1998. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.101(a) (2012). 6. The issue of entitlement to an effective date earlier than November 15, 2010 for the grant of a TDIU has been rendered moot by the grant of 100 percent disability rating for PTSD from October 23, 1998. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.101(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to these claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). 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 a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the claims to reopen service connection for a left knee disorder and service connection for diabetes, there is no reason to explain how VA has fulfilled the VCAA duties to notify and assist for this particular claim because this Board decision constitutes a full grant (reopening) of the new and material evidence claim for service connection for a left knee disorder and service connection for diabetes. With regard to the claim for a higher initial rating for PTSD, there can be no prejudice to the Veteran from any alleged failure to give adequate notice because this case is granting the maximum schedular disability rating of 100 percent for the entire rating period. Moreover, because this is an initial rating appeal that comes before the Board following the decision to grant service connection and assign an initial rating, no additional VCAA notice is required. Courts have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). Because the Veteran is in receipt of the maximum disability rating of 100 percent, and this is an initial rating appeal, no further notice is needed under VCAA for this appeal. With regard to the duty to assist, the Veteran's service treatment records (STRs) have been secured. The RO obtained relevant private and VA treatment records and reports. The Veteran has not indicated additional relevant medical records pertinent to the claims at issue here. Furthermore, the Veteran has been provided with several VA compensation examinations during the appeal period into his claim of service connection for diabetes, as well as his claim for a higher initial rating for PTSD. These examinations were conducted in May 1999, August 2004, March 2006, November 2006, January 2009, and November 2010. The examinations are found to be adequate for rating purposes. The reports of record indicate that each examiner reviewed the Veteran's medical history and complaints, made clinical observations, and rendered assessments regarding whether the Veteran has diabetes, and regarding the severity of the PTSD. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). Additionally, as the Veteran is receiving the maximum schedular disability rating for the entire period from October 23, 1998, he is in receipt of the full grant of benefits sought on appeal. The grant of 100 percent disability rating for PTSD from October 23, 1998, the entire rating period on appeal, also moots the issues of effective dates earlier than November 15, 2010 for a 70 percent rating for PTSD and for TDIU. For this reason, there is no further VCAA duty to obtain evidence or assist in the development of evidence as there is no reasonable possibility of further substantiating the rating appeal as to these issues. The Board will rely on all the evidence of record, including VA examination reports and lay statements, to determine the claim to reopen service connection and the appeal for a higher initial rating for PTSD. As such, the record is sufficiently developed for determinations at this time. Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection for Diabetes The Veteran contends that service connection should be established for diabetes based on his service in Vietnam in the late 1960s and in particular to his presumed exposure to herbicides while serving there. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as diabetes and arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e) (2012). The diseases listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (2012). VA regulations specify that the last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii) (2012). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board has reviewed all the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative 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) (West 2002); 38 C.F.R. § 3.102 (2012). 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran contends in this matter that he should be awarded service connection for diabetes based on his service in Vietnam in the late 1960s. The record establishes that the Veteran served in Vietnam from February 1966 to February 1967; therefore, he is presumed to have been exposed to herbicides. The Board finds that the evidence for and against the claim is in equipoise on the question of whether the Veteran now has a current disability of diabetes. To determine whether the Veteran has diabetes, the RO provided the Veteran with VA compensation examinations in March 2006 and February 2009. The March 2006 VA examiner indicated a review of the claims file, that the Veteran reported that he was diagnosed as diabetic when hospitalized in 2004 and 2005 for heart problems, and that the Veteran reported that he followed a restricted diet, used an oral hypoglycemic and insulin, and visited a diabetic care provider every two months. Nevertheless, the examiner concluded that the Veteran did not have diabetes. Based on laboratory testing in March 2006, the examiner stated that the Veteran's blood sugars indicated no diabetes mellitus "in this examination." The Board notes that, despite the March 2006 VA examiner's findings, certain evidence of record tends to show that the Veteran has diabetes. The Veteran's VA dietician, in VA treatment records dated throughout 2005, indicated that the Veteran had diabetes. In a private medical report received in October 2006, the Veteran is diagnosed with diabetes. A September 2007 VA treatment record indicating endocrinology treatment for hypothyroidism noted "DM" under a list of "comorbidities." A May 2008 VA treatment record included diabetes on a problem list, and listed prescribed medications to include insulin and glucose liquid. A December 2009 VA primary care follow up note reflects an assessment of controlled diabetes mellitus II. Furthermore, the Veteran submitted several statements of record asserting that he had been diagnosed with diabetes. At a second VA examination in February 2009, the examining physician indicated a review of the claims file, and that that "the definition of diabetes requires two separate fasting glucose values" approximating a certain benchmark. The examiner discussed in detail the evidence of record indicating that the Veteran had diabetes, to include the fact that he had been prescribed medication for the disorder, and found the evidence to be inconclusive regarding the question of whether the Veteran had diabetes. The examiner stated that the prior results were not "valid" in that no evidence indicated that the Veteran fasted prior to testing. The examiner stated that the evidence indicating diabetes did not detail on what basis - "laboratory values" - the previous diagnoses were made. As such, the February 2009 examiner conducted further laboratory testing, ensuring that the Veteran properly fasted prior to testing. Those results indicated normal glucose readings. As such, the examiner stated that the Veteran did not have diabetes. The Veteran has reported that he has been diagnosed with diabetes; he is competent to report such a diagnosis. See Jandreau at 1377 (stating that a lay person is competent to report a contemporaneous medical diagnosis). There is also some medical evidence that tends to support a finding of diabetes, although there is other medical evidence and opinion that tends to show he does not have diabetes. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran has a disability of diabetes. Based on his service in Vietnam, he is presumed to have been exposed to herbicides while in Vietnam, such that presumptive service connection for diabetes is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Claim to Reopen Service Connection for a Left Knee Disorder In an October 1993 rating decision, the RO denied the Veteran's claim of service connection for a left knee disorder. The Veteran was properly notified of the rating decision, did not appeal, and it became final. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. In January 1999, the Veteran filed a claim to reopen service connection for a left knee disorder. In a July 1999 rating decision, the RO denied the Veteran's claim. In response, the Veteran filed a timely notice of disagreement in October 1999. 38 C.F.R. § 20.201. A statement of the case was not issued on this claim until October 2006. 38 C.F.R. § 19.26. The Veteran then filed a substantive appeal in November 2006. 38 C.F.R. § 20.202. This is the issue currently on appeal. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. A claim may be reopened only under certain conditions. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). In August 2001, VA changed the regulatory definition of new and material evidence. The change is applicable to all claims filed on or after August 29, 2001. 38 C.F.R. § 3.156. As the Veteran's claim in this case was filed prior to August 29, 2001, in July 1999, the earlier version of 38 C.F.R. § 3.156 defining new and material evidence remains applicable in this case. As defined when the Veteran's claim to reopen was received, new and material evidence is evidence not previously submitted which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with the evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). No other standard than that articulated in the regulation applies to the determination in this case. See Hodge, supra. Moreover, for the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of record at the time of the final decision in October 1993 consisted of the Veteran's STRs. The March 1965 induction reports of medical examination and history were negative for a left knee disorder. August and October 1966 STRs indicated multiple complaints of left knee pain and injury. An undated letter from a surgeon indicated that the Veteran fractured his knee at age 11, and "reinjured his knee" in July 1966. The surgeon noted an impression of posttraumatic osteoarthritis "aggravated" by exposure to wet climate and the "prolonged trauma" from "extensive walking." The July 1967 service separation report of medical examination was negative for a left knee disorder. The May 1967 service separation report of medical history indicated a history of broken bones and arthritis and, in the physician's comments, "probe left knee[.]" In October 1993, the record also contained VA treatment records and reports, none of which notes a left knee disorder. Based on this evidence, the RO found service connection unwarranted. Briefly reviewing the evidence received since the October 1993 RO decision, the record contains VA treatment records and reports documenting a left knee disability (none of which comments on medical nexus to service), private treatment records documenting a left knee disability, lay statements from the Veteran asserting that he injured his left knee during combat operations in Vietnam, lay statements from relatives of the Veteran attesting to his in-service left knee injury, and an April 2002 decision from the Board for the Correction of Military Records which awarded the Veteran a Combat Infantryman Badge (CIB) based on his service in Vietnam. The Veteran's claim to reopen must now be viewed in context of all the evidence. The Board finds that much of the new evidence, particularly the medical evidence documenting a current left knee disorder, the lay evidence attesting to an in-service knee injury, and the award of a CIB, is evidence that bears directly and substantially on the question before the Board - whether the Veteran has a current disability that was either incurred in or aggravated by service. 38 C.F.R. § 3.303. Hence, the new evidence is so significant that it must be considered in order to fairly decide the merits of the claim. The new evidence therefore satisfies the materiality requirements of 38 C.F.R. § 3.156(a). As such, the Veteran's claim for service connection for a left knee disorder is reopened. The claim will be addressed further in the remand section of the decision below. Initial Rating for PTSD In the final October 1993 rating decision, the RO also denied service connection for a psychiatric disorder. In October 1998, the Veteran filed a claim for a TDIU, which the RO also construed as a claim to reopen service connection for a psychiatric disorder, namely PTSD. In the July 1999 rating decision, the RO denied the Veteran's claim. The Veteran appealed that denial to the Board. Following a September 2003 Board remand, the RO granted service connection for PTSD in January 2005. The RO assigned an initial 30 percent rating effective October 23, 1998 (the date the RO received the claim to a TDIU based on psychiatric disability). In subsequent decisions issued during the appeal period, staged ratings were assigned. The initial rating has increased to 50 percent from August 21, 2006, and 70 percent from November 15, 2010. Due to hospital treatment for PTSD, the Veteran was rated as 100 percent disabled between May 7, 2008 and June 1, 2008. 38 C.F.R. §§ 3.400, 4.29 (2012). In this case, the Board has considered the entire period of the initial rating claim from October 23, 1998 to see if the evidence warrants the assignment of different ratings for different periods of time, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative 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. § 4.3. In the process of evaluating a mental disability, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. The VA Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. §§ 501, 1155 (West 2002); 38 C.F.R. § 4.130 (2012). By establishing one general formula to be used in rating more than 30 mental disorders, the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. The schedular rating criteria rate by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan v. Principi, 16 Vet. App. 436, 443 (1992). The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The schedular criteria, effective as of November 7, 1996, incorporate the DSM-IV. 38 C.F.R. §§ 4.125, 4.130 (2012). A rating of 10 percent is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A rating of 30 percent is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating, may be 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 work-like setting); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular evaluation contemplates 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 Code 9411. In assessing the evidence of record, it is important to note that the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). Pertinent to the scores assigned in this appeal, a GAF score of 21-30 indicates behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A GAF score of 31-40 indicates 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). A GAF score of 41-50 indicates "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A GAF score of 51-60 indicates "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)." Id. A GAF score of 61-70 indicates "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." Id. After a review of all of the evidence, including the Veteran's written assertions, the Board finds that the Veteran's PTSD has, during the entire appeal period, more nearly approximated total social and occupational impairment. The earliest evidence of record addressing the Veteran's psychiatric condition during the appeal period is found in a May 1999 VA compensation examination report. The results of this report do not indicate severe symptoms. The report notes alcohol dependence, alcoholic hallucinations, chronic liver disease, an "alcohol induced mood disorder," depression, antisocial personality disorder, and relational problems. The report indicates that the Veteran had not worked for 10 years. The report noted the Veteran's complaints of nightmares, moodiness, poor sleep, and notes diagnoses of depression due to hypothyroidism, but not PTSD. The examiner indicated that the Veteran was clean, adequately dressed and groomed, alert, oriented, attentive, with fair concentration, insight, judgment, and memory, clear and coherent speech, with good impulse control and without homicidal or suicidal ideations. The examiner assigned a GAF score of 65, implying mild symptoms. However, the results noted in a November 1999 private psychiatric examination report, and in a March 2001 addendum report, indicate severely disabling PTSD that approximates the criteria noted for a 100 percent evaluation under DC 9411. 38 C.F.R. § 4.130. The November 1999 report initially indicates that the Veteran's symptoms were not severe. The examiner noted the Veteran as alert, focused, cooperative, with an appropriate affect to thought content, intact judgment, in no acute distress, with a linear and goal-directed thought process, and with relevant and unpressured speech. He noted the Veteran to be without a flight of ideas, illusions, delusions, paranoid ideations, homicidal ideations, or ideas of reference. The examiner found the Veteran with sufficient mental capacity to determine right from wrong, to adhere to right, to understand and participate in administrative proceedings, and that he didn't represent a danger to himself or others. Moreover, the examiner assigned a GAF score of 65, indicating mild symptoms. However, the November 1999 private examiner also indicated that the Veteran had been hospitalized three times previously for schizophrenia which he related directly to the Veteran's Vietnam experiences. He stated that the Veteran was medically retired as a police officer due to repeated incidents of violence, and to chronic alcohol abuse. He indicated 1997 inpatient treatment for "severe alcohol withdrawal syndrome with psychotic features[.]" He indicated that the Veteran then abstained from alcohol but still experienced chronic depression, anxiety, nightmares, and flashbacks. He indicated that the Veteran isolated himself, was suspicious, and had severe sleep disturbances. He indicated that the Veteran heard voices telling him to drink, saw shadows, had a variable mood, was impulsive, irritable, nervous, verbally aggressive, and could not tolerate stressful situations. He also indicated that the Veteran had chronic suicidal ideation. The examiner diagnosed the Veteran with chronic and severe PTSD, manifested by severe anxiety, depression, flashbacks about his war experience, aggressive behavior, suspiciousness, and social isolation. In a March 2001 addendum opinion, the November 1999 private examiner reinforced his findings regarding the severity of the Veteran's PTSD by stating that the Veteran's diagnosis of schizophrenia and chronic alcoholism, and his repeated psychiatric hospitalizations, "were a direct result of his experience in Vietnam[.]" The examiner indicated that the Veteran had been undergoing treatment but that he continued having difficulties, such as having homicidal ideations towards a brother. The examiner indicated that the Veteran has very little human contact because he sees people as threatening. He indicated that the Veteran had no significant relationships except for those with a few family members. In closing his report, the examiner state that the Veteran had a "very restricted lifestyle characterized by chronic anxiety and depression, recurrent nightmares and flashbacks of his experience in Vietnam, a lack of meaningful relationships and a self-imposed exile in his home. This is a direct consequence of his [PTSD], which had its origin in his Vietnam tour and has crippled him emotionally and socially." The evidence of record dated since the November 1999 private report and March 2001 addendum reinforces the conclusion that the Veteran's PTSD has caused total occupational and social impairment during the appeal period. The evidence shows that though he has appeared coherent and cognitively sound at times, he has been socially and occupationally impaired by his severe anxiety, depression, paranoia, and delusions. VA treatment records dated from 2001 to 2004 note the Veteran's dysthymia, depression, alcohol dependence, anxiety, severe PTSD, schizophrenia, aggressive behavior, suspiciousness, suicidal ideations, social isolation, and impaired memory. In 2003, an August 1977 private hospital summary was submitted into the record. The report confirms earlier statements that the Veteran had been treated for schizophrenia, noting his anxiety, suspiciousness, loosened ideations, ideas of reference and of persecution, auditory hallucinations, illogical and unrealistic thought processes, flat affect, poor orientation, poor judgment, and poor insight. An August 2004 VA compensation examination report noted a GAF score of 30, which indicates impairment considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. The examiner reviewed the Veteran's history of severe symptomatology, alcohol abuse, hospitalization, occupational problems, social isolation, and flashbacks to Vietnam. The examiner noted the Veteran as alert, oriented, cooperative, neatly dressed, with good eye contact, soft speech, and with fair memory, insight, and judgment. The examiner stated that the Veteran denied current suicidal or homicidal ideations. But the examiner described the Veteran as depressed and anxious, with a labile affect, paranoid ideations, flashbacks, and auditory and visual hallucinations. The examiner recommended continued psychiatric treatment and continued use of psychotropic medication. A March 2006 VA treatment record indicated that the Veteran's severe symptomatology decreased at that time. A GAF score of 50 was noted for anxiety, depression, poor memory, and no superficial insight. But the examiner also noted the Veteran as cooperative, talkative, logical, coherent, relevant, oriented, with preserved cognitive functions, acceptable judgment, and no active hallucinations, delusions, or harm ideas to self or others. The findings noted in a November 2006 VA compensation examination report reinforced the findings indicating improvement. The examiner reviewed the Veteran's history of severe symptoms and hospitalization, but noted that a VA examiner in August 1996 found no evidence of PTSD and no evidence of traumatic experiences in Vietnam. He also noted the May 1999 VA examination which questioned whether the Veteran had PTSD. He noted that the Veteran once worked as a police officer but was then unemployed. The November 2006 VA examiner noted the Veteran's complaints of panic attacks, depression, irritability, sadness, low energy, insomnia, loss of appetite, poor concentration, anxiety, restlessness, tension, jumpiness, hypervigilance, nightmares, recurrent thoughts of Vietnam, and avoidant behavior. The examiner noted that the Veteran had been married twice and divorced twice, and that he lived alone. On examination, the examiner noted no psychotic or cognitive symptoms, no evidence of psychomotor retardation, agitation, tics, tremors, or abnormal involuntary movements. He noted no evidence of delusions, hallucinations, phobias, obsessions, or suicidal ideation. The examiner noted the Veteran as clean, cooperative, spontaneous, with good eye contact, alert, in contact with reality, oriented, with an intact memory, normal abstraction ability, with fair insight and judgment. The examiner described the Veteran as anxious, hypervigilant, and depressed with a constricted affect, and with recurrent intrusive thoughts of his experiences in the military. The examiner found the Veteran's symptoms moderately disabling. The examiner assigned a GAF score of 60. However, the examiner stated that the Veteran's "poor quality of life" was caused by his PTSD, and that the prognosis was "poor" because the disorder was chronic. VA treatment records dated in May 2008 indicate a worsening of the Veteran's symptoms. The records indicate that the Veteran was hospitalized for treatment of symptoms including psychotic features, poor insight and judgment, suicidal ideations and threats, and psychomotor retardation. The treating psychiatrists noted GAF scores of 25 and 30 which, again, indicate impairment considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. The Veteran underwent his final VA compensation examination in November 2010. As with the other examiners, this examiner reviewed the Veteran's history of severe symptomatology, his history of psychiatric hospitalizations, his social isolation, his long-term unemployment, and his alcohol abuse. On examination, the examiner noted the Veteran as alert, aware, over talkative, clean, coherent, spontaneous, clear, somewhat cooperative, attentive, oriented, without delusions, hallucinations, or obsessive behaviors, with intact judgment, average intelligence, normal remote memory, and mildly impaired recent and immediate memory. But the examiner also noted current sleep disturbances resulting from recurrent Vietnam memories, and constant depression. The examiner described the Veteran as tense, irritable, with a constricted affect, an overabundance of ideas, with only partial insight into his problems, and with poor impulse control. The examiner noted that the Veteran had recently been detained by police as a result of violent behavior towards his family. She found the Veteran avoidant and socially isolated. The examiner's report indicated that the Veteran retired from the police force in the late 1970s shortly after an explosion-related event. The experience "brought back all his Vietnam experiences" so the Veteran retired "due to his mental condition." The November 2010 VA examiner indicated that the Veteran's occupational and social impairment was not total. But the examiner offered a "poor" prognosis, noted deficiencies in several areas of the Veteran's life, and characterized his social and occupational impairment as "severe" primarily due to his inability to handle stress and pressure, and his tendency towards angry outbursts and irritability. She indicated that the Veteran's symptoms would prevent him from adequately "functioning in a normal working environment." She assigned a GAF score of 50 moreover, which indicates serious symptoms. The claims file also contains VA treatment records dated between 2010 and 2011, which indicate that the Veteran's symptoms had moderated. A clinical social worker noted the Veteran's isolation, depression, and anxiety, but found him clear, talkative, cooperative, and coherent. A treating psychiatrist noted similar symptoms and assigned GAF scores of 60. Finally, the Board notes the Veteran's detailed lay statement of record, provided during his March 2001 RO personal hearing, and provided in many written statements submitted into the claims file. In these statements, the Veteran attests to the psychiatric pain associated with his recurrent memories of his documented combat service in Vietnam, his chronic depression, anxiety, and anger, and his inability to function with his family or in a work environment due to his symptoms. The Board finds his statements of probative value because, as a layperson, he is competent to attest to observable symptoms such as psychiatric pain and limitation. In considering whether to assign a 100 percent evaluation under 38 C.F.R. § 4.130, the Board reviewed the relevant criteria under DC 9411. Certain evidence of record indicates that the Veteran has experienced since October 1998 - as a result of psychiatric disabilities including PTSD and schizophrenia that have been attributed to his combat service in Vietnam - the following symptoms: gross impairment in thought processes and communication, persistent delusions and hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). Certain evidence, such as the March and November 2006 VA reports and the VA treatment records in 2010 and 2011, indicates that the Veteran has not experienced severe symptomatology. Moreover, no evidence of record indicates a disorientation to time or place, or memory loss of his own name or of names of close relatives. 38 C.F.R. 4.130, Diagnostic Code 9411. Nevertheless, the Board finds that the Veteran's PTSD has been totally disabling. It has been clear throughout the appeal period that, due to his psychiatric problems, the Veteran has been unable to participate socially or maintain an occupation. The evidence is clear that he has been socially isolated, and has been unable to work. Either as a result of his PTSD and the many symptoms associated with that disorder, or his schizophrenia and its concomitant delusions and hallucinations, the Veteran's impairment has been total. See Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability). Despite the occasional improvement in his condition, the evidence generally indicates a totally disabled person psychiatrically. As such, a 100 percent evaluation has been warranted for the Veteran's service-connected PTSD, effective the date of his October 23, 1998 claim. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). As the Veteran's PTSD has been rated as 100 percent disabling during the entire appeal period, the Board finds consideration of an extraschedular rating unwarranted. Earlier Effective Dates In this case, the Veteran has been granted a 100 percent schedular disability rating for the service-connected PTSD for the entire initial rating period from October 23, 1998. The Board finds that there remains no question of law or fact to decide regarding what was characterized as an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD. The same factual "question" of whether an initial rating in excess of 70 percent for PTSD for the period earlier than November 15, 2010 has been adjudicated as part of the initial rating appeal for PTSD that covered the very same rating period, the same disability of PTSD, the same evidence that reflects on rating assigned, the same adjudicative questions of whether the evidence met the psychiatric rating criteria at 38 C.F.R. § 4.130 for this period. The issue of earlier effective date and the issue of initial rating for PTSD also addressed the same question of law as to when entitlement to a rating in excess of 70 percent arose. See 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2012). The Board finds that, in light of the 100 percent schedular rating grant for PTSD for the period prior to November 15, 2010, there remains no question of law or fact to decide regarding an effective date earlier than November 15, 2010 for the grant of a TDIU because a TDIU, which is an extraschedular form of increased rating, is only available where the schedular disability rating is "less than total." 38 C.F.R. § 4.16 (2012). As the schedular disability rating for PTSD in this case is "total" (100 percent) from October 23, 1998, there remains no question of extraschedular rating for disability that is less than total. For these reasons, the Board finds that the issues that were characterized as entitlement to an effective date earlier than November 15, 2010 for the grant of an initial 70 percent rating for PTSD and for TDIU have been rendered moot by the grant of 100 percent disability rating for PTSD from October 23, 1998. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.101(a); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). ORDER Service connection for diabetes is denied. New and material evidence having been received, reopening of service connection for a left knee disorder is granted. From October 23, 1998, a 100 percent initial rating for PTSD is granted. The appeal for earlier effective date than November 15, 2010 for a 70 percent rating for PTSD has been rendered moot, and is denied. The appeal for earlier effective date than November 15, 2010 for TDIU has been rendered moot, and is denied. REMAND Service Connection for Left Knee and Low Back Disorders The Board finds that, under the facts and circumstances of this case, VA's duty to assist includes affording the Veteran a VA examination and opinion with regard to his claims of service connection for a left knee disorder and for a lower back disorder. VA will provide a medical examination which includes a review of the evidence of record if VA determines it is necessary to decide the claim. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. An examination is deemed "necessary" if the evidence of record (lay or medical) includes competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but does not contain sufficient medical evidence for the Secretary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2). In the present case, the Veteran contends that a current left knee disorder began during service and then caused a post-service lower back disorder. As indicated earlier, the STRs indicate that the Veteran experienced significant left knee problems during service. Moreover, VA medical evidence indicates that the Veteran has chronic left knee and back disorders. Therefore, the Board finds that a VA examination is necessary to determine whether there is a relationship between the Veteran's left knee disorder and service, and between his left knee disorder and his lower back. See Duenas v. Principi, 18 Vet. App. 512 (2004); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's claim of service connection for a lower back disorder is a secondary service connection claim. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.310, a disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. The provisions of 38 C.F.R. § 3.310 were amended, effective from October 10, 2006; however, the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995), the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. The record indicates that the Veteran's secondary service connection claim for a lower back disorder was filed prior to the effective date of the revised regulation. Accordingly, the issues of service connection for left knee and lower back disorders are REMANDED for the following action: 1. Provide a VCAA notification letter to the Veteran which details the criteria for secondary service connection claims under the version of 38 C.F.R. § 3.310 effective at the time of the Veteran's August 2006 claim. 2. Afford the Veteran a VA joints (orthopedic) examination to address the causation or etiology of the left knee disorder, and the lower back disorder. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The relevant documents in the claims file should be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. a. The examiner should offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's chronic left knee disorder was caused by a left knee injury in active service. In rendering the opinion, the examiner should specifically address the evidence of record documenting that the Veteran experienced left knee problems and an injury during service in the mid 1960s. b. If the examiner's opinion is that the Veteran's left knee disorder was incurred in service, the examiner should offer an opinion as to whether it is at least as likely as not (probability 50 percent of more) that a disability of the lower back is caused by the left knee disorder. If not, opine on whether any such lower back disorder is at least as likely as not (probability 50 percent of more) aggravated by the left knee disorder. c. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. d. If the opinion and/or supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly and specifically so specify in the report, and explain why this is so. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner should state whether the inability to provide a definitive opinion is due to a need for further information (with such needed information identified) or because the limits of medical knowledge have been exhausted regarding the etiology of the Veteran's disorders. 3. When the development requested has been completed, the issues regarding service connection for left knee and lower back disorders should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of his claims. See 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs