Citation Nr: 1316295 Decision Date: 05/17/13 Archive Date: 05/29/13 DOCKET NO. 07-14 236 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent from June 15, 2004 to April 4, 2007 and in excess of 70 percent from April 5, 2007 to December 27, 2009. 2. Entitlement to a temporary total disability rating under 38 C.F.R. § 4.29. 3. Entitlement to an increased rating for left knee arthritis, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for right knee arthritis, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from April 2002 to September 2002 and from February 2003 to June 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2005 and June 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In September 2005, the RO, in pertinent part, granted service connection for PTSD assigned at 30 percent disabling from June 15, 2004 and for right knee arthritis and left knee arthritis, both assigned at 10 percent disabling from April 23, 2005. In June 2008, the RO denied entitlement to a temporary total disability rating under 38 C.F.R. § 4.29. In a January 2010 rating decision, the RO increased the initial 30 percent disability rating for PTSD to 70 percent disabling from April 5, 2007 and to 100 percent disabling from December 28, 2009. The Veteran was advised of the January 2010 rating decision, but did not express agreement with the decision or withdraw the appeal. In AB v. Brown, 6 Vet. App. 35 (1993), the United States Court of Appeals for Veterans Claims (Court) held that, on a claim for an initial or increased rating, a veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. Because the assigned 30 percent and 70 percent disability ratings are not the maximum benefits available for the service-connected PTSD, this appeal continues for the respective initial rating periods. In the June 2010 statement of the case (SOC) and May 2012 supplemental statement of the case (SSOC), the RO developed a claim for entitlement to an effective date prior to December 28, 2009 for the assignment of a 100 percent evaluation for PTSD. The Board has recharacterized the issue on appeal as entitlement to an initial disability rating for PTSD in excess of 30 percent from June 15, 2004 to April 4, 2007 and in excess of 70 percent from April 5, 2007 to December 27, 2009, and will decide the issue on its merits as the RO addressed the merits on an increased rating basis in the identified SOC and SSOC. In a July 2012 rating decision, the RO increased the initial 10 percent disability rating for right knee arthritis to 30 percent disabling from December 17, 2009. The Veteran was advised of the July 2012 rating decision, but did not express agreement with the decision or withdraw the appeal. Because the assigned 10 percent and 30 percent disability ratings are not the maximum benefits available for the service-connected right knee arthritis, this appeal continues for the respective initial rating periods. See AB, 6 Vet. App. at 35. In November 2010, the Veteran testified at a Board hearing held before the undersigned Veterans Law Judge in Atlanta, Georgia. The Veteran submitted a waiver of RO review of additional VA outpatient treatment records. The waiver, additional records, and a transcript of the hearing have been associated with the claims file. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issues of entitlement to an increased rating for left knee arthritis, currently rated as 10 percent disabling, and an increased rating for right knee arthritis, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter 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. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. From June 15, 2004 to April 4, 2007, the service-connected PTSD more closely approximated a manifestation of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology. 3. From April 5, 2007 to December 27, 2009, the service-connected PTSD more closely approximated a manifestation of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to psychiatric symptomatology. 4. The Veteran has not required hospitalization for a service-connected disability in excess of 21 days during the pendency of this appeal. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating for PTSD in excess of 30 percent from June 15, 2004 to April 4, 2007 and in excess of 70 percent from April 5, 2007 to December 27, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for the award of a temporary total rating pursuant to 38 C.F.R. § 4.29 based on hospitalization for a service-connected disability in excess of 21 days have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.29 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability Rating Legal Criteria for PTSD Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of a veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates a manifestation of the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim for PTSD on appeal. In a November 2006 notice of disagreement with the initial assignment of a 30 percent disability rating for PTSD, the Veteran requested a raise in the percentage for the service-connected disability. He reported that taking daily medications takes him down and others to keep him up. Thus, the Veteran essentially contends that a higher initial disability rating is warranted for the service-connected PTSD. Pursuant to the rating criteria for mental disorders, the service-connected PTSD is rated at 30 percent disabling from June 15, 2004 to April 4, 2007 and at 70 percent from April 5, 2007 to December 27, 2009 under Diagnostic Code 9411. A 30 percent disability evaluation is assigned for occupational and social impairment with evidence of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130. A 50 percent disability evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Moreover, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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, VA must 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: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The Global Assessment of Functioning (GAF) Scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the DSM-IV. A score of 21 to 30 indicates that behavior is considerably influenced by hallucinations or delusions or there is serious impairment in communication or judgment or the ability to function in almost all areas is seriously impaired. See Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). A score of 41 to 50 is defined as 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 score of 51 to 60 is defined as indicating 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 score of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. A. Rating from June 15, 2004 to April 4, 2007 After a full review of the record and consideration of whether the assignment of separate ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against the Veteran's appeal for an initial disability rating in excess of 30 percent for PTSD from June 15, 2004 to April 4, 2007. As discussed below, the evidence of record during this time period indicates the service-connected disability more nearly approximated a manifestation of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology. The pertinent evidence of record during this period includes VA examination reports dated April 2005 and March 2007, a November 2006 VA outpatient medical opinion, and VA outpatient treatment records from December 2004 to April 2007. On VA examination in April 2005, the Veteran reported having nightmares from military service, flashbacks, intrusive thoughts, and feeling estranged from others. He avoids watching television, especially when it discusses war, does not trust other people, has decreased interest in leisure activities, gets easily startled by loud noise, stays on guard, and is currently attending school. Upon mental status examination, the Veteran displayed casual dress, good personal hygiene, good eye contact, orientation to time, person, and place, and no abnormal movements or memory problems. The Veteran reported his mood as "just going along" and affect as euthymic. Speech was normal in rate and tone, thought processes were logical with no loosening of associations or flight ideas, and thought content was absent of thoughts of hurting himself or others, hallucinations, delusions, and paranoia. A GAF score of 70 was assigned. On VA examination in March 2007, the Veteran reported he has not been an inpatient in any psychiatric facility and reported going to outpatient care but stopped because of transportation problems related to his service-connected knee pain while driving. He sometimes loses track of time, has nightmares and tendency to see soldiers coming to kill him every time he closes his eyes, gets frustrated and angry at people in his military unit for not having discharged him on a medical basis and sometimes feels like hurting them, and isolates himself and pushes people away because he finds it difficult to trust anyone. He lives alone and family relationship is very limited to a sister helping him with his daily needs. The Veteran has no specific leisure pursuits except for watching television programs and has not assaulted anyone or attempted suicide. The Veteran also reported difficulty getting close to people and showing affection, significant memory impairment, irritability, losing his temper, easily startled, being hypervigilant, and that he does not talk to anyone on the phone or use the computer for the internet. Upon mental status examination in March 2007, Veteran was casually dressed and adequately groomed, no impairment of thought processes or communication was observed and speech was in a soft volume deliberately and slowly in a monotone. He reported being free of delusions but has difficulty trusting people, admitted to visual hallucinations of soldiers three to four times per week when he closes his eyes, and difficulty sleeping. The Veteran also admitted to some compulsive hand washing and checking his doors, panic attacks about four times a week and precipitated being near a crowd or being reminded of anything military, denied feeling depressed today but admitted to being anxious all the time, blunted affect, and admitted to some impulse control. The examiner observed the Veteran did not make eye contact, mostly tended to look down or straight ahead away from the examiner while talking, there was no inappropriate behavior or suicidal and homicidal thoughts, ability to maintain basic activities of daily living seemed unimpaired, orientation to year, place, person, and situation, memory for immediate recall was three out of three items but the Veteran could not remember any of these three items after three minutes, concentration was slightly impaired, and while the Veteran could spell forward he could not spell backward. A November 2006 VA outpatient medical opinion notes the Veteran suffers from PTSD, receives medication for sleep and anxiety, and has been able to perform successfully at school so far, though it has been stressful. Pursuant to VA outpatient treatment sessions, the Veteran's documented psychiatric symptomatology includes the following: sleep impairment, intrusive recollections, depression, hypervigilance, nightmares, flashbacks, irritability, difficulty trusting others, anxiety, memory impairment per history by the Veteran, easily startled, isolation, and hyperarousal. Additionally, treating physicians noted the Veteran's mood as anxious, sad, and dysthymic; insight as fair; judgment as intact; and eye contact as good and within normal limits. Furthermore, the Veteran exhibited that he was neatly dressed and groomed, cooperative, alert, and oriented to time, person, and place. He denied suicidal and homicidal ideation and thought process was noted as logical, concrete, goal directed, and impoverished spontaneity and content, and with associations intact and circumstantial versus guarded. Memory appeared intact and speech was notably normal in rate, tone, and volume, coherent, and on one occasion slow and quiet. The Board finds that such psychiatric symptomatology is currently contemplated in the assigned 30 percent disability rating for this appeal period. The Board notes the Veteran reported having visual hallucinations at the March 2007 VA examination. Nonetheless, neither the VA examiner nor VA outpatient treatment records document objective findings of total occupational and social impairment due to persistent hallucinations. In fact, VA outpatient treatment records show review of the Veteran's thought content did not include delusions or hallucinations with no formal thought disorder, as dated from December 2004 to August 2006. Next, the Veteran informed the March 2007 VA examiner of his compulsive hand washing. However, neither the VA examiner nor VA outpatient treatment records document objective findings of occupational and social impairment with deficiencies in most areas due to obsessional rituals which interferes with routine activities. The Veteran also informed the March 2007 VA examiner of his panic attacks four times a week and was assessed with a flat affect at February 2005 and October 2006 VA outpatient treatment sessions. Nevertheless, neither the VA examiner nor VA outpatient treatment records document objective findings of occupational and social impairment with reduced reliability and productivity due to panic attacks more than once a week or flattened affect. VA outpatient treatment records are silent as to any complaints of panic attacks. With regard to the Veteran's affect, it was more often characterized during this appeal period at VA outpatient treatment sessions as blunted (February 2005, March 2005, November 2005, January 2006, May 2006, and August 2006), as well as dysthymic and anxious (October 2005), and extremely constricted (December 2008). The GAF scores assigned pursuant to VA outpatient treatment records during this rating period were 45 (November 2005, January 2006, February 2006, May 2006) and 48 (December 2004 to February 2005 and August 2006). The March 2007 VA examiner also assigned a GAF score of 45 and the April 2005 VA examiner assigned a GAF score of 70. These assigned GAF scores are found to be consistent, overall, with the demonstrated symptomatology of record for the entire initial appeal period. The GAF score of 70 indicates some mild symptoms and, while the scores of 45 and 48 indicate serious symptoms, when considering the evidence as a whole, and some evidence that does not support the 30 percent rating (with indications of a mild problem during this time), do not justify assignment of a higher disability rating at any time during this appeal period. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or a GAF score is a factor for consideration and not determinative of the percentage VA disability rating to be assigned. See also 38 C.F.R. § 4.126(a). Therefore, based on the above lay and medical evidence, including the GAF scores and specifically documented psychiatric symptomatology discussed above, the Board finds that a rating in excess of 30 percent is not warranted from June 15, 2004 to April 4, 2007. B. Rating from April 5, 2007 to December 27, 2009 After a full review of the record and consideration of whether the assignment of separate ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against the Veteran's appeal for an initial disability rating in excess of 70 percent for PTSD from April 5, 2007 to December 27, 2009. As discussed below, the evidence of record indicates the service-connected disability more closely approximated a manifestation of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to psychiatric symptomatology. The pertinent evidence of record during this period includes VA outpatient treatment records from April 5, 2007 to December 1, 2009, July 2007 VA examination addendum opinion, and March 2009 Social Security Administration (SSA) decision letter. Pursuant to VA outpatient treatment sessions, the Veteran's documented psychiatric symptomatology includes the following: suicidal ideation, sleep impairment and insomnia, intrusive thoughts depression, panic attacks, hypervigilance, nightmares, odd behavior, feeling useless, lack of interest, anhedonia, flashbacks, difficulty with concentration, irritability, emotional numbing, and physical reactions of stressful past events. Additionally, physicians noted the Veteran's affect as constricted, inappropriate, restricted, blunted, and animated; mood as dysphoric, despondent, angry, dysthymic, and "alright"; impulse control as fair and poor; insight as poor, fair, and improving; judgment as poor, impaired, and improving; and eye contact as fair to good, improved, and poor. Furthermore, the Veteran exhibited that he was adequately and neatly groomed, casually and appropriately dressed, reasonable and cooperative behavior, and oriented to person, place, time, manner, and situation at multiple treatment sessions. His thought process was noted as logical, goal directed and oriented, normal, coherent, relevant, essentially intact, linear, and with no evidence of a thought disorder or loose associations. The Veteran reported seeking assistance from his sister with grocery shopping and denied having problems attending to his activities of daily living. He repeatedly asserted passive suicidal ideation, but also consistently denied current or active suicidal intent and plan as well as homicidal ideation, plans, and intent. The Board finds that such psychiatric symptomatology is currently contemplated in the assigned 70 percent disability rating for this appeal period. The Board notes that the Veteran reported having problems with his memory in November 2007, impaired memory in January 2008, March 2008, September 2008, and January 2009, and decreased memory in May 2008. Nonetheless, following VA outpatient treatment sessions, there were no objective findings, nor assertions by the Veteran or his representative, of total occupational and social impairment due to memory loss for either names of close relatives, own occupation, or own name. In fact, treating physicians documented grossly intact recent and remote memory in April 2007; some memory impairment in September 2007, November 2007, March 2008, May 2008, July 2008, October 2008, December 2008, and March 2009; and intact memory and recall for visuospatial and verbal material in December 2009 pursuant to a traumatic brain injury (TBI) evaluation. Next, with regard to communication, the Veteran's speech was noted as somewhat slow but otherwise normal in September 2007; slow in October 2007; minimally coherent, delayed, and slow with a delayed response when answering questions in November 2007; delayed and slow in July 2008l and slow with low tone in June 2009. Nonetheless, following VA outpatient treatment sessions, there were no objective findings, nor assertions by the Veteran or his representative, of total occupational and social impairment due to gross impairment in communication. In fact, January 2008 and September 2008 records documented the Veteran provided clear and articulate answers to questions. His speech was clear and coherent with spontaneity in answering questions in March 2008, October 2008, December 2008, March 2009, and September 2009. The Veteran displayed coherent speech with limited spontaneity in May 2008 and July 2008, and a December 2009 record noted speech was intact with language and cognitive fluency. The Veteran also repeatedly denied hallucinations during treatment sessions but endorsed experiencing auditory hallucinations at other times, as documented in VA outpatient treatment records dated November 2007, March 2008, May 2008, July 2008, October 2008, December 2008, and March 2009. However, following VA outpatient treatment sessions, there were no objective findings, nor assertions by the Veteran or his representative, of total occupational and social impairment due to persistent delusions or hallucinations. In fact, such records document the Veteran's thought content as relevant in January 2008, March 2008, September 2008, January 2009, and June 2009; and the Veteran denied auditory and visual hallucinations in June 2009. The Board further notes that pursuant to an October 2007 VA outpatient treatment session, the physician documented an inability to attribute all of the Veteran's behavior to the working diagnosis of PTSD and the Veteran's level of irritability towards physician was him not providing the Veteran with a letter for Social Security. In December 2007, a GAF score was unable to be determined because the Veteran's symptom presentation, behavior, and response patterns on the psychological measures administered suggest the Veteran is malingering his mental illness as well as his memory problems, and it is possible that Veteran has incentive to exaggerate his symptoms for secondary gain purposes. It is important for the Veteran to understand that such indications only provide highly probative factual evidence against all claims before the Board, and suggest further review of the evaluation may be necessary in the future. A March 2008 VA outpatient treating physician also noted there appears to be some disconnect between the Veteran's reported/experienced symptoms, providing more evidence against this claim. In a July 2007 VAX addendum opinion, after reviewing the claims file and the March 2007 VA psychiatric examination, the VA examiner opined there is no reason to change anything in the report. The Board further acknowledges that review of the evidentiary record shows the Veteran was awarded Disability Insurance Benefits by the Social Security Administration (SSA) in March 2009. The Veteran was found not to have engaged in substantial gainful activity since September 2009 and the Veteran is unable to perform any past relevant work. The medical evidence established he had the following "severe" impairments: major depression, PTSD, and arthritis affecting the knees. It was also noted, citing to a medical report from Dr. Singh, that the Veteran has a significantly reduced ability to respond appropriately to supervision, coworkers and the usual work situations, has a significantly reduced ability to deal with changes in a routine work setting as a result of depression and PTSD. While the determination of the SSA is probative evidence in favor of the Veteran's claim, SSA regulations and administrative decisions, including its factual conclusions regarding the date on which he became unable to work, are not necessarily binding on VA or the Board. See Colliet v. Derwinski, 1 Vet. App. 413, 417 (1991). The GAF scores assigned pursuant to VA outpatient treatment records during this rating period were 30 (June 2009), 45 (April 2007, November 2007, January 2008), 48 (April 2007 and March 2008), 49 (August 2007 and June 2009), 50 (January 2008 and March 2008 to March 2009), 60 (September 2009), and 65 (October 2007). These assigned GAF scores are found to be consistent with the demonstrated symptomatology of record for the entire initial appeal period. The GAF score of 30 contemplates the presence of hallucinations and impairment in communication and judgment, and GAF scores from 41 to 50, 51 to 60, and 61 to 70 are indicative of serious, moderate, and mild symptoms, respectively, but when considering the evidence as a whole, do not justify assignment of a total disability rating at any time during this appeal period. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or a GAF score is a factor for consideration and not determinative of the percentage VA disability rating to be assigned. See also 38 C.F.R. § 4.126(a). Therefore, based on the above lay and medical evidence, including the GAF scores and specifically documented psychiatric symptomatology discussed above, the Board finds that a rating in excess of 70 percent is not warranted from April 5, 2007 to December 27, 2009. C. Additional Considerations With respect to both periods on appeal, the Board is aware that the symptoms listed under the next-higher ratings are essentially examples of the type and degree of symptoms for those ratings, and that the Veteran need not demonstrate those exact symptoms to warrant a higher initial rating. See Mauerhan, 16 Vet. App. at 436. In this case, the Board has considered the next higher rating for each period but finds that the periods are rated appropriately. The Board has considered the reported history of symptomatology regarding the service-connected PTSD by the Veteran and acknowledges that he is competent to report such symptoms because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran is not competent to identify a specific level of the disability on appeal according to the appropriate diagnostic code. In this case, such competent evidence concerning the nature and extent of the service-connected PTSD has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints and increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, with respect to the claim as required by the Court. See Schafrath, 1 Vet. App. at 594. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign ratings higher than the currently assigned evaluations for the service-connected PTSD on appeal for any period. The evidence of record raised the issue of a total disability rating based on individual unemployability (TDIU) due to the service-connected PTSD and the RO denied entitlement to TDIU in a June 2008 rating decision. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The evidence within these appeal periods would, overall, provide evidence against such a finding, with indications of exaggeration only providing evidence against the current evaluations, let alone higher evaluations. Lastly, the Board has considered whether referral for an extra-schedular evaluation is warranted for the service-connected PTSD. In exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extra-schedular 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, 115-16 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Turning to the first step of the extra-schedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology from June 15, 2004 to April 4, 2007 and by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to psychiatric symptomatology from April 5, 2007 to December 27, 2009. These symptoms are part of the schedular rating criteria. In addition, the level of occupational and social impairment is explicitly part of the schedular rating criteria. The GAF scores are also incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. For these reasons and in the absence of exceptional factors, the Board finds that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Therefore, fully considering the lay and medical evidence of record, the Board finds that an initial disability rating for PTSD in excess of 30 percent from June 15, 2004 to April 4, 2007 and in excess of 70 percent from April 5, 2007 to December 27, 2009 is not warranted for any period. 38 C.F.R. §§ 4.3, 4.7. Temporary Total Disability Rating under 38 C.F.R. § 4.29 The Veteran seeks a temporary total rating under 38 C.F.R. § 4.29 for a period of medical treatment between April 2007 and October 2007. Specifically, in an October 2007 statement, via a VA Form 21-4138, he stated that he was in the hospital at a VA facility in Augusta, Georgia for PTSD through the Operation Enduring Freedom-Operation Iraqi Freedom (OEF-OIF) program from April 2, 2007 to October 12, 2007. A temporary total disability rating will be assigned pursuant to 38 C.F.R. § 4.29 when it is established that one or more service-connected disabilities has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. In the present case, the Veteran has been granted service connection for PTSD, right knee arthritis, left knee arthritis, right knee instability, and left knee instability. Review of the record does not indicate that the Veteran was hospitalized at a VA or private medical facility during this period; rather, he was under VA outpatient mental health treatment through individual and group therapy at the VA Medical Center (VAMC) in Augusta, Georgia. In fact, a July 2007 mental health record documented the Veteran's participation in the OEF/OI[F] Domiciliary Residential Rehabilitation Treatment Program (DRRTP) as an outpatient since April 2, 2007. October 12, 2007 records also note the Veteran appeared for a scheduled mental health visit and an unscheduled visit with a social worker, both of which suggests the Veteran's outpatient status. As such, a temporary total rating is not warranted, as the requirements of such an award have not been met. The Veteran has not required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. Thus, his claim for 38 C.F.R. § 4.29 benefits must be denied. Insomuch as the Veteran contends he was hospitalized from April 2007 to October 2007 due to his service-connected PTSD, the Board does not find these assertions to be credible, as the remainder of the record suggests he was merely receiving outpatient treatment during this period. In conclusion, the preponderance of the evidence is against the award of a temporary total rating pursuant to 38 C.F.R. § 4.29 due to hospitalization for treatment of a service-connected disability, as such hospitalization has not been demonstrated within the record during the pendency of this appeal. As a preponderance of the evidence is against the award of a temporary total rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and 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). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a June 2005 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. The VCAA requirements have also been satisfied by a March 2008 letter in which VA informed the Veteran that in order to substantiate a claim for a temporary total disability rating under 38 C.F.R. § 4.29. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. These letters also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the June 2005 and March 2008 letters included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claims on appeal, the evidence of record includes VA outpatient treatment records, VA outpatient medical opinions, statements from the Veteran, and VA psychiatric examination reports dated March 2007 and April 2005. The VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination reports are probative for the rating of PTSD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Although no VA medical examination or opinion was provided for a temporary total disability rating under 38 C.F.R. § 4.29, none was required because all of the evidence of record pertinent to the claim is of record. In November 2010, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge (VLJ). Any deficiencies in development were addressed in the subsequent Board remands, as discussed below. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the VLJ who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). Pursuant to the Board's February 2011 remand instructions, the RO obtained and associated with the record outstanding SSA records and readjudicated the claims on appeal in a May 2012 Supplemental Statement of the Case (SSOC). VA's duty to assist is met. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER An initial disability rating for PTSD in excess of 30 percent from June 15, 2004 to April 4, 2007 and in excess of 70 percent from April 5, 2007 to December 27, 2009 is denied. A temporary total disability rating under 38 C.F.R. § 4.29 is denied. REMAND A remand is required in this case to ensure there is a complete record upon which to decide the issues of entitlement to an increased rating for left knee arthritis, currently rated as 10 percent disabling, and an increased rating for right knee arthritis, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2012); Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). After a review of the record, the Board finds that additional pertinent VA outpatient treatment records from January 2011 to January 2012 were associated with the claims file on the "Virtual VA" system in April 2012. Although these records were associated with the record before issuance of the May 2012 Supplemental Statement of the Case (SSOC), the RO only noted review of VA outpatient treatment records from February 2010 to December 2010. Thus, the VA outpatient treatment records dated from January 2011 to January 2012, which were added to the claims file on the "Virtual VA" system, raises concern as to whether the agency of original jurisdiction (AOJ) initially reviewed such records. As a result, the Board finds these claims must be remanded to the AOJ for initial review of the additional evidence of record. See 38 C.F.R. § 20.1304(c) (2012). Subsequently, an additional VA examination for the service-connected left and right knee arthritis disabilities is warranted because the evidence of record since the December 2009 VA examination through QTC Medical Services (QTC) suggests a worsening of the left and right knee arthritis disabilities. Findings from the December 2009 VA QTC examination of bilateral knee arthritis revealed complaints of weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, subluxation, pain, and dislocation. The Veteran also reported having flare-ups causing functional impairment, to include pain while bending joints, limitation of motion, difficulty standing/walking, and inability to function normally without use of braces and cane. Clinical evaluation revealed bilateral tenderness, guarding of movement, instability, and locking pain, and the Veteran exhibited forward flexion to 40 degrees on the right side and to 36 degrees on th left side. Since then, the Veteran testified at the November 2010 Board hearing that he undergoes physical therapy and takes daily prescribed pain medication for the knees. Most recently, VA outpatient treatment records from February 2010 to January 2012 document the Veteran's complaints and treatment for bilateral knee pain and inflammation. Therefore, the Board finds that an additional VA examination is deemed necessary to ascertain the Veteran's current severity and degree of these service-connected disabilities during the appeal period since the December 2009 VA QTC examination more than three years ago. When available evidence is too old for an adequate evaluation of a veteran's current condition, VA's duty to assist includes providing a new examination. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). While a new examination is not required simply because of the time that has passed since the last examination, VA's General Counsel has interpreted that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95. Accordingly, the issues of entitlement to an increased rating for left knee arthritis, currently rated as 10 percent disabling, and an increased rating for right knee arthritis, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter are REMANDED for the following actions: 1. Schedule the Veteran for the appropriate VA examination to determine the current severity and impairment (if any) of his service-connected left and right knee arthritis disabilities. The relevant documents in the claims file should be made available to the VA examiner for review. All indicated studies and tests, deemed necessary by the examiner, should be performed and all pertinent symptomatology should be reported in detail. The VA examiners should also request a history from the Veteran. A notation to the effect that the record review and history took place should be included in the examiner's report. A rationale should be given for all findings and conclusions expressed. As noted above, indications of exaggeration should be noted for the record. If an opinion or the requested information cannot be provided without resorting to speculation, the VA examiner should state so and explain why it would be speculative to respond. 2. Thereafter, readjudicate, to include a review of all the most recently associated evidence of record since April 2012 on the "Virtual VA" system, the issues of entitlement to an increased rating for left knee arthritis, currently rated as 10 percent disabling, and an increased rating for right knee arthritis, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran and representative have the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). These claims must be afforded expeditious treatment. The law requires that all claims 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 J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012). Department of Veterans Affairs