Citation Nr: 1318346 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 06-08 363 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent prior to September 29, 2010, and 20 percent thereafter for hepatitis C. 2. Entitlement to an initial evaluation in excess of 30 percent prior to November 1, 2010, and 50 percent thereafter for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a lung condition, to include as due to in-service exposure to chemicals. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served as a member of the United States Navy, with active service from April 1974 to June 1976. This case comes before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions rendered by the Department of Veterans Affairs (VA) Regional Office in New York, New York (RO). The Veteran testified at a Travel Board hearing before the undersigned at the New York RO in September 2009. A transcript of the hearing has been associated with the Veteran's VA claims file. As to the Veteran's Hepatitis C, in a March 2008 statement of the case (SOC), the RO increased the Veteran's previously noncompensable rating for Hepatitis C to 10 percent, effective November 5, 2001. A February 2012 rating decision increased the rating to 20 percent, effective September 29, 2010. As to the Veteran's PTSD, the RO granted service connection and assigned an initial 30 percent evaluation for PTSD in a December 2007 rating decision. In a February 2013 rating decision, the AMC increased the rating to 50 percent, effective November 1, 2010. Regardless of the RO/AMC's actions, the issues remain before the Board because the increased ratings were not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran's claims were remanded by the Board for additional development in August 2010 and December 2012. The case has since been returned to the Board for further appellate consideration. A review of the Veteran's virtual VA electronic claims file reveals that additional relevant VA treatment records from the Brooklyn VAMC dating from 2008 to 2012 have been associated with the record. These records have been reviewed and considered by the Board. The issue of entitlement to an earlier effective date for eligibility to disability pension has been raised by the Veteran's representative in a March 2013 statement. As this issue has been raised by the record but it has not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issues of entitlement and increased initial ratings for PTSD and entitlement to service connection for a lung condition to include as due to in-service chemical exposure 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. Prior to September 29, 2010, the Veteran's hepatitis C has been manifested by intermittent fatigue, malaise, and anorexia; there is no objective evidence of incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). 2. Since September 29, 2010, the Veteran's hepatitis C has been manifested by daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication; there is no objective evidence of incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)having a total duration of at least 4 weeks but less than 6 weeks. CONCLUSIONS OF LAW 1. Prior to September 29, 2010, the schedular criteria for a rating in excess of 10 percent for hepatitis C have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.112, 4.113, 4.114, Diagnostic Code 7345; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.21 (2012). 2. Since September 29, 2010, the schedular criteria for a rating in excess of 20 percent for hepatitis C have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.112, 4.113, 4.114, Diagnostic Code 7345; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.21, 4.115, Diagnostic Code 7354 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Stegall Considerations As noted above, the Board remanded this matter for further development in August 2010 and December 2012. In August 2010, the Board, in relevant part, instructed the RO/AMC to request that the Veteran indicate if she received any VA or non-VA medical treatment regarding her claim for increase for hepatitis C, and if so, to obtain and associate those records with the claims file; afford the Veteran an appropriate examination to determine the extent and severity of her Hepatitis C, and; readjudicate the claim. In September 2010, the AMC requested to identify and submit or request VA assistance in obtaining any treatment records pertinent to her Hepatitis C disability. Also in September 2010, the Veteran was afforded a VA examination for evaluation of the current severity of her Hepatitis C disability. In September 2010, the Veteran submitted VA Form 21-4142, Authorization and Consent to Release Information to the VA for records of private treatment received for Hepatitis C from Dr. JB dating since 2001 and VA treatment from SA, a liver transplant coordinator in July and August 2010. In November 2011, the AMC requested that the Veteran submit an updated VA Form 21-4142 so that VA could obtain private treatment records from Dr. JB. In December 2011 and February 2012, the Veteran submitted private treatment records from Dr. JB dating from May 2010 to January 2011 and a January 2011 liver biopsy performed by Dr. FM. She also submitted VA Form 21-4142s for obtainment of private treatment records from Dr. JB dating from November 2007 to December 2011 and Dr. FM dating from 2003 to 2011 for hepatitis C. The authorizations were signed and dated by the Veteran in November 2011. In January 2012, VA treatment records dating from 2008 to 2012 were associated with the Veteran's Virtual VA electronic claims file. The claim was readjudicated in a February 2012 supplemental statement of the case. The claim was again remanded in December 2012 as there was no indication that any attempt had been made to obtain the aforementioned private treatment records from Drs. FM and JB as identified by the Veteran in the authorizations dated in November 2011. The RO/AMC was to seek the private treatment records identified in those authorizations and readjudicate the claim. In a December 2012 letter, the Veteran was requested to identify any VA and non-VA treatment that she has received for the claimed disability and to complete separate VA Form 21-4142 for each non-VA provider from which she had received treatment. To date, however, the Veteran has failed to respond to that request. The claim was most recently readjudicated in a February 2013 SSOC. Thus, there is compliance with the Board's remand instruction. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist In correspondence dated in June 2005, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO/AMC notified the Veteran of: information and evidence necessary to substantiate his claim for increase; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The letter informed the Veteran that in order to establish a higher rating, the evidence would need to show that her disability had increased in severity. A subsequent January 2007 letter provided notice of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Additionally, a July 2008 letter informed the Veteran of the types of evidence that could be submitted to support her claim for an increased rating and of the types of evidence that could be submitted to support her claim. The claim was last readjudicated in a February 2013 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (noting that VA cured its failure to afford statutory notice to the claimant prior to an initial rating decision by issuing a notification letter after the decision, readjudicating the claim, and notifying the claimant of such readjudication in the statement of the case). VA has done everything reasonably possible to assist the Veteran with respect to her claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Evidence that has been obtained and associated with the claims file includes identified VA and private treatment records. As noted above, relevant private treatment records have not been obtained from Drs. FM and JB as identified in authorizations dated in November 2011. These records or authorization sufficient to enable VA to obtain them were requested from the Veteran in December 2012 in accordance with the Board's December 2012 remand, however, the Veteran did not respond. In March 2013, the Veteran and her representative submitted a response to the February 2013 SSOC, which clearly indicated that authorization to obtain records from Dr. JB and FM was requested from the Veteran in December 2012 and had not been received. The Veteran and her representative requested expedited processing of her claim and she waived the 30 day waiting period. The claim is now before the Board for further appellate consideration. In this regard, while VA has a statutory duty to assist the Veteran in developing evidence pertinent to a claim, she also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way-street. See Hayes v. Brown, 5 Vet. App. 60, 68 (1993) (VA's duty to assist is not a one-way-street; if a veteran wishes help, [s]he cannot passively wait for it in those circumstances where his/her own actions are essential in obtaining the putative evidence). Thus, the Board declines to remand the claim for a third time to try to obtain private treatment records from Drs. JB and FM. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. See 38 C.F.R. § 3.159(c). Additionally, the Veteran was provided with VA examinations to determine the nature and severity of her service-connected hepatitis C disability in June 2005 and September 2010. The aforementioned examination reports reflect that the examiners reviewed and recorded the Veteran's documented and/or reported past medical history and current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board finds that the clinical findings in the 2005 and 2010 examination reports, in combination with the clinical findings contained in VA and private treatment records, as well as the Veteran's own statements and testimony of record, provide a full and accurate picture of the Veteran's disability so as to allow the Board to render an informed decision. Although the most recent VA examination of the Veteran's hepatitis C disability is dated in September 2010, more than two years ago, and the most recent VA treatment records associated with the claims file document the Veteran's report that she was reportedly told that a private liver biopsy in January 2011 indicated that her liver condition had worsened, she has not alleged an increase or worsening of signs and symptoms associated with her service-connected hepatitis C disability since the September 2010 VA examination. Moreover, liver biopsy in 2007, prior to the most recent 2010 VA examination, and liver biopsy in 2011, subsequent to the 2010 VA examination, both show stage II to III liver disease. Thus, it does not appear that her liver condition has worsened since the most recent 2010 VA examination as alleged in the most recent VA treatment records. Moreover, as explained in greater detail below, the Board has evaluated the Veteran's signs and symptoms of her hepatitis C disability under Diagnostic Code 7354 for hepatitis C (or non-A, non-B hepatitis), which directs that sequelae, such as cirrhosis or malignancy of the liver be evaluated under an appropriate diagnostic code, but not using the same signs and symptoms as the basis for evaluation under DC 7354 and under a diagnostic code for sequelae. Diagnostic Code 7311, for residuals of injury to the liver, directs that depending on the specific residuals, separately evaluate as adhesions of the peritoneum (DC 7301), cirrhosis of the liver (DC 7312), and chronic liver disease without cirrhosis (DC 7345). In this case, because neither adhesions of the peritoneum nor cirrhosis of the liver have been shown at any time since the claim for increase was received in 2005, residuals of injury to the Veteran's liver would be evaluated under Diagnostic Code 7345 for chronic liver disease without cirrhosis, which uses the same criteria for evaluation as the criteria used to evaluate her hepatitis C disability. Thus, unless adhesions of the peritoneum or cirrhosis of the liver is shown or alleged, which is not the case here, a separate evaluation due to worsening of residual liver injury is not warranted. The passage of time alone does not trigger the need for a new examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) ("Although evidence submitted between the date of the regional office's decision and the Board's review of that decision could, in particular instances, conceivably require that a new medical examination be provided, the mere passage of time between those events does not."). Thus, the Board concludes that the evidence of record is adequate for purposes of rendering a decision in the instant appeal and VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of her claim. Statements and testimony received from the Veteran and her representative show that they have actual knowledge of the information and evidence necessary to substantiate the claim. Therefore, the duties to notify and assist have been met. Accordingly, the Board may proceed with adjudication of the claim. 38 C.F.R. § 20.1304(c) (2012). The Board also observes that in September 2009, the Veteran was afforded a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) during which she presented oral argument in support of her claim for an increased rating. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issue on appeal during the hearing. Significantly, neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Legal Criteria Historically, service connection was granted for hepatitis C in an August 1977 rating decision, which assigned a 10 percent disability evaluation effective June 25, 1976. The current appeal stems from a March 2005 claim for increase wherein the Veteran asserted that her hepatitis C disability has worsened. The Veteran and her representative essentially contend that her Hepatitis C disability presents a greater degree of impairment than is reflected by the currently assigned 10 percent evaluation prior to September 29, 2010, and the 20 percent evaluation assigned from September 29, 2010. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings, i.e., disability ratings for separate periods of time based on the facts found. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the Board resolves the benefit of the doubt for each such issue in favor of the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. 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. 38 C.F.R. § 3.159(a) (2012). However, in ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1) (2012). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. See Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Historically, service connection for Hepatitis C was granted in an August 1977 rating decision, which assigned a 10 percent disability evaluation effective June 25, 1976 under 38 C.F.R. § 4.114, Diagnostic Code 7345 for chronic liver disease without cirrhosis (excluding hepatitis C). Hepatitis C (or non-A, non-B hepatitis), however, with serologic evidence of Hepatitis C infection and signs and symptoms due to Hepatitis C infection is evaluated using essentially the same rating criteria under 38 C.F.R. § 4.114, Diagnostic Code 7354. In light of the foregoing, the Board finds that Diagnostic Code 7354 for evaluation of Hepatitis C is the appropriate Diagnostic Code to be applied in this case. Under Diagnostic Code 7354 for evaluation of Hepatitis C, a noncompensable rating is assigned for asymptomatic Hepatitis C. A 10 percent rating requires intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12- month period. A 20 percent rating requires daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent rating requires daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A 60 percent rating requires daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A 100 percent rating requires serologic evidence of Hepatitis C infection and signs and symptoms due to the Hepatitis C infection of near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). According to Note (1) in this DC, sequelae (i.e., residuals), such as cirrhosis or malignancy of the liver, are to be evaluated under an appropriate DC, but not using the same signs and symptoms as the basis for evaluation under DC 7354 and under a DC for sequelae. (This would violate VA's anti-pyramiding regulation. See 38 C.F.R. § 4.14). Note (2) provides that for purposes of evaluating conditions under DC 7354, an "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. Factual Background Historically, liver biopsy in November 2001 was consistent with chronic hepatitis with grade II and stage II liver disease without evidence of cirrhosis. The Veteran was treated with Interferon/Ribavirin in June 2002, which did not clear the virus. She underwent pegylated Interferon/Ribavirin treatment from March 2003 to August 2004, which cleared the virus, however, relapse occurred in June 2005. In her March 2005 claim for increase, the Veteran indicated that her Hepatitis C disability was manifested by symptoms of severe fatigue, weakness, anemic diarrhea, nausea, irritability, weight loss, and trouble sleeping. She had reportedly missed significant time from work due to Hepatitis C and it prevented her from performing daily activities that she had been accustomed to. In May 2005, the Veteran was employed as a consultant at Diamond Managing Consultants. In June 2005, the Veteran underwent a VA examination for hepatitis C. The claims file was not available for review, however, the Veteran presented private treatment records for review at the time of examination. Symptoms at the time of the June 2005 examination included weakness, anorexia, malaise, daily right upper quadrant pain (rated as 5/10 with 10 at worst), and she reportedly required bed rest. She reported a weight loss of 10 to 15 pounds in the 2 to 3 months prior to examination. Her usual occupations were an adjunct professor at a local college and a law clerk. She reportedly lost her law clerk job in 2004 due to her inability to meet expected job requirements secondary to fatigue, arthralgia, right upper quadrant pain, dizziness, and shortness of breath, which resulted in increased absenteeism. She also underwent surgical treatment for colon cancer and a myomectomy in September 2000 which required her to miss work. She had been unemployed from her job as an adjunct professor for at least one year reportedly due to fatigue and tiredness. Her past medical history was also significant for cervical cancer in 1984 status post conization, status post pilonidal cyst incision in 1997, status post tonsillectomy, status post cerebral vascular accident in 1996 with mild left sided weakness due to a clotting disorder, and carpal tunnel syndrome status post right hand surgery in 2004. On physical examination in June 2005, the Veteran weighed 180 pounds. Her abdomen was soft with pain and tenderness to palpitation of the right upper and lower quadrants. Hepatosplenomegaly was not appreciated and there were no ascites or superficial abdominal veins. There was an incisional scar to the mid abdomen. There was bilateral hand swelling. There was no muscle wasting or evidence of malnutrition. The examiner diagnosed hepatitis C with complaints of fatigue and tiredness which prevented her from fulfilling her occupational duties as a law clerk and an adjunct professor. It also reportedly limited some of her daily activities due to complaints of fatigue and tiredness which most of the time required her to have bed rest. In a July 2005 statement, the Veteran's mother indicated that she had difficulty performing significant tasks due to severe pain in her bilateral hands and elbow. Private treatment records show that the Veteran underwent surgery on her right hand in December 2004 and that she needed surgery on her left hand. In September 2005, a review of symptoms during a VA oncology consultation revealed that the Veteran had a fair appetite without weight loss; however, she was nauseated often and had loose stools three to four times a day. In October 2005, it was noted that she had been off of medication for treatment of hepatitis C for six months. Her weight was 198 pounds. A May 2006 abdominal CT scan indicated that the Veteran's liver was unremarkable. In August 2006, the Veteran inquired as to when she could return to work following removal of a lipoma from her ankle. In December 2006, the Veteran sought emergency VA treatment due to complaints of right lower quadrant pain with radicular pain down her right leg, diarrhea, and nausea since 1 week prior after eating at a fast food restaurant that had since been closed due to e-coli contamination. She denied any fever or vomiting. A CT scan of the abdomen was ordered, however, the Veteran left against medical advice as she had to go to work. In a February 2007 statement, the Veteran claimed that she was unable to work due to symptoms of hepatitis C. However, a February 2007 VA mental health note showed that she was employed and looking for alternate employment due to fear of being laid off. In March 2007, the Veteran complained of right lower quadrant pain with recent worsening. She denied fever, chills, nausea, vomiting, change in bowel movements, associated weight loss, chest pain, and shortness of breath. Abdominal x-rays were negative for obstruction. Pelvic sonogram showed multiple cystic structures in the right ovary which may have been a normal variant or resolving hemorrhagic cysts. Follow-up gynecological examination indicated that right lower quadrant pain was not likely gynecology-related. A March 2007 treatment note showed complaints of fatigue, mild anorexia, occasional nausea, and a 10 pound weight loss in the last year. Her weight was 191 pounds. In April 2007, the Veteran underwent a psychological assessment to assess her readiness for Interferon treatment. Despite numerous documentations in VA treatment records stating otherwise, the Veteran indicated that she had not worked since 2000 when she was employed as a law clerk. She reported that she "drank socially once in a while". A May 2007 hepatology note shows that the Veteran denied fever, nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath, abdominal pain, weight loss, and her appetite was good. Review of private records brought for review showed liver biopsy with stage II disease without evidence of cirrhosis. However, wedge was done in the left hepatic vein where reflux of contrast into the portal vein was noted to be suggestive of cirrhosis. Biopsy and wedge hepatic vein pressures were a bit contradictory and a repeat biopsy was needed. A May 2007 psychiatric treatment note shows that the Veteran had found a new job. In November 2007, review of symptoms was positive for fatigue, occasional right lower quadrant pain, and joint and back and neck pain. Weight loss was denied and appetite was good. A longer course of pegylated Interferon/Ribavarin treatment was recommended. Abdominal echogram showed dense heterogeneous echo pattern of the liver. Common bile duct and biliary ductal system in the liver were normal size and the liver measured 18.23 cm. There was no evidence of ascites. Portal flow was normal. Fatty infiltration in the liver could not be ruled out. In a December 2007 statement, a VA liver team coordinator indicated that the Veteran was undergoing treatment that required special accommodations and additional time during testing. Abdominal sonogram in December 2007 revealed small gallbladder polyps. It was noted that some parts of liver biopsy revealed stage III liver disease. Diagnosis was hepatitis C with a high viral load and preserved synthetic liver function, thus, a longer course of pegylated Interferon/Ribavirin treatment was recommended. A December 2007 VA emergency note for sinusitis showed that the Veteran denied fever, chills, shortness of breath, abdominal pain, weight loss, diarrhea, and vomiting. In January 2008, the Veteran complained of pain in her right upper and lower quadrants with a lot of gas, nausea, and epigastric pain with radicular pain to the mid chest. She reported nausea after eating spicy food and persistent nausea. She experienced a cough when placed in recumbent position. She had gained 14 pounds in the last month and she had mild lower extremity edema and finger swelling. Poor inspiratory effort was noted on examination of her lungs. There was 1+ edema of the lower extremities. Abdominal series was negative for cholecystitis. Cardiac etiology needed to be ruled out. In a January 2008 statement, the Veteran indicated that her liver disease had progressed from stage II to stage III and continued to progress despite failed treatment of her liver disease for two years. In March 2008, she submitted electronic research concerning the stages of liver disease and signs and symptoms of hepatitis C. A February 2008 mental health outpatient note showed that the Veteran was active in school and in studying for the bar examination. Her weight was 200 pounds. In March 2008, she companied of intermittent left sided chest pain, however, symptoms of nausea, vomiting, and dizziness were denied. She had been in a skiing accident 2 days prior when she was struck in the chest with vague complaints of chest pain since. A March 2008 VA hepatology note shows that the Veteran decided that she did not want to be retreated for hepatitis C and her liver condition. CT scan of the chest showed that her liver appeared normal in size. In June 2008, the Veteran was writing a book which she sent to a publisher in July 2008. In August 2008, the Veteran complained of chronic right lower quadrant abdominal pain and generalized fatigue. She also complained of occasional nausea and vomiting over a few weeks prior. She denied fever, chills, chest pain, and diarrhea. She was interested in a 3rd treatment for chronic hepatitis C with stage II-III liver disease, however, a decision was made for watchful observation. She was informed that with initial response and relapse, she may be able to clear the virus with longer duration of therapy. Symptoms were stable and of years in duration with no alarm symptoms. In September 2008, the Veteran was enjoying school. In October 2008, she was looking forward to a trip to Hawaii to make an educational presentation. In January 2009, the Veteran sought emergency treatment for a three week history of diarrhea. She noted vague right lower quadrant pain and symptoms of nausea, vomiting, and fever were denied. She was concerned that her diarrhea may be indicative of recurrence of colon cancer. LFTs were more abnormal than her normal baseline. Complaints of frequent diarrhea continued with report of a 10 pound weight loss over the next few weeks. Diarrhea resolved by late January and a new complaint of constipation was noted. She admitted to consuming alcohol over the holiday and a rise in transaminases was noted, possibly secondary to a "recent alcohol binge." Upon seeking emergency VA treatment for diagnosis of sinusitis in February 2009, the Veteran denied symptoms of chills, weight loss, nausea, vomiting, diarrhea, loss or change in vision, and headaches. She was preparing to take the bar examination later that month. Downtrended transaminase elevations were noted later in February 2009. In April 2009, the Veteran was having difficulty coping with her workload. She was looking for a steady job and she was in school trying to obtain another degree. She was also waiting to find out her bar examination results which she subsequently found out that she did not pass. In August 2009, she was working as an advocate for Veterans in assisting them with their educational goals. In a September 2009 statement, the Veteran's significant other and roommate since 1997 indicated that she had witnessed the Veteran experience severe fatigue and nausea. The Veteran indicated that she had recently been advised that she was not a candidate for further treatment of her liver disease due to her gender, race, and history of two prior failed treatments. She endorsed symptoms of, right sided abdominal pain, nausea, anorexia, severe fatigue, and diarrhea. She reported difficulty sustaining work and social relationships due to panic and anxiety. During the September 2009 Travel Board hearing, the Veteran testified that that symptoms associated with her service-connected hepatitis C included constant daily fatigue, weight fluctuations due to swelling, poor appetite, nausea, diarrhea which had lasted for approximately 6 weeks, irritability, tiredness, mood swings, and depression. Prior treatment included Interferon/Ribavirin combination therapy for two years at different intervals with private Dr. JB and VA treatment at the Brooklyn VAMC. She was reportedly employed part time 10 to 20 hours a week depending on how she felt. She worked a desk job at a local college where had worked since 2 years prior assisting college students with adjustment to college life, however, she had no longevity, and she was too tired to perform any physical activity. She had a flexible work schedule to accommodate her disability. She had no energy for bike rides or walks in the park. She reportedly had been advised by doctors to "take it easy" and engage in relaxing activities, however, she explicitly denied ever having been prescribed with bed rest due to signs and symptoms of hepatitis C. A September 2009 duplex of arterial inflow and venous ultrasound revealed an echogenic liver due to fatty infiltration without evidence of focal lesion. A complete abdominal echogram revealed an enlarged and echogenic liver without sonographic evidence of focal hepatic mass. In September 2010, a chronic complaint of right lower quadrant pain radiating to the right leg was noted. She also reported symptoms of nausea, especially in the morning, loss of appetite, a 9 pound unintentional weight loss, and generalized fatigue. Nausea and right quadrant pain may have represented gastroesphageal reflux disease. It was noted that she may be a candidate for future hepatitis C treatment, however, she was started in the VA hepatitis surveillance program. On reevaluation a few weeks later, the Veteran denied weight loss and vomiting. Diagnosis was hepatitis C with high viral load and stage II-III liver disease on liver biopsy in 2007. Her most recent sonogram was negative for liver lesions. She had elevated liver function tests which were declining. In September 2010, the Veteran was afforded an additional VA examination to determine the nature and severity of her hepatitis C, which had been intermittent with remissions since diagnosis during service. Current treatment included medication. Past treatment included Interferon, Ribavirin, and dietary restriction. Treatment was productive of mild side effects of fever, diarrhea, patchy hair loss, and auditory changes. Moderate effects included malaise, anorexia, headache, muscle pain, impaired concentration, and moderate autoimmune disorder (rheumatoid arthritis). Severe side effects included nausea, depression or mood change, and insomnia. Side effects did not include vomiting, thyroid abnormality, anemia, skin rash, eye problems, or seizures. She was hospitalized due to hepatitis C in 1975 when she was treated with supportive care and rest. Symptoms at the time of examination included daily fatigue and malaise, and intermittent nausea, vomiting, anorexia, and right upper quadrant pain. Based on the Veteran's reported history and medical documentation, the examiner concluded that the Veteran experienced less than 10 incapacitating episodes lasting for 3 days in duration due to signs and symptoms severe enough to require bed rest and treatment by a physician during the 12 months prior to examination. There was no history of neoplasm or extra-hepatic manifestations of liver disease. The Veteran weighed 187 pounds and there was no current weight loss or evidence of malnutrition. Abdominal examination revealed that the Veteran's liver was enlarged and firmer than normal. There was no evidence of abdominal tenderness, ascites, portal hypertension, or other signs of liver disease. Ultrasound of the liver showed that it was enlarged and ecogenic. The examiner diagnosed chronic hepatitis C with high viral load, stage II-III on liver biopsy in 2007, status post Interferon/Ribavirin treatment with relapse as sustained virological response was not achieved. At the time of September 2010 examination, the Veteran was reportedly unemployed but not retired. Hepatitis C had significant effects on her occupational activities due to decreased concentration, problems lifting and carrying, lack of stamina, and weakness or fatigue. Hepatitis C had no effects on her activities of daily living. In a September 2010 statement, a VA liver transplant coordinator indicated that the Veteran had been treated at VA with Interferon combination therapy for chronic hepatitis C with relapse and liver biopsy in 2007 showed stage II-III liver disease. In an October 2010 statement, the Veteran's significant other indicated that she had seen the Veteran suffer from severe fatigue, nausea, and mood swings for years. She struggled in supporting the Veteran in obtaining her certification license for teaching and taking her boards over the years, both of which she had been unsuccessful in obtaining. The Veteran indicated that her hepatitis C was productive of extreme fatigue, fever, nausea, headaches, body aches, difficulty sleeping, and depression. Private treatment records from Dr. JB dating from May to November 2010 show that the Veteran weighed 196 pounds. Complaints included chronic fatigue, chronic mild right-sided abdominal pain, chronic intermittent dyspnea and dry cough. She drank alcohol socially. Physical examinations revealed no liver enlargement or abdominal tenderness. In January 2011, a liver biopsy was performed for staging by Dr. FM, which showed mild chronic inflammation of portal areas, mild fibrosis and moderate steatosis. There was portal area fibrosis and essentially preserved lobules. Findings were consistent with chronic active hepatitis C, Grade II inflammation, and stage I-II inflammation. A February 2011 VA emergency treatment note shows complaints of right upper quadrant pain since liver biopsy in January 2011 and loose stools since 1 day prior. Symptoms of nausea, vomiting, fever, chills, weight loss, shortness of breath, and cough were denied. Diagnosis was abdominal pain status post liver biopsy. A May 2011 VA hepatology note shows that the Veteran underwent Interferon/Ribavirin treatment twice between 2007 and 2009 with relapse both times. She reported that she underwent private liver biopsy and colonoscopy in January 2011 and that she was told that her liver pathology had worsened. Right upper quadrant pain was intermittent and noted to be unrelated to food. The Veteran was willing to be retreated with a direct antiviral. In a December 2011 statement, the Veteran stated that her hepatitis C is manifested by diarrhea at least three times a week, fatigue, nausea, and inability to sleep regularly. She reportedly missed work for her liver and hepatitis symptoms in an effort to adjust to reoccurring symptoms and due to the anxiety and depression that hepatitis C symptoms caused. A March 2012 VA emergency treatment note shows that a review of symptoms at that time was negative for fever, chills, weight loss, shortness of breath, and cough. She weighed 198 pounds. Analysis Taking into account all relevant evidence, the Board finds that, for the period prior to September 29, 2010, the Veteran's hepatitis C is currently properly rated as 10 percent disabling. In this regard, findings on VA examination in June 2005 and VA and private treatment records dating prior to September 29, 2010, all correspond to a 10 percent evaluation under the rating criteria for Hepatitis C under Diagnostic Code 7354. At no time prior to September 29, 2010, did the Veteran's hepatitis C disability warrant a higher 20, 40, or 60 percent disability rating as there are no complaints or findings of daily fatigue, malaise and anorexia requiring dietary restriction or continuous medication, nor is there any objective medical evidence of incapacitating episodes having a total duration of at least 2 weeks or more in the last 12 months. While the June 2005 examiner noted that the Veteran reported near constant bed rest or incapacitation due to signs and symptoms of hepatitis C, there is no objective medical evidence that best rest and treatment was required by a physician. Indeed, during the September 2009 Travel Board hearing, the Veteran explicitly denied that she experienced signs and symptoms of hepatitis C that required bed rest and treatment by a physician. Moreover, although the Veteran testified at the hearing that she experienced constant daily fatigue and malaise, which she is competent to report, such report is not consistent with the March 2008 treatment note indicating that she was involved in a skiing accident around that time. Accordingly, the Board finds that the Veteran's self-report of constant daily fatigue and malaise to be not credible. Thus, the Board finds that the evidence dating prior to September 29, 2010, more nearly approximates a finding of intermittent fatigue, malaise, and anorexia. At no time prior to September 29, 2010, did the Veteran's hepatitis C disability warrant an evaluation in excess of the 10 percent disability rating previously assigned. In light of the foregoing, the Board concludes that the criteria for a rating in excess of 10 percent for hepatitis C are not met at any time prior to September 29, 2010. As to the remaining time frame under consideration from September 29, 2010, the Board sees fit to continue the assignment of the existing 20 percent rating insomuch as by all available indications, the Veteran's hepatitis C has not been manifested by signs and symptoms of daily fatigue, malaise, and anorexia with minor weight loss and hepatomegaly, or; incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks, during the past 12 month period. While the Veteran reported daily fatigue and malaise, she reported only intermittent anorexia. Moreover, there were no complaints or findings of weight loss associated with hepatitis C at any time since September 29, 2010. The September 2010 examiner found no evidence of current weight loss or malnutrition and the Veteran's weight at that time was 187 pounds. A November 2010 private treatment record showed that the Veteran's weight had increased to 196 pounds. VA treatment records dated in February 2011 and March 2012 show that a review of symptoms was negative for weight loss on both occasions. In March 2012, her weight was 196 pounds. Accordingly, the evidence shows that since September 29, 2010, the Veteran gained rather than lost weight. Thus, the next-higher 40 percent evaluation is not warranted since September 29, 2010, for hepatitis C unless the evidence shows that the Veteran experienced incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks. In this regard, VA and private treatment records are negative for any objective medical indication that signs and symptoms of the Veteran's hepatitis C resulted in any incapacitating episodes at any time. Nevertheless, the September 2010 VA examiner found that based on review of treatment records and the Veteran's own self-report, she experienced less than 10 incapacitating episodes during the last 12 months which lasted for 3 days in duration. Thus, she experienced no more 27 days of incapacitating episodes at best in the 12 months prior to that time, which is less than 4 weeks or 28 days as required for the next higher 40 percent evaluation based on incapacitating episodes. In light of the foregoing, the resumption of the 0 percent rating as of September 29, 2010, is warranted under the provisions of the rating schedule. The Court has distinguished when rating criteria are conjunctive versus disjunctive. If conjunctive, such as evidenced by the use of the word "and" in a statutory provision or when reciting the relevant regulatory requirements, then all of the criteria must be satisfied to warrant a higher rating. See Melson v. Derwinski, 1 Vet. App. 334, 337 (1991). Whereas, if disjunctive, as evidenced by the use of the word "or" instead, then only one of the listed requirements must be met in order for an increased rating to be assigned. See Johnson v. Brown, 7 Vet. App. 95 (1994). The Court has further explained that the joining of criteria by the conjunctive "and" in a DC does not always require all criteria to be met, except, as here, in the case of DCs that use successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met. See Tatum v. Shinseki, 23 Vet. App. 152 (2009). The Board has considered whether a higher or additional rating may be assigned under alternative diagnostic codes for both periods of the claim. While DC 7354, Note (1) provides that sequelae such as cirrhosis or malignancy of the liver be evaluated under an appropriate diagnostic code, for the reasons stated above, as residual injury of the Veteran's liver has not been shown to be productive of cirrhosis or adhesions of the peritoneum, diagnostic codes 7301 and 7312 are not applicable. Additionally, a separate evaluation may not be assigned under diagnostic code 7345 for chronic liver disease without cirrhosis because evaluations under this diagnostic code are based on the same rating criteria as the evaluations currently assigned and would violate the rule against pyramiding. See 38 C.F.R. § 4.14. In reaching the above conclusions with respect to the Veteran's claim, the Board has not overlooked the Veteran's statements with regard to the severity of her hepatitis C. The Board has considered the Veteran's reports along with findings from the medical evidence. The Veteran is competent to report on factual matters of which she had firsthand knowledge, e.g., experiencing daily fatigue, malaise, anorexia, and weight loss; however, as noted above, the Board questions the credibility of the Veteran's reported symptoms. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Moreover, the Veteran is not competent to relate her reported signs and symptoms to her service-connected hepatitis C. As there is no evidence that the Veteran has any medical educational background, experience or expertise, and given her multiple non service-connected conditions which may or may not be productive of the same or similar symptoms, the record does not reflect that she is competent to make such medical opinions. Accordingly, the objective medical findings and opinions provided in the Veteran's treatment and examination reports have been accorded greater probative weight. In light of the foregoing, the Board concludes that the weight of the evidence of record does not show that, for any of the periods on appeal, the Veteran's hepatitis C disability has met the criteria for an evaluations higher than those currently assigned for her hepatitis C disability. Extraschedular Consideration The Board has also considered whether the Veteran's hepatitis C disability warrants an extraschedular evaluation in excess of those currently assigned. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations currently assigned for the Veteran's service-connected hepatitis C disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's hepatitis C with the established criteria found in the rating schedule for hepatitis C shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology and provides for higher evaluations for more severe and/or frequent manifestations of signs and symptoms of hepatitis C. Since the available schedular evaluations adequately contemplate the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. In any event, the Board observes that, even if the available schedular evaluations for the Veteran's hepatitis C disability were inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." While the Veteran has indicated that she has missed significant work due to signs and symptoms attendant to her hepatitis C disability, she has also related missed work to psychological symptoms related to her hepatitis C, which the Board notes have been or will be considered in relation to her claim for increased initial ratings for her service-connected PTSD. Moreover, the Veteran has not submitted any evidence corroborating her assertion that she has missed significant time from work due to signs and symptoms of hepatitis C. Indeed, VA treatment records show that during the rating period currently under consideration, she has missed work due to surgical removal of a lipoma from her foot, however, there is no indication that she has missed work due to signs and symptoms of hepatitis C. The Board has been unable to identify an exceptional or unusual disability picture, and neither has the Veteran. While the Veteran undoubtedly has missed work to attend clinical appointments and likely due to signs and symptoms hepatitis C on occasion as alleged, the Board finds that these functional effects caused by the Veteran's hepatitis C disability do not constitute any exceptional or unusual disability picture warranting consideration of an extraschedular rating. In short, there is nothing in the record to indicate that the Veteran's service-connected hepatitis C disability causes impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence of record is against the claim for an increased rating for the Veteran's hepatitis C, and the benefit-of-the-doubt rule is therefore not for application. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert supra. As the preponderance of the evidence of record is against this claim, it must be denied. Rice Consideration In denying the Veteran's claim for increased rating, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In the instant case however, there is no evidence this disability alone renders her unable to work. While the Veteran has stated that she has not worked since 2000 due to signs and symptoms of hepatitis C, as pointed out above, review of the record shows that surgical treatment for colon cancer and a partial hysterectomy preceded her release from her law clerk position in 2000. Hand surgery preceded her release from employment as an adjunct professor in 2004. Moreover, she was documented on multiple occasions since 2000 to be employed, volunteering in her community, in law school or working to obtain additional degrees or professional certification, or writing and publishing a book. The Veteran has not submitted any evidence showing that she is unable to obtain or maintain substantially gainful employment solely due to her hepatitis C disability. Under these circumstances, the Board does not find consideration of a TDIU rating to be necessary. ORDER Entitlement to an increased rating for service-connected Hepatitis C, currently evaluated as 10 percent disabling prior to September 29, 2010, and as 20 percent disabling from September 29, 2010, is denied. REMAND As noted above, the Veteran is seeking entitlement to service connection for a lung condition to include as due to in-service chemical exposure and increased initial ratings for PTSD. After a thorough review of the Veteran's claims file, the Board has determined that additional development is necessary prior to the adjudication of these claims. Under the Veterans Claims Assistance Act of 2000 (VCAA), the duty to assist includes making reasonable efforts to obtain private medical records. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c)(1) (2012). Pursuant to the Board's August 2010 remand, the Appeals Management Center (AMC) requested that the Veteran provide information as to any private treatment providers for the above claimed disabilities. In compliance with that request, the AMC sent the Veteran a letter in September 2010 requesting such information and asked the Veteran either to provide any private records herself or authorization for VA to seek those records directly from the private providers. In December 2011, the Veteran provided authorization to enable VA to obtain private mental health treatment records from CM, a VA turned private clinical psychiatric nurse, dating since June 2009. As noted in the December 2012 remand, it did not appear that the AMC requested the authorized records from the private physicians authorized. Thus, the Board directed that the authorized private treatment records be requested, and if current authorizations are needed, they should be requested from the Veteran. Pursuant to the December 2012 remand, it appears that the AMC sent the Veteran a letter in December 2012, which requested that she provide information as to any private treatment providers who have treated her for the claimed disabilities and she was requested to complete and submit separate updated VA Form 21-4142s Authorization and Consent to Release Information to the VA for providers other than CM. As noted in the February 2013 SSOC, the Veteran failed to respond to the AMC's request for such information. As the Veteran has not been notified that private treatment records from CM have not yet been obtained and she was not specifically requested to provide updated authorization sufficient to enable VA to obtain private mental health treatment notes from CM dating since June 2009, the Veteran should be provided with another opportunity to submit authorization to enable VA to obtain those records or submit them herself for review. Additionally, the Veteran's service-connected PTSD was most recently evaluated in November 2010, more than two years ago. Subsequently, a statement received from CM, the Veteran's now private (since June 2009) mental health treatment provider, indicated that her mental condition with regard to her PTSD and her medical condition have worsened. CM stated that the Veteran's hepatitis C condition triggers and worsens her PTSD and if it continues and she remains paralyzed in moving forward, she will continue to remain in jeopardy at work and she may not continue to function at work. Where the evidence of record does not reflect the current state of the Veteran's disability, a contemporaneous VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). As to the Veteran's claim for service connection for a lung condition, during the September 2009 Travel Board hearing, the Veteran testified that she had been diagnosed with interstitial lung disease in the late 1990s, which she believes is related to her active military service. Specifically, she testified that her military occupational specialty as an aviation mechanist mate required that she perform preflight operations on jets, such as cleaning and fueling jet engines with certain unknown "green chemicals." She testified that she was exposed to fumes from jet fuel and unknown chemicals daily without use of a protective apparatus. She stated that inhalation of the fumes resulted in difficulty breathing and caused dizziness resulting in a fall and head injury on at least one occasions during service. While she could not recall whether she sought treatment for respiratory complaints specifically during service, she indicated that dizziness resulting in a fall and head injury should be documented in her service treatment records. The Veteran denied any pre-military history of asthma or respiratory complaints. In accordance with the Board's August 2010 remand, the Veteran was afforded a VA examination in September 2010 to determine the nature and etiology of any current lung condition. Following a review of the claims file and examination of the Veteran, the examiner diagnosed a chronic dry cough with normal chest x-ray, CT scan of the thorax, and pulmonary function test except a mild decrease in diffusion capacity. He could not make a more specific diagnosis based on the Veteran's history, physical examination, and diagnostic studies. He concluded that such diagnosis is less likely than not causally related to the Veteran's active military service, to include her presumed exposure to hazardous chemicals therein, because there was no documentation of any difficulty breathing or other respiratory or lung complaints during service. He stated that even considering the Veteran's current report of difficulty breathing during service, her service treatment records are negative for complaints or treatment for cough or other respiratory complaints during service. Thus, he opined that her currently diagnosed respiratory condition is not related to service as respiratory complaints started many years after her discharge from active duty. On review, however, the Veteran's service treatment records show complaints of an upper respiratory infection since 2 days prior in May 1974. In March 1975, she complained of dizziness and had hit her head on a jet engine as alleged during the Travel Board hearing. In April 1975 she complained of light headedness and dizziness. In April 1975 she experienced sinus congestion and rhinorrhea and chest x-ray was normal. In March 1976, she was diagnosed with an upper respiratory infection. As respiratory complaints and findings were clearly documented during the Veteran's active military service which were not considered by the September 2010 examiner, nor was the Veteran's report of dizziness resulting from inhalation of fumes from jet fuel and unknown chemicals during service considered, the Board finds that the September 2010 VA examination is inadequate for the purpose of adjudicating the Veteran's claim for service connection for a lung condition. Moreover, the June 2005 liver VA examination report notes that the Veteran developed increased dyspnea with a chronic dry cough following completion of interferon/ribavirin treatment for her service-connected hepatitis C disability. Thus, an opinion is needed as to whether the Veteran's service-connected hepatitis C disability or treatment thereof may have caused or aggravated the Veteran's claimed lung condition. Finally, since obtainment of the September 2010 examination and opinion pertaining to the Veteran's claimed lung condition, a September 2011 VA pulmonary treatment note documents the Veteran's report of a strong family history of asthma and an allergic history dating since childhood which has not been considered. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Veteran should be afforded an additional VA examination to determine the likely etiology of her claimed lung condition on remand. Accordingly, the case is REMANDED for the following action: 1. Request mental health outpatient treatment records from CM dating since 2009 as identified in the December 2011 authorization. If current authorization is needed, it should be requested from the Veteran. All records obtained or any response received should be associated with the claims file. 2. Contact the Veteran and request that she provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated her for a psychiatric disability dating since June 2009, and the claimed lung condition since her discharge from service. After the Veteran has signed the appropriate releases, if any, those records should be obtained and associated with the claims folder. Also request VA treatment records from the Brooklyn New York VAMC, if any, to include all respiratory and psychiatric treatment records, diagnostic testing, and evaluations dating March 2012. Appropriate efforts must be made to obtain all available treatment records. All attempts to procure records should be documented in the file. If the RO/AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and her representative are to be notified of unsuccessful efforts in this regard, in order to allow them the opportunity to obtain and submit those records for VA review. 3. After the above evidence is obtained, to the extent available, schedule the Veteran for an appropriate VA examination to determine all manifestations and residuals associated with her service-connected PTSD and the severity of any such manifestations and residuals. The claims folder, to include any relevant records contained in Virtual VA, must be made available to the examiner, and, the examiner must review the entire claims file in conjunction with the examination. All appropriate tests and studies should be performed, to include an interview and a comprehensive mental status examination. Upon review of the record and examination of the Veteran, the examiner should set forth all manifestations of the Veteran's service-connected PTSD and discuss the impact of such symptoms on her daily activities and social and occupational functioning. A Global Assessment of Functioning (GAF) score should be assigned, and the examiner should explain the basis for the assigned score. To the extent possible, the examiner should discuss any effects due to psychiatric symptoms and manifestations of the Veteran's PTSD on her ability to obtain or retain substantially gainful employment. Any and all opinions must be accompanied by a complete rationale. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 4. Thereafter, schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature and etiology of any lung condition diagnosed on examination and in treatment records dating since the claim for service connection was received in March 2005, taking into account both medical evidence and lay testimony from the Veteran as to the onset of difficulty breathing during service and the progression of the claimed disability. The examiner should review the claims file, to include any relevant records in Virtual VA, and a copy of this REMAND in conjunction with the examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner must address the following inquiries: a) Identify any lung condition that is (1) currently shown or (2) indicated by the record at any time since March 2005. b) For each lung condition identified, provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such diagnosis is (or was, if resolved) caused or aggravated by or otherwise etiologically related to injury, illness or event during active military service (to include her presumed exposure to jet fuel (daily) and unknown cleaning chemicals while cleaning jet engines and fuel tanks which resulted in dizziness during service as alleged). c) The examiner should also determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected hepatitis C disability, to include at least two courses of Interferon/Ribavirin antiviral treatment, to include from 2003 through 2004, with subsequent development of increased dyspnea and chronic dry cough, has caused or aggravated (permanently worsened beyond normal progression) any current lung condition. If aggravation is shown, the examiner should specify what permanent, measurable increase in the severity of the lung condition is attributable to service-connected hepatitis C and/or treatment thereof. Any and all opinions must be accompanied by a complete rationale. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 5. Review the claims folder to ensure that the foregoing requested development has been completed. In particular, review the examination reports to ensure that they are in complete compliance with the directives of this REMAND. If the examination reports are deficient in any manner, the RO/AMC must implement corrective procedures at once. See Stegall v. West, 11 Vet. App. 268 (1998). 6. Then, after ensuring that any other necessary development has been completed, readjudicate the issues on appeal. If the benefits sought on appeal are not granted, issue a supplemental statement of the case, and afford the Veteran and her representative an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs